When a coverage decision involves your medical care, it is called an organization determination.

Some examples of an organization determination are:

• If you want our plan to decide if we will cover certain medical care, you want and you believe that this care is covered by our plan
• If you have received and paid for medical care that you believe should be covered by the plan and you want to ask our plan to reimburse you for this care
• If you have received medical care that you believe should be covered by the plan, but we have said we will not pay for this care

You can ask us for an organization determination yourself, or your doctor or someone you have legally appointed to act on your behalf may do it for you. This person would be called your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. If you want someone other than your doctor, you must complete the Appointment of Representative Form. When we reference “you” on this page, we mean you, your doctor or your appointed representative. 

If your health requires a quick response, you can ask us to make a “fast decision,” which is also called an “expedited determination.” More information about standard organization determinations and expedited determinations is available within this section. 

Mail: Submit a written request for an organization determination to the address listed below. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care. 

Phone: You may call the customer service number on your ID card. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care. 

Fax: Fax a written request for an organization determination to the fax number listed below. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care.

Coverage Decisions for Medical Care Part C and B – Contact Information

For a standard organization determination, we will give you an answer as quickly as your health condition requires, but no later than 14 days after receiving your request. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request. 

However, for a request for a medical item or service, if we find that some information is missing that may benefit you or if you need more time to get information to us for our review, we can take up to 14 more calendar days to make our decision. We will let you know if we decide to do this. We cannot take extra time to make a decision if your request is for a Medicare Part B prescription drug. 

If you believe we should not take extra days, you can file a “fast” grievance, and we will give you an answer to your grievance within 24 hours. For more information about grievances, see Grievances. 

If we do not give you our answer within 14 calendar days (or, if there was an extended review period, by the end of that period), or within 72 hours if your request is for a Part B prescription drug, you have the right to file an appeal. See Appeals for more information. 

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals. 

If your request was for us to pay our share of the bill for medical care you already received, and we determine that the care you paid for was not covered or did not follow plan rules, we will send you a letter that says we will not pay for these services and why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals. 

If your health requires it, you can ask us for an expedited determination. To get an expedited determination, you must meet two requirements: 

You must be asking for coverage for medical care you have not yet received. You cannot ask for an expedited determination if your request is about payment for medical care, you have already received. 

Using the standard deadlines could cause serious harm to your health or hurt your ability to function. 

If your doctor tells us that your health requires an expedited determination, we will automatically agree to give you an expedited determination. 

If you ask for an expedited determination on your own without your doctor’s support, we will decide whether your health requires that we give you an expedited determination. If we decide your medical condition does not meet the requirements for an expedited determination, we will process your request as a standard organization determination and notify you of our decision to process your request as a standard determination by sending you a letter. Our letter will indicate that we will automatically give you an expedited determination if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard determination instead of an expedited determination. For more information about grievances, see Grievances. 

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals.

Coverage decision involves your Part D prescription drugs, it is called a coverage determination. 

Some examples of a coverage determination are: 

• If you ask us to make an exception^*, including: 
  • Asking us to cover a Part D drug that is not on the plan’s formulary (our list of covered drugs) 
  • Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get) 
  • Asking to pay a lower cost-sharing amount for a covered drug 
  • Asking us to pay for a prescription drug you have already bought 
  • If you ask us if a drug is covered for you and whether you satisfy any applicable coverage rules

^*Please note: If you are requesting an exception, you will also need to provide a supporting statement from your doctor or prescriber that explains the medical reason why you need the exception approved.

You can ask us for an organization determination yourself, or your doctor or someone you have legally appointed to act on your behalf may do it for you. This person would be called your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. If you want someone other than your doctor, you must complete the Appointment of Representative Form. When we reference “you” on this page, we mean you, your doctor or your appointed representative. 

If your health requires a quick response, you can ask us to make a “fast decision,” which is also called an “expedited determination.” More information about standard organization determinations and expedited determinations is available within this section. 

Mail: Submit a written request for an organization determination to the address listed below. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care. 

Phone: You may call the customer service number on your ID card. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care. 

Fax: Fax a written request for an organization determination to the fax number listed below. You may refer to your Evidence of Coverage, Chapter 2; see the section for Coverage Decisions for Medical Care.

Coverage Decisions for Part D Prescription Drugs – Contact Information

For a standard coverage determination about a drug, you have not yet received: 

• We will give you an answer as quickly as your health condition requires, but no later than 72 hours after receiving your request or your doctor’s supporting statement (if required). 
• Remember, if your coverage determination request is for an exception, a supporting statement from your doctor or prescriber that explains the medical reason why you need the exception is required; we will give you our answer within 72 hours after we receive your doctor’s or other prescriber’s supporting statement. 
• If we do not meet this deadline, we are automatically required to send your coverage determination request to level 2 of our appeals process. See Appeals for more information. 

