2023 Member Resources & Forms

Coverage decisions are decisions we make about your benefits or coverage or about the amount we will pay for Part C medical services or Part D drugs. A coverage decision about Part C medical services is called an “organization determination.” A coverage decision about Part D drugs is called a “coverage determination.” Coverage determinations and organization determinations are the first step in addressing problems you may have regarding medical or prescription drug benefits, coverage or payment amounts.

Who may ask for a coverage decision?

You, your prescribing physician, or someone you name may ask us for a coverage determination. Other persons may be authorized under state law to act on your behalf.

Asking for a “standard” or “fast” coverage determination or organization determination

To ask for a “standard” or “fast” decision for a Part D drug or Part C medical care, you, your doctor or your representative should call, fax or write to us at the addresses and numbers listed below under Part D Coverage Determinations or Part C Organization Determinations.

For Part C Organization Determinations:

Mailing Address:

Gold Kidney Health Plan Inc.

Attention: Utilization Management Dept.

P.O. Box 14050

Scottsdale, AZ 85267

Phone: 1-844-294-6535
TTY Users: 711
Fax: 1-866-515-7869 Attention: Utilization Management Dept.

For Part D Coverage Determinations:

Mailing Address:

MedImpact

Attention: Appeals & Grievances Dept.

10181 Scripps Gateway Court

San Diego, CA 92131

Phone: 888-672-7206

Fax: 858-790-6060

Webpage: https://mp.medimpact.com/partdappeal

Most standard coverage determination requests are requests for exceptions to our rules or restrictions that apply to a certain drug. These requests require that your doctor or other prescriber submit a written statement giving the medical reasons for requesting an exception to our rules or restrictions.In these cases, we must give you our decision no later than 72 hours after we receive your doctor’s or prescriber’s statement supporting your request.

For a standard coverage determination about a request for payment for a Part D drug you have already purchased, we must give you our decision no later than 14 days after we receive your request. If our decision is favorable, we must also make payment to you within 14 days after we received your request.If these standard deadlines could cause serious harm to your health, you can ask for a “fast” or “expedited” coverage determination.

If your doctor or other prescriber tells us you need a fast coverage determination, we will automatically agree to give you one. For a fast coverage determination about a Part D drug, we will give you our decision within 24 hours. This usually means 24 hours after we receive a written statement from your doctor or other prescriber supporting your request.

For Part C Coverage Determinations:

Mailing Address:
Gold Kidney Health Plan Inc.
Attention: Utilization Management Dept.
P.O. Box 14050
Scottsdale, AZ 85267

Phone: 1-844-294-6535

TYY Users: 711

Fax: 1-866-515-7869

Attention: Utilization Management Dept.

For a standard organization determination, we must give you our decision within 14 days after we receive your request. However, we may take up to 14 additional days if you ask for more time or if we need more information to help us with our decision. We will let you know in writing if we need extra time to make our decision.If the standard organization determination deadlines could result in serious harm to your health, you can ask us for a “fast” or “expedited” organization determination. If your doctor tells us you need a fast organization determination, we will give you one automatically. For a fast organization requirement, we will answer your request within 72 hours. However, we may take up to 14 more days if you need more time to prepare for this review or we need additional information from you or your doctor.