Coverage Determination and Appeals

CF-Health will provide Coverage Determination review (prior authorizations and formulary step therapy, and quantity limit exceptions) and first level redetermination (appeal) services. CF Health will provide the Client with all required CMS reporting and will ensure that all CMS requirements are met.

CF Health will provide a dedicated Helpdesk and fax line with unique phone and fax numbers for TMG Health. CF Health will provide a dedicated Clinical Services team to handle TMG Health account. Clinical justifications and completed forms will be maintained in our system and will be available for review by Client.

CF Health will prepare approval and denial letters for the prescriber and the member. CF Health will fax the provider letters to all prescribers that have fax numbers on file. The Client will be responsible for all postage and mailing costs for beneficiary letters and prescriber letters that are mailed. CF Health will provide a report of the approvals and denials which can be used by the Client to enter the authorizations into their respective system for online adjudication. CF Health can directly upload the decisions into the Client PBM software upon Client training and access at an additional cost.