Organizational & Coverage Determinations
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Organizational & Coverage Determinations

What is an organizational determination?

An organizational determination is a decision we make about whether medical items or services are covered. Organizational determinations are also called service decisions.
 

What is a coverage determination?

A coverage determination is a decision we make about whether a drug is covered by the plan. Coverage determinations are also called coverage decisions.
 

Asking for an organizational or a coverage determination
You, your doctor, or your representative can contact us and ask for an organizational or coverage determination if your doctor is unsure whether we’ll cover a particular medical service or drug, or if we refuse to provide medical care or a drug you think that you need. In other words, if you want to know if we’ll cover a medical service or drug before you receive it, you can ask us to make an organizational or coverage determination. You may appoint an individual to act as your representative by filling out a Appointment of Representative Form.

There are two ways you, your doctor, or your appointed representative may request an organizational or drug coverage determination:

Call us at 1-866-610-2273 (TTY 711).
 
Mail or fax 

Submit your written appeal to:
Commonwealth Care Alliance
Member Services
30 Winter Street
Boston, MA 02108
Fax: 1-855-341-0720
 

How long will it take to get a decision?
When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard organizational decision means we will give you an answer within 14 days after we receive your request.

A fast organizational decision means we will answer within 72 hours.

To get a fast organizational decision, you must meet two requirements: If your doctor tells us that your health requires a "fast decision," we will automatically agree to give you a fast organizational decision.

  • You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
  • You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.


If you ask for a fast decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.

In some cases, we might decide that a medical service is not covered or is no longer covered by Medicare. If you disagree with this service decision, you can make a medical care appeal.

If you don’t agree with a drug coverage determination, you have the right to make a pharmacy appeal.

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