Requesting an organization determination
- You have the right to ask your plan to provide or pay for items or services you think should be covered, provided, or continued. The decision by the plan is called an "organization determination." You, your representative, or your doctor can request an organization determination from your plan in advance to make sure that services are covered. If the plan denies coverage or payment after you receive services, that denial is the organization determination that you can appeal.
- If you think your health could be seriously harmed by waiting the standard 14 days for a decision, ask your plan for a fast or "expedited" decision. The plan must give you its decision within 72 hours if it determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.
- If the plan won't cover the items or services you asked for, you'll get a notice explaining why your plan fully or partially denied your request and instructions on how to appeal your plan's decision by requesting a reconsideration. If you appeal the plan’s decision, you may want to ask for a copy of your file containing medical and other information about your case. Your plan may charge you for this copy.
Your doctor or other prescriber (for prescription drug appeals) can request this level of appeal for you, and you don’t need to appoint them as your representative.
What if I disagree with the organization determination?
If you disagree with your plan's initial decision, you can file an appeal. The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.
- Level 1: Reconsideration from your plan
- Level 2: Review by an Independent Review Entity (IRE)
- Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA)
- Level 4: Review by the Medicare Appeals Council (Appeals Council)
- Level 5: Judicial review by a federal district court
If you have coverage through
, your appeal rights are different. The PACE organization will provide you with written information about your appeal rights.