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Provider Reference Tools & Resources

Member Rights and Responsibilities

Claims Coding Resources

Guidelines for claim coding & inquiry processes. Visit our Provider Education Materials page.

Help Honor Your Patients’ Wishes.Our physicians and practitioners should discuss advance directives with their patients (as appropriate) and file a copy of any advance directive document (e.g., living will, durable power of attorney for health care, health care proxy or do not resuscitate (DNR) request) in a prominent place within the medical record. Each medical record that contains an advance directive should clearly indicate that said document is included.

Prior Authorization for Medical Care
Timeframes for Authorization Requests

Ultimate Health Plans processes authorization requests according to the following general time frames, which comply with Medicare guidelines:

  • Standard- decision within 14 calendar days from the date of request.
  • Expedited- decision within 72 hours from the date of the request (including weekends and holidays). Conditions meeting criteria for expedited review include an imminent or serious threat to the health of the Member, including, but not limited to, severe pain, potential loss of life, limb or major bodily function. Please, only submit authorizations for expedited review if you can support that the above criteria applies to your request.

NOTE: Please ensure that your authorization request includes adequate documentation and/or information to medically support the request. If the information submitted is not adequate, the determination will be based upon the available information and/or lack of medical information. To expedite the process and to ensure appropriateness of the decision, it is very important that relevant clinical information be submitted with the request.

Request for Extensions: Ultimate may extend the decision time frame up to 14 calendar days. This extension is allowed if the enrollee requests the extension or if the provider or Ultimate can justify a need for additional information and documents how the delay is in the best interest of the enrollee.

Pharmacy Policies and Forms

Prescription Drug Determination Requests

The Prescription Drug Determination Request Form can be used for the following:

  • To request prior authorization for prescription drug that requires it.
  • To request prior authorization for a drug designated as a high-risk medication.
  • To request that we cover a non-formulary drug.
  • To request that we waive quantity limit on a drug.
  • To request that a drug be covered at a lower tier.
  • To request that we waive the requirement to try an alternative drug first.

Appeals for Part D Prescription Drugs

To file an appeal (request for redetermination) for a Medicare prescription drug denial please have your provider complete the form below:

Drug Transition Policy

Ultimate Health Plans will cover a Transition Supply for enrollees who have a level of care change. We will provide the member with a written notice after we cover the Transition Supply. This notice will explain the steps they can take to request an exception and how to work with their doctor to decide if they should switch to an appropriate drug that we cover. These reference guides were specifically designed for our providers to quickly outline the benefits offered under each plan. For the full list of benefits and descriptions, visit our Plan Documents page.

Inflation Reduction Act – Insulins and Vaccines

We care about our members’ health and their ability to afford medications. That is why we are pleased to share information on new legislation passed in August 2022, known as the Inflation Reduction Act (IRA). All Medicare Advantage Plans with drug coverage are required to enhance benefits around insulin and vaccines, effective January 1, 2023.

Insulin cost-sharing is $35 or less each month

Starting January 1, 2023, members enrolled in a Medicare prescription drug plan will not pay more than $35 for a 1-month supply of each insulin they take that is covered by their Medicare prescription drug plan and dispensed at a retail pharmacy or through a mail-order pharmacy. In addition, Part D deductibles won’t apply to the covered insulin product.

Vaccine cost-sharing, $0 for shingles and other vaccines

Starting January 1, 2023, adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), including the shingles vaccine, will be available to members through their Medicare prescription drug plan at no cost.

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