Medical coverage determinations
You have the right to ask Range Health to pay for items or services you think should be covered. This is called an "organization determination" (also called a coverage decision).
An organization determination (referred to here as a coverage decision) is a decision Range Health makes about your benefits and coverage and whether we will pay for the medical services you or your doctor have requested. You can also 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.
You, your representative, or your doctor can ask us for a coverage decision by calling, writing, or faxing your request to us. For expedited coverage decisions, phone or fax.
Phone: 1-833-574-6031
Fax: 208-519-3964
Mail:
P.O. Box 9018
Boise, ID 83707-9018
When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "expedited" (fast) deadlines. A "fast coverage decision" is called an "expedited determination."
- Prior authorization (pre-service): Standard within 7 days. Expedited within 72 hours
- Claim (post service): Standard within 60 days. No expedited response available
- Grievances and other complaints: Standard within 30 days. No expedited response available
To get a fast coverage decision, you must meet two requirements:
- You must be asking for coverage of 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 must need a fast decision because using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells Range Health 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 explain that we will automatically give a fast coverage decision if your doctor asks for it.
- The letter will also explain how you can file a "fast complaint" about our decision to give you a coverage decision using the standard deadline. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
We can take up to 7 more calendar days to make either a standard or fast 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.
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 we do not give you our answer within the standard or fast time (or if there is an extension at the end of that period), you have the right to appeal. You also have the right to file an appeal if you disagree with our coverage decision.
In some cases we might decide a service is not covered or is no longer covered by your plan. If we say no to part or all of what you requested, we will send you a detailed written explanation as to why we said no and instructions on how to appeal our decision.
For some types of items or services, your doctor may need to get approval in advance from our plan (this is called getting "prior authorization"). Those services that require advance approval are included in your Evidence of Coverage.