Part C Organization Determination


ASKING FOR AN ORGANIZATION DETERMINATION FOR PART C DECISIONS

An organization determination is a type of coverage decision made by our plan with respect to medical care. This includes asking our plan to authorize, provide, or pay for services, including the type or level of services, that you believe you should receive.


Asking for an Organization Determination

Start by calling, writing, or faxing our plan to make your request for the type of coverage decision you want (organization determinations are a type of coverage decision made by our plan with respect to medical care). You, your doctor, or a representative can do this.


Contact Information for Organization Determinations

CALL

(Main) 305-559-5366
(Toll-free) 1-866-393-5366

Calls to this number are free. Seven days a week from 8:00 am to 8:00 pm

TTY

711

This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

Calls to this number are free. Seven days a week from 8:00 am to 8:00 pm

FAX

305-642-1144

WRITE

8600 NW 41st Street, Suite 201
Doral, FL 33166



If your health requires a quick response, you should ask our plan to make a Fast Decision. To get a Fast Decision, you must meet two requirements:

1. You are asking for coverage for medical care you have not yet received; and
   
2. Using the standard deadlines could cause serious harm to your health or hurt your ability to function. If your doctor tells us that your health requires a Fast Decision, we will automatically agree to give you a Fast Decision. If you ask for a Fast Decision on your own, our plan will decide whether your health requires that we give you a Fast Decision. Unless you ask for a Fast Decision, we will use the Standard Decision deadlines for giving you our decision.

The following table shows when you can expect our plan to give you a decision:

 
Decisions about Medical Care
Standard Decision
14 Days
Fast Decision
72 hours*

* We will give you an answer sooner if your health requires us to do so.

If you disagree with a coverage decision we have made, you can appeal our decision. For more information about organization determinations, coverage determinations, and appeals, see your Evidence of Coverage.

Have questions about process or status?

Call 1-866-393-5366