Coverage Decision for Medical Care

Step-by-step: How to ask for a coverage decision for Medical Care

How to ask our plan to authorize or provide the medical care coverage you want

Step 1: You ask our plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a “fast coverage decision.

How to request coverage 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.

Method

Coverage Decisions for Medical Care – Contact Information

Call

1-866-333-3530 - Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

TTY 711

This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Fax

1-866-207-6539

Write

Vitality Health Plan of California
Member Services Department (Coverage Decisions)
18000 Studebaker, Road, Suite 960
Cerritos, CA 90703

Click here to download the Medical Coverage Decision (Organization Determination) Request Form: English | Spanish

Download Adobe Acrobat Reader

For expedited requests, please call or fax using the contact numbers above.

Generally we use the standard deadlines for giving you our decision

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer within 14 calendar days after we receive your request.

  • However, we can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.
  • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
If your health requires it, ask us to give you a “fast coverage decision”
  • A fast coverage decision means we will answer within 72 hours.
    • However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing (such as medical records from out-of-network providers), or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing.
    • If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. We will call you as soon as we make the decision.
  • To get a fast coverage decision, you must meet two requirements:
    • You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
    • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
  • If your doctor tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.
  • If you ask for a fast coverage decision on your own, without your doctor’s support, we will decide whether your health requires that we give you a fast coverage decision.
    • If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
    • This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.
    • The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested.

Step 2: We consider your request for medical care coverage and give you our answer.

Deadlines for a “fast coverage decision”
  • Generally, for a fast coverage decision, we will give you our answer within 72 hours.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period.
  • If our answer is no to part or all of what you requested, we will send you a detailed written explanation as to why we said no.
Deadlines for a “standard coverage decision”
  • Generally, for a standard coverage decision, we will give you our answer within 14 calendar days of receiving your request.
  • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 14 calendar days after we received your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.

  • If we say no, 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.
  • If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.

For more information on the medical care coverage decision process, you may refer to Chapter 9 Section 5 of the Evidence of Coverage (EOC).

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to file a grievance, request a coverage decision, or make an appeal at any level of the process. Go to our “How to Appoint a Representative” page to find out more.

You may ask to obtain the aggregate numbers of the plan’s grievances, appeals, and exceptions. Please contact Vitality Member Services Department at 1-866-333-3530 (TTY: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31, except holidays, and 8 a.m. to 8 p.m., Monday through Friday, from April 1 through September 30, except holidays. Messages received on holidays and outside of our business hours will be returned within one business day.

Last updated 12/20/2018