Part C Coverage Decisions & Prior Authorization

You, an authorized representative or your physician/provider can ask for a coverage decision by calling 1-844-282-3026, five days a week from October 1 – March 31, seven days a week from 8 a.m. to 8 p.m., local time; or April 1 –September 30. TTY users (for people with hearing and speech difficulties) can call 711.

You may also write a coverage decision request and fax it to 1-844-357-7562 or mail it to:

CHRISTUS Health Plan
PO Box 169009
Irving, TX 75016

After hours, members or physician can leave a message, including the member’s name and contact phone number, and we’ll get back to you the next business day.

For a non-emergent request, CHRISTUS Health Plan will give you a decision within 14 days of receiving the request. If the service is approved, we’ll notify you or your provider by phone or electronically.

If your medical condition requires a fast decision, you can request an expedited coverage decision, also known as an expedited determination. Expedited coverage decisions can only be requested for medical care you have not yet received and because using the standard timeline could cause serious harm to your health, life or ability to function. 

 

There are two ways to request an expedited coverage decision:

• If your provider notifies us that you need a fast decision (orally or in writing), we will automatically provide an expedited coverage decision.
• If you request the expedited decision without a physician’s notification by calling 1-844-282-3026, CHRISTUS Health Plan will decide if the standard time could jeopardize your health, life or ability to regain maximum function. If we decide that your condition doesn’t meet requirements for a fast decision, we will call your provider and send a letter notifying you and your provider that the standard timeline will be followed.

For expedited coverage decisions, CHRISTUS Health Plan will provide a decision within 72 hours of receipt.

 

Open seven days a week, 8:00 a.m. to 8:00 p.m., local time, from October 1 – March 31, and Monday – Friday, 8:00 a.m. to 8:00 p.m., local time, from April 1 – September 30. A voice response system is available after hours. 

In some cases, we might decide that a service is not covered or is no longer covered by your plan. If we deny part or all of the service, you have the right to file an appeal or grievance.

To qualify for coverage on some services, your provider may need prior authorization. Prior authorization means getting approval on medical services from CHRISTUS Health Plan before they are provided. If your care requires prior authorization and your provider or hospital doesn’t get it, the services and costs may not be covered.

Services that require prior authorization are listed in your Evidence of Coverage. You can also call the phone number on the back of your ID card to verify services that need authorization. If it’s needed, your physician or provider can complete a Prior Authorization Request Form.