Coverage Determinations

FOR MEDICAL CARE COVERAGE DETERMINATIONS AND MEDICAL CARE PAYMENT REQUESTS:

If your provider tells you that a service is not covered by the Plan or Medicare and you believe it should be covered, you can request a coverage determination (coverage decision). You can also request a coverage decision if there is a prior authorization restriction or other limitation for a service or item, or if you feel you are paying more than you should be.

To request a coverage decision on a medical service/item, you or your doctor can:

Call Member Services: 1-833-999-0103

Write to us at: Farm Bureau Advantage Prior Authorizations P.O. Box 240, Columbia, TN 38402-9966

If you need to request a coverage decision on a prescription drug, you or your doctor can:

Log on to optumrx.com and submit a request. New users will be required to register.

To make a payment request you can:

Call Member Services: 1-833-999-0103

Write to us at: Farm Bureau Advantage c/o Payment Requests P.O. Box 240, Columbia, TN 38402-9966

What happens if we deny your medical service or payment request?

If we deny your request, we will send you a written reply explaining the reasons for denial. You have the right to appeal if you are not satisfied with the initial decision. See the Farm Bureau Medicare Advantage "Appeals" section for more information. You can also click here to visit Medicare’s website for information on how to make an appeal.

To file a complaint, click here to go to Farm Bureau Advantage’s Grievance page.

FOR PRESCRIPTION DRUG COVERAGE DETERMINATIONS AND PAYMENT REQUESTS:

If your pharmacy tells you that a prescription drug is not covered and you believe it should be covered, you can request a coverage determination (coverage decision). You can also request a coverage decision if there is a prior authorization restriction or quantity limit for a drug, or if you feel you are paying more than you should be.

To request a Prescription Drug coverage decision, you or your provider can:

Call Member Services: 1-866-868-2495

Write to us at: Optum Rx c/o Prior Authorization P.O. Box 2975, Mission, KS 66201

Fax your request to us at 1-844-403-1028; or

Log on to optumrx.com and submit a request. New users will be required to register.

To make a payment request for a Prescription Drug:

Call Member Services: 1-866-643-6924

Write to us at: Farm Bureau Advantage Attn: Medicare Part D 6860 W. 115^th Street,  Overland Park, KS 66211

The Medicare Prescription Drug Coverage Determination Request Form is available for your use, however, it is not required.

Medicare Prescription Drug Coverage Determination Request Form – for use by members and providers. This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members.

A standard coverage determination request will be reviewed, and a decision made within 72 hours of receiving your request or your prescribing doctor’s statement.

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite the decision is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

What happens if we deny your prescription drug coverage or payment request?

If we deny your request, we will send you a written reply explaining the reasons for denial. You have the right to appeal if you are not satisfied with the initial decision. See the Farm Bureau Medicare Advantage Prescription Drug "Appeals" section for more information. You can also click here to visit Medicare’s website for information on how to make an appeal.

For more information from Medicare on how to file a complaint, click here to go to Medicare.gov.

To request information for Aggregate Number of Grievances, Appeals and Exceptions to Grievances please call Member Services.