Prior Authorization
MyTruAdvantage provides prior authorization services to ensure members receive services that are medically and clinically necessary, and that the services are appropriate for your condition or diagnosis.
There are two parts to the prior authorization process:
1. Your provider submits a request to MyTruAdvantage in the Provider authorization portal or through other means such as fax. The request includes the specific diagnosis and treatment codes for review, along with medical or clinical records to support the request.
2. MyTruAdvantage reviews the clinical documentation submitted with the request using appropriate coverage documents and/or clinical criteria to make a decision. If the service is determined to be a covered benefit and medical necessity criteria are met, the request is approved. If not, the request is reviewed by a Medical Director for a decision. Your provider is notified of the decision in the electronic authorization portal as well through fax and mail, when applicable.
Notice of approval or denial is also sent to the MyTruAdvantage members for any authorization request received. If the authorization is denied, members will receive a denial letter which includes their appeal rights. If you have any questions about your authorization, contact customer service.
Criteria utilized for Medical Necessity Reviews:
In addition to utilizing the Plan Document to confirm plan coverage, MyTruAdvantage utilizes Medicare National (NCD) and/or Local Coverage Determination (LCD) when completing a medical necessity review. Access to these NCD and LCD coverage criteria can be accessed by following the link below:
Questions:
The criteria provided are intended to be utilized by clinical professionals. In the event you have questions regarding the criteria, MyTruAdvantage encourages you to reach out directly to your Provider or the MyTruAdvantage clinical team at (844) 425-4280. For any other questions about prior authorizations, please send us a message in your member account or call the customer service contact number listed above.
Coverage Determination / Redetermination
Prior Authorization/Coverage Determination Form
What is a coverage decision?
A coverage decision is a decision about your medical or prescription drug benefits and coverage. A coverage decision may be made prior to you receiving a service or after the service is received. Whenever you ask MyTruAdvantage to authorize, provide, or pay for medical or prescription drug services, including the type or level of services you believe you should receive, you are asking us for a pre-service coverage decision. Coverage decisions are also known as
- Organization Determinations (Part C or medical benefits) or
- Coverage Determinations (Part D or prescription drug benefits).
What is the difference between a prior authorization (PA) and a request for a coverage decision?
Both a PA and a coverage determination are about asking the plan if something will be covered. Some medical and prescription drug services might be specified in your Evidence of Coverage as requiring that you obtain a PA or they will be denied for payment. However, there may be some services or drugs that you are unsure are covered. These may not require a PA but because you are asking us if they will be covered, you are asking for a coverage determination.
Criteria utilized for Coverage Determination Reviews:
In addition to utilizing the Plan Document to confirm plan coverage, MyTruAdvantage utilizes Medicare National (NCD) and/or Local Coverage Determination (LCD) when completing a Coverage Determination review. Access to these NCD and LCD coverage criteria can be accessed by following the link below:
Who may ask for a coverage decision?
You or your appointed representative (someone you name to act for you) may request an appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you. You may have someone already authorized under state law to act on your behalf or an individual appointed with power of attorney for example. If you don’t and wish to have someone represent you, click on this link to download the appointment of representative form required by the Centers for Medicare and Medicaid Services (CMS). This form is for use for appeals, coverage decisions, or grievances and is valid for one (1) year from the date from the date it has your signature and the signature of your appointed, unless revoked. For example, if the enrollee signs the form on January 1, 2025 and the representative signs on January 3, 2025 (or vice versa), the form is effective for one year starting on January 3, 2025.
Can your doctor request a coverage decision?
For coverage or initial decisions about coverage, your physician or his/her staff may submit a request on your behalf. For appeals and grievances, your physician must be appointed your representative.
How do you request a coverage decision?
To request either a Part C or Medical organization or coverage determination you may do one of the following:
By phone: 1-844-425-4280 (TTY 711)
We are available as follows:
October 1 through March 31:
8:00 a.m. to 8:00 p.m., local time, 7 days a week
April 1 through September 30:
8:00 a.m. to 8:00 p.m., local time, Monday through Friday
On weekends and holidays, you will need to leave a message.
By writing:
MyTruAdvantage
P.O. Box 428
Columbus, IN 47202-0428
By fax: 1-812-378-7048
For Part D or Drug coverage requests, you or your physician may use the CMS Model Coverage Determination form or by contacting us using one of the methods below:
By Phone: 877-403-6035 (TTY users, please call 711)
24 hours a day, 7 days a week
By Writing:
MyTruAdvantage
MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court
San Diego, CA 92131
By Fax:
How long will it take for MyTruAdvantage to make a 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 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. However, for a request for a medical item or service 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. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. 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 if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.
