Part C Coverage Decisions & Prior Authorization

Medicare Part C Coverage Decisions & Prior Authorization

A benefit determination, also known as an organizational determination, is a decision CHRISTUS Health Plan makes about whether to authorize, approve and pay for proposed medical care. As a member of the CHRISTUS Health Plan Generations or Generations Plus (HMO) plan, you have the right to ask us to pay for services you think should be covered.

You can ask us for a coverage decision before you receive medical services if you’re not sure if it’s covered, or if you think your physician or provider is refusing to provide medical services or care you think is needed.

You, an authorized representative or your physician/provider can ask for a coverage decision by calling 1-844-282-3026, five days a week from 8 a.m.- 8 p.m. local time. TTY users (for people with hearing and speech difficulties) can call 1-800-659-8331, five days a week from 8 a.m.- 8 p.m. local time.

You may also write a coverage decision request and fax it to 1-800-277-4926 or mail it to:

CHRISTUS Health Plan
PO Box 169001
Irving, TX 75016

After hours, members or physician can leave a message, including the member’s name and contact phone number, and we’ll get back to you the next business day.

For a non-emergent request, CHRISTUS Health Plan will give you a decision within 14 days of receiving the request. If the service is approved, we’ll notify you or your provider by phone or electronically.

If your medical condition requires a fast decision, you can request an expedited coverage decision, also known as an expedited determination. Expedited coverage decisions can only be requested for medical care you have not yet received and because using the standard timeline could cause serious harm to your health, life or ability to function.

There are two ways to request an expedited coverage decision:

  • If your provider notifies us that you need a fast decision (orally or in writing), we will automatically provide an expedited coverage decision.
  • If you request the expedited decision without a physician’s notification by calling 1-844-282-3077, CHRISTUS Health Plan will decide if the standard time could jeopardize your health, life or ability to regain maximum function. If we decide that your condition doesn’t meet requirements for a fast decision, we will call your provider and send a letter notifying you and your provider that the standard timeline will be followed.

For expedited coverage decisions, CHRISTUS Health Plan will provide a decision within 72 hours of receipt.

In some cases, we might decide that a service is not covered or is no longer covered by your plan. If we deny part or all of the service, you have the right to file an appeal or grievance.

To qualify for coverage on some services, your provider may need prior authorization. Prior authorization means getting approval on medical services from CHRISTUS Health Plan before they are provided. If your care requires prior authorization and your provider or hospital doesn’t get it, the services and costs may not be covered.

Services that require prior authorization are listed in your Evidence of Coverage. You can also call the phone number on the back of your ID card to verify services that need authorization. If it’s needed, your physician or provider can complete a Prior Authorization Request Form.

H1189_MM143 pending approval
Last Updated: 2/23/17