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An organization determination is any decision made by a Medicare health plan regarding: 1. Receipt of, or payment for, a managed care item or service; 2. The amount that the health plan requires an enrollee to pay for an item or service; or 3. A limit on the quantity of items or services.
An enrollee, a physician, or an enrollee's representative may request an expedited organization determination by filing a request with the health plan. A physician may request a standard organization determination only if acting as an appointed representative for the enrollee. For more information about appointing a representative, see section 60.1.1 in Chapter 13 of the Medicare Managed Care Manual. You may view Chapter 13 of the Medicare Managed Care Manual by clicking on the "Downloads" section below. How to Request an Organization Determination Expedited requests may be filed orally or in writing. Standard requests must be filed in writing, unless the health plan accepts oral requests. How a Health Plan Processes Organization Determination Requests For expedited organization determination requests, a health plan must notify an enrollee of its organization determination within 72 hours after receiving the request. For a chart illustrating the managed care appeals process, click on the "Managed Care Appeals Flow Chart" in the "Downloads" section below. For standard organization determinations, a health plan must issue a decision about providing an item or service within 30 days, or 60 days for decisions about providing an item or service. For more information about how a health plan processes organization determinations, see section 30 of Chapter 13 of the Medicare Managed Care Manual in the "Downloads" section below.
Page Last Modified: 04/11/2008 5:28:31 PM
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