Organization Determinations

An organization determination is any decision made by a Medicare health plan regarding:

1. Authorization or payment for a health 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.

How to Request an Organization Determination

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. Standard or expedited requests for benefits may be made verbally or in writing.  Standard requests for payment must be made in writing, unless the health plan accepts requests verbally.  

For more information regarding organization determinations, and appointment of a representative to assist with these, see section 40 and section 20 (respectively), of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance 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.