Initial Organizational & Coverage Determinations, Exceptions, Appeals & Grievances *

If you would like to learn more about our policies regarding initial organization & coverage determinations, exceptions, appeals and grievances, read our policies and procedures:

  Policies and procedures for HMO plans
  Policies and procedures for PPO plans

Other things you can do on this page:

To access additional resources, such as the Appoint a Representative, Medicare Prescription Drug Coverage Determination, and Medicare Prescription Drug Coverage Re-Determination forms, please visit the Documents page.

You can also find information about grievance, coverage determination, exception and appeals processes by referring to your Evidence of Coverage.

To obtain information about the aggregate number of grievances, appeals and exceptions filed with your health plan, contact Customer Service.

*Documents may also refer to these processes using simpler terms such as “coverage decision” or “coverage determination” rather than “initial organizational determination” or “making a complaint” vs “filing a grievance”.

Y0132_19-529_ITLU - Last updated 01/30/2020