What is a coverage determination?
A process in which the awarding body or any other interested party (such as a contractor, employee, union or labor-management compliance organization) may request a written determination by the director of the Department of Industrial Relations about a specific construction project or type of work to be performed.
The following are the utilization management tools requiring coverage determination to be requested that are currently utilized by Windsor Rx: • Prior Authorization (3 types) • Prior Authorization (whether New Start or not) • Prior Authorization for New Starts • Prior Authorization Part B versus Part D • Exception (5 types) • Quantity Limit Exception • Step Therapy Exception • Non-formulary Exception • Tiering Exception • Prior Authorization Exception