For a standard coverage determination about payment for a drug you have already bought: 

• We will give you our answer within 14 calendar days after we receive your request 
• If we do not meet this deadline, we are automatically required to send your coverage determination request to level 2 of our appeals process. See Appeals  for more information. 

If your request is about a drug, you have not yet received and our answer is “YES” to all or part of what you requested, we must provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 72 hours after we receive your request or doctor’s statement supporting your request. 

If your request is about payment for a drug, you have already received and our answer is “YES” to all or part of what you requested, we must send any payment due to you within 14 calendar days after we receive your request. 

For any coverage determination request, if our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals.  

If your health requires it, you can ask us for an expedited determination. To get an expedited determination, you must meet two requirements: 

• You must be asking for a drug you have not yet received. You cannot ask for an expedited coverage determination if you are asking us to pay you back for a drug you already bought. 
• Using the standard deadlines could cause serious harm to your health or hurt your ability to function. 

If your doctor or other prescriber tells us that your health requires an expedited coverage determination, we will automatically agree to give you an expedited determination. 

If you ask for an expedited coverage determination on your own without your doctor’s support, we will decide whether your health requires that we give you an expedited determination. If we decide your medical condition does not meet the requirements for an expedited coverage determination, we will process your request as a standard coverage determination and notify you of our decision by sending you a letter. Our letter will indicate that we will automatically give you an expedited coverage determination if your doctor requests it. You will also be provided with information about your right to file a “fast” grievance about our decision to give you a standard coverage determination instead of an expedited coverage determination. For more information about grievances, see Grievances. 

If you meet the requirements for an expedited coverage determination, we will give you an answer as quickly as your health condition requires, but no later than 24 hours after receiving your request or your doctor’s supporting statement (if required). 

• If we do not meet this deadline, we must automatically send your coverage determination request to level 2 of our appeals process. For more information see Appeals

If our answer is “YES” to all or part of what you requested, we will provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 24 hours after we receive your request or doctor’s statement supporting your request. 

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. You have the right to ask us to reconsider this decision by submitting an appeal. To learn more about submitting an appeal, see Appeals . 

If you appeal, Preferred Care Partners review the decision. If any of the items/services or Part B drugs you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of our Medicare Advantage Organization or prescription drug plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens. 

Timing of the appeal answer depends on the type of request. 

Fast Decisions/Expedited Appeals 

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize: 

• your life or health, or 
• your ability to regain maximum function. 

If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus fourteen (14) calendar days, if an extension is taken, after receiving the request.  For Part B drugs, your Medicare Advantage plan will provide a decision as fast as possible, but no later than 24 hours in Time-Sensitive situations with no allowable extensions. 

If we do not give you our answer by the deadlines noted above, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.  

If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 30 calendar days if your request is for a medical item or service, or within 7 calendar days if your request is for a Medicare Part B prescription drug. 

If you requested us to pay you back for medical care you already received: If the independent review organization decides we should pay, we must send you or the provider the payment within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days (65 calendar days beginning in 2025). We must give you our answer within 60 calendar days (65 calendar days beginning in 2025) after we receive your appeal. 

If our answer is “NO” to all or part of what you requested, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.  

If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal. 

If our answer is “NO” to part or all of what you requested, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. 

The Independent Review Organization will review your appeal. This organization is hired by Medicare and is not connected with Preferred Care Partners and is not a government agency. We send the information about your appeal to the organization. You have the right to provide the organization with additional information to support your appeal. 

If you had a standard Level 1 Appeal, you would have a standard Level 2 Appeal. 

• The organization must give you an answer within 30 calendar days of when it receives your appeal. If your request is for a Medicare Part B prescription drug, the organization must give you an answer within 7 calendar days of when it receives your appeal. 
• If the organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The Independent Review Organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. 

If you had a fast Level 1 Appeal, you would have a fast Level 2 Appeal. 

• The organization must give you an answer within 72 hours of when it receives your appeal. 
• If the organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The Independent Review Organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.  

If the organization’s answer is “YES” to all or part of what you requested for a standard appeal, we must authorize the coverage within 72 hours or provide the service within 14 calendar days after we receive its decision; and if the organization’s answer is “YES” to all or part of what you requested for a fast appeal, we must authorize the coverage within 72 hours after we receive its decision. If the organization’s answer is “YES” to all or part of a standard appeal request for a Medicare Part B prescription drug, we must authorize or provide coverage within 72 hours after we receive its decision; and if the organization’s answer is “YES” to all or part of a fast appeal request for a Medicare Part B prescription drug, we must authorize or provide the coverage within 24 hours after we receive its decision. 

