Organization Determinations

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, an enrollee's representative, or any provider that furnishes, or intends to furnish, services to an enrollee, may request a standard organization determination by filing a request with the health plan. Expedited requests may be requested by an enrollee, an enrollee's representative, or any physician, regardless of whether the physician is affiliated with the health plan.

For more information about appointing a representative, see 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 more information about how a health plan processes expedited organization determinations, see section 50 of Chapter 13 of the Medicare Managed Care Manual 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 paying for an item or service. For more information about how a health plan processes standard organization determinations, see sections 30 and 40 of Chapter 13 of the Medicare Managed Care Manual in the "Downloads" section below.

For a chart illustrating the managed care appeals process, click on the "Managed Care Appeals Flow Chart" in the "Downloads" section below. 

Downloads
Chapter 13 - Medicare Managed Care Manual [PDF, 764KB] Managed Care Appeals Flow Chart [PDF, 44KB]
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Page Last Modified: 04/14/2010 5:35:29 PM
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