Find tools, information, and other resources to help you get the most out of your benefits.
What is an organization determination?
An organization determination (OD) is a decision made by the Medicare Health Plan regarding:
- Receipt of, or payment for, managed care item or service;
- The amount a Plan requires an enrollee to pay for an item or service; or
- A limit on the number of items or services.
This means ProCare Advantage will authorize, provide, or pay for medical services.
An enrollee, or any physician regardless of whether the physician is affiliated with the Plan may request for an Expedited Organization Determination (EOD) when an enrollee or his/her physician believes that waiting for a decision under the standard timeframe could place the enrollee’s life, health, or ability to regain maximum function is in serious jeopardy
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 the Plan.
Expedited requests may be made by an enrollee, an enrollee’s representative, or any physician, regardless of whether the physician is affiliated with Simpra Advantage.
If you want someone to act for you as your appointed representative, then you and the person must sign and date the Appointment of Representative (AOR) form that legally allows that person to act as your appointed representative. This form does not need to be filled out if your doctor is sending a request. The AOR must be faxed or mailed to us at
PO Box 5849
Glen Allen, VA 23058
Where can an organization determination be filed?
To start an organization determination, you must file a Preservice Organization Determination, also known as a Prior Authorization Request, by phone, mail, or fax.
Phone: 1-833-610-2399 (TTY 711)
Calls to this number are free.
8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30
PO Box 5849
Glen Allen, VA 23058
Once ProCare Advantage receives the request, it must make its decision and notify the enrollee of the decision as quickly as the enrollee’s health requires but no later than 14 days for standard medical requests, 72 hours for standard Part B medication requests, 72 hours for expedited medical requests, and 24 hours for expedited Part B medication requests.
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; or
- 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.
Important things to know about asking for standard determination
- Emergency services are excluded from prior authorization requirements.
- Our Plan can approve or deny your request. If we approve your request, our approval is valid until the end of the period stated in the approval notice.
If you do not agree with an organization’s determination you have the right to appeal our decision. More information on the appeal process and how to file an appeal can be found here: https://procareadvantageplan.com/for-members/exceptions-and-appeals/file-an-appeal/