An organization determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. See Chapter 9 of your Evidence of Coverage for complete details about this process. We are making an organization determination whenever we decide what is covered for you and how much we pay. You or your doctor can contact us and ask for an organization determination if your doctor is unsure whether we will cover a particular medical service or refuses to provide the medical care you think that you need.

We are committed to providing high-quality care for our members.

• When reviewing coverage requests, we follow Medicare guidelines, using National Coverage Determination (NCD) and Local Coverage Determination (LCD). We use evidence-based medical data when making determinations for requests without fully established criteria.
• Our decisions are based on the appropriateness of care and medical necessity.

Providers or other health care professionals are not financially rewarded based on denial of care or for limiting services.
If you have any questions or concerns about covered services, please contact Member Services for help.

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard organization determination means we will give you an answer within 14 calendar days after we receive your request. If your health requires it, ask us to give you a “fast” organization determination, which is an expedited organization determination. An expedited organization determination means we will answer within 72 hours. You can get an expedited organization determination:

• if you are asking for coverage for the medical care you have not yet received.
• if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If you ask for an expedited organization determination on your own, without your doctor’s support, we will decide whether your health requires such, which may require contacting your doctor.

How to request a determination for the medical care you want

Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.

• CALL 1-800-656-8991 – Calls to this number are free. Hours of operations are 8 a.m. to 8 p.m. 7 days a week.
• TTY 711 – This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Hours of operations are 8 a.m. to 8 p.m. 7 days a week.
• FAX – 1-877-424-5680
• WRITE:

Health Choice Pathway
Attn: HCP Prior Authorization
8220 N. 23rd Ave. 
Phoenix, AZ 85021
Fax: 480-760-4739

An “appeal” is the type of complaint you make when you want us to reconsider and change a decision we have made about what medical services or benefits are covered for you or what we will pay for a medical service or benefit.

You can request an initial decision from us, or you can appoint someone to act on your behalf; this person would be your Authorized Representative. For more information about Authorized Representatives, please refer to your Evidence of Coverage.

There are six possible steps you can take to make complaints related to your medical coverage or payment for your medical care.

At each step, your request is considered and a decision is made. The decision may be partly or entirely in your favor, or it may be completely denied. If you are unhappy with the decision, you may be able to take another step to request a further review of your case. Whether you can take the next step may depend on the dollar value of the medical care involved or other factors.

If you are unhappy with the decision at any step of the process, you may be able to take another step if you want to continue requesting the care or payment.

• In Steps 1 and 2, you make your request directly to us. We review it and give you our initial decision. If our initial decision is to turn down your request, you can proceed to Step 2, where you can appeal this initial decision.
• In Steps 3 through 6, your appeal goes outside of our plan, where people who are not connected to us make the decisions about your request. To keep the review independent and impartial, those who review the request and make the decision in Steps 3 through 6 are part of (or in some way connected to) the Medicare program or the federal court system.

A decision about whether we will cover medical care can be a standard decision that is typically made within 14 days or it can be a fast decision that is typically made within 72 hours.

You can ask for a fast decision only if you or any doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. Fast decisions apply only to requests for medical care and you cannot get a fast decision on requests for payment for the care you have already received.

If you have not received written notice within 5-7 business days after the 72-hour timeframe, you may file a State Fair Hearing using the process as specified in this section.

If you wish to dispute a decision regarding your Prescription Drug benefit, there is a separate process called “Coverage Redetermination”. Please refer to your Evidence of Coverage.

If you are asking for a Standard Decision, you have the right to initiate an appeal verbally by telephone at 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week. You or your authorized representative can also submit your Appeal in writing to:

Health Choice Pathway
Attn: HC Appeals
8220 N. 23rd Ave.
Phoenix, AZ 85021

For more information about filing an appeal, please see Chapter 2, Section 1 of your Evidence of Coverage.

If you are asking for a Fast Decision, you, any doctor, or your authorized representative can do so verbally by telephone by calling 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week.

Note: You, any doctor or your authorized representative should have available any necessary documentation to support your request for a fast decision.

If you would like to appoint a person to file a grievance or request an appeal on your behalf, you and the person accepting the appointment must complete this form. Submit the completed form with the grievance or appeal request.

If you have further questions about appointing someone to speak or make healthcare decisions on your behalf, contact Member Services at 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week.

Appointment of Representative Form

Appointment of Representative Form (Spanish)