Get the free Coverage Determination Request Form - AmeriHealth Caritas VIP ...

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: AmeriHealth VIP Select Urgent: 1-855-756-9909 Attn: Pharmacy Prior Authorization/

How to fill out coverage determination request form

How to fill out a coverage determination request form:

1. Start by obtaining the coverage determination request form from your health insurance provider. It may be available on their website or you can request a copy from their customer service department.
2. Carefully read the instructions on the form to understand the required information and supporting documents that need to be submitted.
3. Begin by providing your personal information, such as your name, address, phone number, and member ID. Make sure to double-check the accuracy of this information to avoid any processing delays.
4. Next, you will need to specify the prescription drug or medical service for which you are requesting coverage determination. Include the name, strength, and dosage of the medication or a clear description of the medical service.
5. Provide detailed reasons for why you believe coverage should be approved. This may include information about the medical necessity of the drug or service, any past trials or treatment failures, and any supporting medical evidence or documentation.
6. If applicable, you may need to provide additional information such as the name of the prescribing healthcare provider or any relevant medical records or test results.
7. Review the completed form to ensure all fields are correctly filled out and all necessary documents are included.
8. Make a copy of the completed form and any supporting documents for your records.
9. Submit the coverage determination request form either electronically through your health insurance provider's online portal or by mailing it to the designated address. Keep a record of the submission date and consider sending it through certified mail to confirm its delivery.
10. Wait for a response from your health insurance provider. They should contact you with their decision on the coverage determination request within a specified period of time, usually within 72 hours for urgent requests or 14 days for non-urgent requests.

Who needs a coverage determination request form?

1. Individuals who are seeking coverage or reimbursement for a prescription drug or medical service may need a coverage determination request form.
2. It is particularly important for members of health insurance plans to fill out this form when they believe their health insurance provider should cover all or part of the costs for a specific drug or service.
3. Patients who have been prescribed a medication or recommended a medical service that is not typically covered by their insurance may also need to complete a coverage determination request form to request an exception.

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