If the organization’s answer is “YES” to your request about a payment we denied for medical services, we must send the payment you requested within 30 calendar days to you or the provider. 

If the organization’s answer is “NO” to part or all of what you requested, it means it agrees with us that your request or part of your request should not be approved. The organization will send you a letter explaining its decision and that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.  

For a standard Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 7 calendar days after we receive your appeal. 

• We will give you our decision sooner if you have not received the drug yet and your health requires it. 
• If we do not give you our answer within 7 calendar days, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal.

If you are requesting that we pay you back for a drug you have already bought, we must give you our answer within 14 calendar days after we receive your request. If we do not give you our answer within 14 calendar days, we are required to send your request to the Independent Review Organization as a Level 2 Appeal. 

If you requested coverage for a drug and our answer is “YES”, we must provide the coverage we have agreed to provide as quickly as your health condition requires, but no later than 7 calendar days after we receive your appeal. 

If you requested us to pay you back for a drug you already bought and our answer is “YES”, we are required to send you payment within 30 calendar days after we receive your appeal. 

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why. This notice will also provide information on how to appeal your decision as a Level 2 Appeal. 

If your health requires it, you can ask us for a “fast” appeal. To get a fast appeal, you must meet two requirements: 

• You must be asking for a drug you have not yet received. You cannot ask for a fast appeal if you are asking us to pay you back for a drug you already bought. 
• Using the standard deadlines could cause serious harm to your health or hurt your ability to function. 

If your doctor or other prescriber tells us that your health requires a fast appeal, we will automatically agree to give you a fast appeal. 

If you ask for a fast appeal on your own without your doctor’s or other prescriber’s support, we will decide whether your health requires that we give you a fast appeal. If we decide your medical condition does not meet the requirements for a fast appeal, we will process your request as a standard appeal and notify you of our decision to process your request as a standard appeal by sending you a letter. Our letter will indicate that we will automatically give you a fast appeal if your doctor or other prescriber requests it. We will also provide you with information about your right to file a “fast” grievance about our decision to give you a standard appeal instead of a fast appeal. For more information about grievances, see Grievances (Complaints). 

For a fast Level 1 Appeal, we will give you an answer as quickly as your health condition requires but no later than 72 hours after we receive your appeal. If we do not give you our answer within 72 hours, we will automatically send your appeal to the Independent Review Organization as a Level 2 Appeal. 

If our answer is “YES” to all or part of what you requested, we must authorize or provide the coverage we have agreed to provide as quickly as your health condition requires but no later than 72 hours after we receive your appeal. 

If our answer is “NO” to part or all of what you requested, we will send you a letter that explains why we said no and how to appeal our decision as a Level 2 Appeal.

If we say no to your appeal, you then choose whether to accept this decision or continue by submitting another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. This organization is hired by Medicare and is not connected with Preferred Care Partners and is not a government agency. 

To file a Level 2 Appeal, you must contact the Independent Review Organization listed in the letter we sent you when we said “NO” to your Level 1 Appeal. This letter also includes instructions on how to file a Level 2 Appeal, including deadlines for contacting the organization. If you do file a Level 2 Appeal, we will send the information we have about your appeal to the organization. You have the right to provide the organization with additional information to support your appeal. 

For a standard Level 2 Appeal, the organization must give you an answer within 7 calendar days of when it receives your appeal. 

If your health requires it, you may ask the organization for a fast Level 2 Appeal. If the organization agrees to a fast appeal, it must give you an answer within 72 hours of when it receives your appeal. 

If your appeal was for coverage of a drug and the organization’s answer is “YES” to all or part of what you requested, we must provide the drug coverage: 

• Within 72 hours after we receive the organization’s decision if it was a standard Level 2 Appeal 
• Within 24 hours after we receive the organization’s decision if it was a fast Level 2 Appeal 

If your appeal was for us to pay you back for a drug you already bought and the organization’s answer is “YES” to all or part of what you requested, we must send payment to you within 30 calendar days after we receive the organization’s decision. 

If the organization’s answer is “NO” to part or all of what you requested, it means it agrees with us that your request or part of your request should not be approved. The organization will send you a letter explaining its decision and that tells you the dollar value that must be in dispute for you to continue with the appeals process. If your case meets these requirements, you decide if you would like to continue the appeals process.