What is an organization determination or coverage decision?
An organization determination is a decision your health plan makes regarding a request by you, your authorized representative or a physician for the Plan to cover health services, a payment request of a claims for services you have already received or increased coverage for services your are already receiving. This is also called a coverage decision. A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical care. A coverage decision is often called an "initial determination" or "initial decision." You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Asking for coverage decisions
You, your authorized representative or your physician can ask for us to cover medical services you feel you need such as medical equipment, physician services or other medical care which you think your health plan should covered. The Plan will make an organizational determination about whether to approve or deny your request for medical services.
Some services can only be approved if there is a recent visit or medical information from your physician which documents the need for the medical services, For example we cannot approve oxygen equipment without physician orders with information about clinical need and operating settings for the equipment. Usually we have 14 days to make a decision on your request for services you have not received. You ask for a fast decision because of an urgent health situation and then we will make our decision within 72 hours. If we do not approve the organizational determination request you will get a written denial notice with your appeal rights.
An Organization determination can also be a request for payment for services you have already received.
Sometimes when you get medical care, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). Usually we have 60 days to respond to your request if all the necessary information has been provided to make a decision.
Our plan can say yes or no to your request
When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision.
If we decide that the medical care is covered and you followed all the rules for getting the care or drug, we will pay for our share of the cost. If you have already paid for the service, we will mail your reimbursement of our share of the cost to you. If you have not paid for the service yet, we will mail the payment directly to the provider. (Chapter 3 of your Evidence of Coverage explains the rules you need to follow for getting your medical services covered.)
If we decide that the medical care is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.
How to ask us to pay you back or to pay a bill you have received
Send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records.
It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for medical services or drugs that are covered by our plan. Our plan covers up to the Medicare reimbursement rates less any copayment or coinsurance. Medicare providers are not meant to bill you for more than Medicare payment for covered Medicare services.
There may also be times when you get a bill from a provider for the full cost of medical care you have received. In many cases, you should send this bill to us instead of paying it. We will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly.
Mail your request for payment together with any bills or receipts to us at this address:For Medical Claims:
Attn: Member Services
P.O. Box 841569
Pearland, TX 77584-9832
You must submit your claim to us within 12 months of the date you received the service, item, or drug.For more detailed coverage information, please review your Evidence of Coverage.
You may call Member Services if you have questions about our coverage decision process at 1-877-853-9075. If you don’t know what you should have paid, or you receive bills and you don’t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us. Calls to this number are free. Hours are 8:00 a.m. to 5:00 p.m., Monday - Friday. During this period on Saturdays, Sundays, and holidays, calls are handled by our voicemail system. TTY 1-866-302-9336 (This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.) Calls to this number are free. This number is available Monday – Friday from 8:00 a.m. to 8:00 p.m.
What if I need someone else to submit this information for me?
If you need someone to file an organization determination, request for reimbursement or appeal on your behalf, you can name a relative, friend, advocate, doctor or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. Per Medicare guidelines in order for us to process a request from a representative of a Medicare member we require a valid Authorization of Representative (AOR) notice. To appoint a representative ,you must sign, date, and complete a representative form (Form CMS-1696 Appointment of Representative or other equivalent written notice). You can find more information about the Appointment of Representative (AOR) notice here:
Appointment of Representative Info and Form
What is an appeal?
You can find more information about Appeals and submitting an Appeal here:
Appeals and Grievances