An “organization determination” is a decision we make about your medical benefits and coverage or about the amount we will pay for your medical services. This includes asking our plan to authorize, provide, or pay for medical services, including the type or level of services, you believe you should receive.
You can ask us for an organization determination yourself, or your doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. If you want someone to act for you, then you and that person must sign and date the Appointment of Representative form that gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address. This form does not have to be completed if your doctor is submitting a request.
To initiate an organizational determination for your Part C plan, start by calling, writing, or faxing our plan to make your request for the type of coverage decision you want.
|Contact us by mail:||Contact us by phone or fax:|
PO Box 2888
Houston, TX 77252
- Phone Number: 1 (800) 668-3813
- TTY/TDD: 711
- Fax Number: 1(877) 809-0783
- 8 am to 8 pm, 7 days a week (your local time)
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 2 requirements:
- You are asking for coverage for medical care or a drug you have not yet received; and
- 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||Decisions About Part D Prescription Drugs|
*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.
You have the right to file a complaint:
If you have a complaint, you can submit feedback directly to Medicare using the Medicare Complaint form at https://www.medicare.gov/medicarecomplaintform/home.aspx (English) / https://www.medicare.gov/MedicareComplaintForm/home.aspx?language=Spanish (en Español).