Learn more about Medicare coverage decisions and exceptions such as requirements, forms, and contact information.

What’s a coverage decision?

A coverage decision is a decision we make about your benefits and coverage and whether we will pay for the medical services you or your doctor have requested. You can contact us to ask for a coverage decision before you receive certain medical services. You might want to ask us to make a coverage decision beforehand if your doctor is unsure whether we will cover a particular medical service or if your doctor refuses to provide medical care you think you need.

For more information, see your Evidence of Coverage.

You can ask us for a coverage decision yourself, or your doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. If you want someone to act for you, then you and that person must sign and date the Appointment of Representative form that gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address. This form does not have to be completed if your doctor is submitting a request.

To request a coverage decision, start by calling, writing, or faxing our plan to make your request.


Call

1-866-393-5366 or 305-559-5366 (TTY 711).
We’re here from 8:00 a.m. to 8:00 p.m., seven days a week, from October 1 through March 31 and Monday to Friday, the rest of the year.

Email

MemberSupport@lmchealthplans.com

Write

Leon Medical Centers Health Plans
Attn: Utilization Mgmt
PO Box 66-9440
Miami, Florida 33166

Fax

305-642-1142

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 for a medical item or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request.


If your health or ability to function could be seriously harmed by waiting up to the standard 14 days for a decision, you can ask us to give you a “fast coverage decision.” A fast coverage decision means we will give you an answer within 72 hours if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 24 hours. 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 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.

You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot ask for a fast coverage decision if your request is about payment for medical care you have already received.)


We can take up to 14 more calendar days to make a decision 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. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.

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. To submit a complaint to Medicare, complete the Medicare Complaint Form.

If we do not give you our answer by the standard or fast deadlines (or if there is an extended time period, by the end of that period), you have the right to
appeal.


In some cases we might decide a medical service, item or prescription drug is not covered by your plan. If we say no to part or all of what you requested, we will send you a detailed written explanation. 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 or prescription drug coverage you want.

For more information, see your Evidence of Coverage.