An organization determination is a decision we make about your benefits and coverage or about the amount we will pay or you may pay for your medical services. To receive coverage for the medical care you want, you, your doctor or your representative can start by calling, writing, or faxing us with your request.
If you disagree with an organization determination we have made, you can appeal our decision. (This plan review of a decision is also known as reconsideration.)
How to request an organization determination
Step 1: Start by calling, writing, or faxing us to make your request. You, your doctor, or your representative can do this.
For a standard organization determination, call or fax your request:
Or mail your request (or deliver it in person) to:
Attn: Medical Management Department
Health Partners Medicare
901 Market Street, Suite 500
Philadelphia, PA 19107
For an expedited organization determination, call or fax your request:
If your health status requires a fast (or expedited) decision, we will respond within 72 hours.
Step 2: We will review your request for medical care coverage and give you our answer, generally within 14 days from when we receive your request.
- If our answer is YES to part or all of what you requested, we must authorize or provide the services we have agreed to provide within 14 days from when we received your request. If we need more time to make our decision, we will notify you of the extended time frame. We will then give you a decision before this period ends.
- If our answer is NO to part or all of what you requested, we will send you a written statement that explains why we said no.
Step 3: If we say NO to your request, you have the right to request an appeal.