Virginia Premier Gold
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Coverage Determinations & Exceptions - Provider

What is a Coverage Determination?
A coverage determination is any decision (an approval or denial) that Virginia Premier Gold makes when a member asks for coverage or payment of a drug that they believe Virginia Premier Gold should provide.

  • Physicians and members can ask for a coverage determination.
  • Members can also appoint someone (such as a relative) to request a coverage determination on their behalf.
  • You can ask for a standard coverage determination, Virginia Premier Gold will give you and the member a decision in 72 hours.
  • You can also ask for an expedited "fast" coverage determination if you or the member believes that their health could be seriously harmed by waiting up to 72 hours for a decision, Virginia Premier Gold will give you and the member an answer in 24 hours.

What type of Coverage Determination do I need?
There are different types of coverage determinations. Please click on the coverage determination type below for more information about the most commonly requested coverage determinations.

What can be done if a Coverage Determination is denied?

If Virginia Premier Gold denies the coverage determination the member or their representative has the right to request a redetermination appeal. Physicians have the right to request an expedited redetermination appeal on a member's behalf. Please see our section on Appeals and Grievances for information about member appeal rights, or contact our Member Services Department 8:00 a.m. - 8:00 p.m., seven days a week.

Telephone: 1-866-616-1041
TTY/TDD: 1-800-828-1120/1140

Click here for more information on Appeals & Grievances.

 
 
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