Coverage Determinations

Medical & Part C Coverage

What is a coverage decision?

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. When a coverage decision involves your medical care, it is called an “organization determination.”

We are making a coverage decision whenever we decide what is covered for you and how much we pay.

Examples of Coverage Decisions:

Your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist.
You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need.

In some cases, we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

How to request coverage for the medical care you want?

You, your doctor, or your representative can make a request for us to authorize or provide coverage for the medical care you want. To do this, please call our Customer Care Center.

You may also submit a request in writing at the address below:

Banner Medicare Advantage
5255 E Williams Circle, Ste 2050
Tucson, AZ 85711
Fax: (866) 465-8340

Denial of Coverage Request

If we deny your request, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. Making an appeal means making another try to get the medical care coverage you want.

Visit our Grievances & Appeals page for more information on the appeal process or the Appointment of Representative form.

Pharmacy & Part D Coverage

What is a coverage determination?

A coverage determination, also known as a coverage decision, is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. If you are not sure if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

If Banner Medicare Advantage makes a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

There are examples of situations that involve coverage decisions and appeals:

Your Part D prescription drugs: How to ask for a coverage decision or make an appeal
How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon
How to ask us to keep covering certain medical services if you think your coverage is ending too soon” (Applies to these services only: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services).

How to request coverage for prescription drugs?

You, your doctor, or your representative can make a request for us to authorize or provide coverage for the medical care you want. To do this, please call our Customer Care Center.

You may also submit a request in writing at the address below:

Banner Medicare Advantage
5255 E Williams Circle, Ste 2050
Tucson, AZ 85711
Fax: (866) 465-8340

Denial of a Coverage Request

If we deny your coverage request, you have the right to request an appeal. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made.