Organization Determination and Payment Request (Medical Part C)

What is an organization determination or coverage decision?

An organization determination, also called a coverage decision, is when your health plan decides whether it will cover a medical service or how much it will pay.

You, your doctor, or someone you choose can ask for this decision. You can ask before you get care to find out if it will be covered, or after you receive care to request payment.

For example, every time you get care from a network doctor or are referred to a specialist, the plan is making a coverage decision about what is covered and how much it will pay.

If the plan decides not to cover a service and you disagree, you have the right to appeal.

Asking for coverage decisions

You, your doctor, or your representative can ask the plan to cover a service you think you need, like medical equipment or doctor visits.

Some services require medical records from your doctor to show why the service is needed. For example, oxygen equipment must include a doctor’s order with details about your condition.

• Most decisions are made within 14 days
• If your situation is urgent, you can ask for a fast decision (within 72 hours)

If your request is denied, you will get a letter explaining why and how to appeal.

An Organization determination can also be a request for payment for services you have already received.

If you paid for care yourself, you can ask the plan to pay you back (this is called reimbursement).

• The plan usually responds within 60 days if all information is provided

Our plan can say yes or no to your request

If approved:

• The plan pays its share
• If you already paid, you will be reimbursed
• If not, the provider will be paid directly

If denied:

• You will get a letter explaining why
• The letter will include your appeal rights

How to ask us to pay you back or to pay a bill

Send your request along with your bill and any receipts. Keep copies for your records.

You have the right to be reimbursed if you paid more than your share for covered services. The plan pays based on Medicare rates (minus your copay or coinsurance).

If you receive a bill, you may want to send it to the plan instead of paying it right away. The plan will review it and decide whether to pay.

Mail your request to:

For Medical Claims:
KelseyCare Advantage
Attn: Member Services
P.O. Box 841569
Pearland, TX 77584-9832

Claims must be submitted within 12 months of the service date. For more details, check your Evidence of Coverage. 

How to contact us when you are asking for an Organization Determination (coverage decision about your medical care)

If you have questions or need help, call Member Services toll-free at 1-866-535-8343 (TTY 711).

• Oct 1 – Mar 31: 8 a.m. – 8 p.m., 7 days a week
• Apr 1 – Sept 30: 8 a.m. – 8 p.m., Monday–Friday

You can also mail or fax your request:
Fax: 713-442-5450

What if I need someone else to submit this information for me?

You can choose someone to act for you, like a family member, friend, or doctor. This person is called your appointed representative.

To do this, both you and the person must sign a form giving them permission. This is required by Medicare.

You can use Form CMS-1696  Appointment of Representative Info and Form

What is an appeal?

An appeal is when you ask the plan to review a decision you don’t agree with.

You, your representative, or your doctor can request an appeal within 65 days of the decision. If you miss the deadline, you may still be allowed more time if you have a good reason.

During an appeal (also called a reconsideration), the plan reviews your case again to make sure the decision was fair. The plan may ask for more information from you or your doctor.

For more details about the appeal process, see your Evidence of Coverage.

Who can file an appeal?

You, your doctor, or someone you choose to represent you can request an appeal. This can be a standard or fast (expedited) appeal.

You may qualify for a fast appeal if waiting for a standard decision could seriously harm your health. This can be determined by the plan or supported by your doctor.

The timelines for decisions are listed below:

How do you file an appeal?

If you received the service or medication, your appeal must be sent in writing by you, your representative, or your doctor. Your request should include:

• Your name, address, and member ID number
• The service or item you’re appealing, including the date(s) you received it
• Your signature
• Any extra information that may support your request
• If you have not yet received the service or medication, you can submit your appeal in writing, in person, or by phone.

How to contact us when you are making an appeal:

1-866-535-8343 (TTY: 711) 

Download the Waiver of Liability Statement

What about coverage decisions regarding Part D prescription drugs?

Click here to read more information about Part D Coverage Decisions.