Organization Determinations
Guidance for any decision made by a Medicare health plan for an organization determination.
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: February 11, 2020
An organization determination is any decision made by a Medicare health plan regarding:
- Authorization or payment for a health care item or service;
- The amount a health plan requires an enrollee to pay for an item or service; or
- A limit on the quantity of items or services.
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 a request with the health plan. Expedited requests may be requested by an enrollee, an enrollee's representative, or any physician, regardless of whether the physician is affiliated with the health plan.
For more information regarding organization determinations, and appointment of a representative to assist with these, see section 40 and section 20 (respectively), of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance in the "Downloads" section below.
For a chart illustrating the managed care appeals process, click on the "Managed Care Appeals Flow Chart" in the "Downloads" section below.
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.