MMP coverage decisions in Texas

What is a coverage decision (determination)?

A coverage decision (determination) is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs.

Coverage decisions about your healthcare

A coverage decision about your healthcare is a decision about:

Your benefits and covered services, or
The amount we will pay for your healthcare services.

Coverage decisions about your drugs

A coverage decision about your drugs is a decision about:

Your benefits and covered drugs, or
The amount we will pay for your drugs.

This applies to your Part D drugs, Texas Medicaid prescription drugs, and Texas

Medicaid over-the-counter drugs.

Appointed representative

You can ask someone to represent you when you ask for a coverage decision. An appointed representative can be:

A relative
A friend
An advocate
A doctor

Fill out the Appointment of Representative form in English or Spanish to have someone act on your behalf.

Requests about a non-Part D drug, Medicare-covered service or Medicaid-covered service

You, your doctor or appointed representative can ask for a coverage decision in one of these ways:

1. Call Member Services at 855-878-1784 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. local time. The call is free.

2. Mail to:
MMP Clinical Department
5959 Corporate Dr., Suite 1300
Houston, TX 77036

3. Fax to 866-959-1537

Requests for coverage of a drug under Part D

You or your appointed representative can ask for a coverage decision in one of these ways:

1. Call Pharmacy Member Services at 833-232-1711 (TTY: 711) 24 hours a day, 7 days a week.

2. Mail to:
Wellpoint
Attention: Pharmacy Department
P.O. Box 47686
San Antonio, TX 78265-8686

3. Fax to: 844-494-8342

4. Submit a Coverage Determination form

Your doctor can submit a request on your behalf through the online prescriber portal.

If the answer is, “No,” we’ll send you a letter telling you our reasons for saying, “No.” If we say, ”No,” you have the right to ask us to reconsider – and change – this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage. You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision.

The Health and Human Services (HHS) Office of the Ombudsman helps act as a neutral party to solve members’ problems with their health plan.

The HHS Office of the Ombudsman works as an advocate on your behalf. They can answer questions if you have a problem or complaint and can help you understand what to do. The HHS Office of the Ombudsman also helps people enrolled in Texas Medicaid with service or billing problems. They are not connected with our plan or with any insurance company or health plan. The HHS Office of the Ombudsman is an independent program, and their services are free.

You can reach the Office of the Ombudsman at 866-566-8989 (TTY: 800-735-2989) Monday through Friday from 8 a.m. to 5 p.m. Central time.