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 a 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 regarding how a Medicare health plan processes standard organization determinations, see sections 30 - 50 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.