Coverage requests and determinations

Organization Determination

An organization determination is a decision CCA Health makes about whether medical items (e.g., a wheelchair) or services are covered. Organization determinations are also called service decisions.

Prior Authorization

Prior authorization means we need to review an item or service before we agree to cover it for you. Certain items and services require review by CCA Health before they are covered. This ensures that our members receive the right item or service with the best value for their condition.

Specific procedures for filing coverage requests and determinations are outlined in the document below.

Here are Centers for Medicare and Medicaid Services (CMS) model Redetermination and Coverage Determination Request forms developed specifically for use by all Part D prescribing physicians or enrollees. You may use the Model Part D Redetermination Request form or the Coverage Determination form. Both of these forms will be accepted.

Appointing a Representative

If you need someone to file an organization or coverage determination, or appeal on your behalf, you can name a relative, friend, advocate, doctor, or anyone else as your appointed representative. If you want someone to act for you, then you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative.

If you are making a request through an appointed representative, you should download form CMS-1696 (pdf).¹ 

If you have any questions about naming your appointed representative, you can call us at 855-959-5855 (TTY 711).