An organization determination is a decision we make about the medical care, including Part B drugs, that you are planning to receive or that you’ve paid out-of-pocket and believe should be covered. You, your appointed representative, or your doctor have a right to request us to make an organization determination.
Types of organization determinations
Request coverage for medical care
Your benefits for medical care are described in Chapter 4 of your plan’s Evidence of Coverage. If you are planning to receive a medical service or item and believe should be covered, you can ask for a coverage decision. The medical services or items may be subject to our prior authorization rules, learn more .
To submit a request for a standard review, Contact the Customer Care team by phone or send a message by logging into your member portal.
You can also write us at:Health Management Department, MS-1255
Priority Health Medicare
1231 East Beltline Ave. NE
Grand Rapids, MI 49525
Fax us at 888.647.6152
To help us better process your request, please include your full name, date of birth, address, contract number, and a brief description of your request.
When you’ll hear from us
- We must make a decision within 7 calendar days when the medical item or service is subject to our prior authorization rules, or 14 calendar days for all other medical items or services.
To submit a request for an expedited (fast) review, Contact the Customer Care team by phone or send a message by logging into your member portal. To get a fast coverage decision, you must meet 2 requirements:
- You may only ask for coverage for medical items and/or services (not requests for payment for items and/or services you already got).
- You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to regain function.
If your doctor tells us that your health requires a fast coverage decision, we’ll automatically agree to give you a fast coverage decision. If you ask for a fast coverage decision on your own, without your doctor’s support, we’ll decide whether your health requires that we give you a fast coverage decision.
When you’ll hear from us
- For accepted expedited (fast) reviews, we must make a decision within 72 hours.
Request coverage for a Part B medical drug
These include drugs you wouldn't usually give to yourself–like those you get at a doctor's office. Examples of drugs covered under Part B can include, but are not limited to:
- Drugs used with durable medical equipment, like nebulizer solutions or insulin when using an insulin pump
- Injectable and infused drugs
- Blood clotting factors
- Some oncology drugs
For Part B drug coverage requests, contact the Customer Care team by phone, send a message by logging into your member portal, or use a Medicare Part B drug request form (non-oncology) (PDF) or Medicare Part B oncology drug request (PDF) form.
When you’ll hear from us
- When you request a standard coverage decision, we will make a decision within 72 hours of receiving your request for a Part B drug.
- When you request an expedited (fast) coverage decision, we will make a decision within 24 hours of receiving your request. To get a fast coverage decision, you must meet 2 requirements:
- You may only ask for coverage for a Part B drug that you have not received already
- You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to regain function.
If your doctor tells us that your health requires a fast coverage decision, we’ll automatically agree to give you a fast coverage decision. If you ask for a fast coverage decision on your own, without your doctor’s support, we’ll decide whether your health requires that we give you a fast coverage decision.
Request for payment
This is for medical care (service or item) that you’ve paid out-of-pocket and believe should be covered, also known as filing a claim or requesting reimbursement.
For medical service or item payment requests, send us a request in writing within one year of the date you got the service, item, or Part B drug. To make sure you’re giving us all the information we need to make a decision, you can use the Medical claim reimbursement form (PDF) to make your request for payment.
When you’ll hear from us
We must make a decision within 60 calendar days of receipt of your request.
If you disagree with our decision
You, your appointed representative, or your prescriber can ask us to reconsider if you are not satisfied with our coverage decision. This is called “filing an appeal.” Learn how.
Appointment of Representative
If you want someone else, like a family member or friend, to act on your behalf, you can sign a form that makes the person your official “authorized representative." Learn how.