Prior Authorizations & Appeals
We're here to help guide you through the drug prior authorization process, including appeals and overrides.
Some prescription drugs must be authorized by the US Family Health Plan before the service is delivered. Asking for a “Prior Authorization” is the starting point of this process.
If a certain prescription drug is not covered under your plan or if a Prior Authorization appeal request is denied, you can apply for an appeal or override.
Table of Contents:
- Why Was My Prescription Denied?
- Prior Authorization Process
- Appealing a Coverage Decision
- Information for Providers
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For plans with a deductible: If your prescription needs prior authorization, it means we need a bit more information before we can approve it. Please get in touch with your doctor to initiate start this process, as we cannot override this requirement.
More information on the prior authorization process can be found below.
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"Maintenance medications" (prescription drugs you take for ongoing conditions like high blood pressure, high cholesterol, etc.) must be filled using our Mail-Order Pharmacy service. Exceptions include:
- First-time Fills of Maintenance Medications: This is a one-time fill to help you transition smoothly to the Mail-Order Pharmacy.
- Urgent/One-Time Fills: These are typically fills of antibiotics for an acute infection, medications for short-term pain, etc.
- Unexpected Needs: If you’re caught off guard without your medication, we may approve a one-time retail refill.
- Medicaid Coverage: If you have Medicaid that requires you to use a retail pharmacy, we might provide an extended override.
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Do you need your prescription medication before your next scheduled refill?
There are a few scenarios where we can help:
- Vacation: Heading out of town? Apply for a Vacation Override to get your medication early.
- Mail-Order Delays: If there's a delay in your Mail-Order delivery, request a "Fill Too Soon Override."
- Lost or Stolen Medication: If your medication has been lost or stolen, let us know immediately to discuss your options.
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If the medication is not covered under your plan, this claim cannot be overridden. Please discuss alternative medications that are covered with your health care provider.
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If there’s a problem or an issue with the quantity or cost of your medication, we can review the situation to see if an override is possible.
How to Request an Override
Overrides are intended to be exceptions to ensure the provision of necessary care when needed. They are not standard procedure, and each case is assessed individually to provide the best solution.
If you are in a situation that you believe requires an override, there are three steps to take:
1. Immediately call one of the following teams:
MPHC Mail-Order Pharmacy: 1-800-707-9853
Member Services: 1-800-961-4572
2. Prepare to provide a detailed explanation of your situation to facilitate our assistance.
3. After starting an override request, follow up with your pharmacy within 24 hours to verify if the claim has been re-processed.
Prior Authorizations
If your prescription needs prior authorization, it means we need a bit more information before we can approve it. Please get in touch with your doctor to initiate start this process, as we cannot override this requirement.
It is your provider’s responsibility to request authorization from the US Family Health Plan to request coverage for certain prescription drugs/services.
After the review, the Plan will send an authorization approval or denial letter to the beneficiary and the provider explaining the coverage decision.
Note: Baby formula is not covered, even if a prior authorization is granted by the Health Management Department.
The Plan will review the authorization request to determine the following:
Prior Authorizations | FAQs
Do Prior Authorizations expire?
Depending on the drug as well as diagnosis information, some Prior Authorizations can expire.
The expiration date depends on several factors and can vary—some expire after six months and others expire after one year. Some Prior Authorization approvals are "forever", meaning there is not an expiration date.
Depending on the medication, members may receive a letter detailing that the prior authorization will expire. The expiration date would be included in the mailed letter.
NOTE: The letter is not sent to primary care providers or specialists who prescribed the medication or submitted the prior authorization.
How long does the review process take?
Once the prior authorization form is filled out completely, the turn around time is generally 1-2 business days, but can take up to 14 days.
The time frame may be longer if we don’t have the information necessary to make a determination. If there is additional clinical information required, we will reach out to your provider for that information.
What if I already have an active Prior Authorization with another insurance plan?
If you are a new member and have an active prior authorization through another insurance plan (including another TRICARE® plan), you must provide documentation. Any active prior authorizations will be considered as part of the Martin's Point prior authorization process.
If you cannot provide the necessary documentation, you will need to obtain a new authorization through the US Family Health Plan.
Appeals
Members who are not satisfied with medical decisions made by the US Family Health Plan or who disagree with the US Family Health Plan decision to deny an authorization or claim, may pursue the formal appeals process.
When an authorization is denied, an appeal can be requested within 90 days of the authorization denial date. Your provider will help you file the necessary appeal documentation.
There are two main types of appeals:
Factual Appeals |
A factual appeal is a request to reconsider a claim or an authorization request that has been denied for any of the following reasons:
- The requested service is not a covered benefit under the TRICARE® program (e.g. chiropractic services).
- Determinations related to coverage based on plan limitations (e.g. 32 CFR 199, the TRICARE Policy Manual, and other TRICARE guidance).
Medically Necessary Appeals |
Medical-necessity appeals are requests to reconsider a claim or an authorization request that has been denied for any of the following reasons:
- The requested service is a covered benefit, but the member’s condition does not meet medical-necessity standards.
- Services extend beyond what is considered to be medically necessary (e.g. extended hospital stay).
Submitting An Appeal
Appeals must be filed, in writing, within 90 calendar days after the date of the notice of the initial denial determination in order to be accepted for review. Appeals can be submitted by mail, fax, or by email.
Appeals may be submitted by a member, the member’s appointed representative, the parent of a minor, or a provider (if the member has signed an “Appointment of Representative” statement authorizing the provider to act on his or her behalf).
All appeals should include the following information:
Once an appeal letter is received, the US Family Health Plan will mail you an acknowledgment letter confirming receipt and stating when a final determination of your appeal request will be made, following TRICARE guidelines. The US Family Health Plan will issue a written determination letter once the appeal is processed.
Expedited Appeals
Expedited appeals must be medical-necessity appeals and be submitted prior to the service being delivered. They must be filed within three (3) calendar days after the date of the mailing of the initial denial determination. An appeal can be expedited for the following reasons:
- In the opinion of the practitioner, the member’s health or ability to function could be seriously harmed by waiting for the standard appeals process.
- Continuing coverage for inpatient or skilled nursing level of care has been denied.
For concurrent appeals, the member must be a patient in the facility on the date of the appeal filing.
Prior Authorization Form Search
Need to complete a prior authorization for a patient? All prior authorization forms can be found by using the Forms & Documents Search Tool:
Need More Information?
Need more information? If you are a provider and have questions, contact Martin's Point and one of our representatives can assist you:
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Have questions? We're here to help.
Call US Family Health Plan Member Services to speak with one of our health plan specialists today. We're here for you!