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Organization Determination

What is an organization determination?

An organization determination is any determination (i.e. approval or denial) made by a Medicare health plan (e.g., ProCare Advantage) regarding:

  • Receipt of, or payment for, a managed care item or service;
  • The amount a health plan requires an enrollee to pay for an item or service; or
  • A limit on the number of items or services.
Where can an organization determination be filed?

The way you submit an organization redetermination depends on when your service is happening. If you are requesting an organization redetermination:

Before the service is performed: This is considered an authorization request, please contact our UM department at 1-844-206-3719 (TTY 711),  option #3.

After a service is provided: This is considered a claim so you should follow the procedures above for submitting a claim.

Our plan has fourteen (14) calendar days (for a standard organization determination request) or seventy-two (72) hours (for an expedited request) from the date it gets your request to notify you of its decision.

Who can 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 an oral or written request with ProCare Advantage.

Expedited requests may be requested by an enrollee, an enrollee’s representative, or any physician, regardless of whether the physician is affiliated with ProCare Advantage.

When can an organization determination be requested?

An organization determination made by ProCare Advantage can be requested with respect to any of the following:

  • Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services
  • Payment for any other health services furnished by a provider other than ProCare Advantage that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the ProCare Advantage
  • ProCare Advantage’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by ProCare Advantage
  • Reduction, or premature discontinuation of a previously authorized ongoing course of treatment
  • Failure of ProCare Advantage to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee
What is a standard determination?

If ProCare Advantage denies an enrollee’s request for an item, service in whole or in part, or any amounts the enrollee must pay for a service (issues an adverse organization determination), the enrollee may appeal the decision to the plan by requesting a reconsideration.

Who can request a standard or expedited determination?
  • An enrollee or an enrollee’s appointed or authorized representative may request a standard or expedited reconsideration.
  • A non-contract physician or provider to a Medicare Health plan may request a standard reconsideration without being appointed as the enrollee’s representative, on the enrollee’s behalf.
  • Non-contract providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal.  Waiver of Liability
  • A physician regardless of whether the physician is affiliated with the plan may request that a Medicare Health Plan expedite a reconsideration.

Contract providers do not have appeal rights.

How to request a determination?

Determination requests must be filed with the health plan within 60 calendar days from the date of the notice.

Expedited requests can be made either orally or in writing.

Standard requests must be made in writing unless the enrollee’s plan accepts oral requests. An enrollee should call the plan or check his or her Evidence of Coverage to determine if the plan accepts oral standard requests.

Where can an organization determination be filed?

You or your representative can request a standard or expedited organization determination by writing directly to us at:

Fax: 1-833-610-2380

ProCare Advantage
Appeals and Grievances Department
PO Box 5849
Glen Allen, VA 23058

Contact Member Services Department at our toll-free number at: 1-844-206-3719 (TTY 711)

Important things to know about asking for standard determination

A party must file the request for reconsideration within sixty (60) calendar days from the date of the notice of the organization’s determination. If a request for reconsideration is filed beyond the sixty (60) calendar day time frame and good cause for late filing is not provided, ProCare Advantage will forward the request to the independent review entity for dismissal.

Once the plan receives the request, it must make its decision and notify the enrollee of its decision as quickly as the enrollee’s health requires, but no later than 72 hours for expedited requests or 30 calendar days for standard requests, or 60 calendar days for payment requests.

Our plan can accept or deny your request. If we approve your request for a standard reconsideration, our approval is valid until the end of the plan year.

What is a good cause exception?

If a party shows good cause, ProCare Advantage may extend the time frame for filing a request for a standard determination. ProCare Advantage will consider the circumstance that kept the enrollee or representative from making the request on time and whether any organizational actions might have misled the enrollee.

Examples of circumstances where good cause may exist to file a late appeal include (but are not limited to) the following situations:

  • The enrollee did not personally receive the adverse organization determination notice, or he/she received it late;
  • The enrollee was seriously ill, which prevented a timely appeal;
  • There was a death or serious illness in the enrollee’s immediate family;
  • An accident caused important records to be destroyed;
  • Documentation was difficult to locate within the time limits;
  • The enrollee had incorrect or incomplete information concerning the reconsideration process; or
  • The enrollee lacked capacity to understand the time frame for filing a request for reconsideration.