Organization Determination and Payment Request (Medical Part C)

What is an organization determination or coverage decision?

An organization determination is a decision your health plan makes regarding a request by you, your authorized representative, or a physician for the plan to cover health services, a payment request of a claims for services you have already received, or increased coverage for services you are already receiving. This is also called a coverage decision. A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical care. A coverage decision is often called an "initial determination" or "initial decision." You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Asking for coverage decisions

You, your authorized representative, or your physician can ask us to cover medical services you feel you need, such as medical equipment, physician services, or other medical care you think your health plan should cover. The plan will make an organizational determination about whether to approve or deny your request for medical services.

Some services can only be approved if there is a recent visit or medical information from your physician which documents the need for the medical services. For example, we cannot approve oxygen equipment without physician orders with information about clinical need and operating settings for the equipment. Usually, we have 14 days to make a decision on your request for services you have not received. You may ask for a fast decision because of an urgent health situation and then we will make our decision within 72 hours. If we do not approve the organizational determination request, you will get a written denial notice with your appeal rights.

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

Sometimes, when you get medical care, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). Usually, we have 60 days to respond to your request if all the necessary information has been provided.

Our plan can say yes or no to your request

When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision.

If we decide that the medical care is covered, and you followed all the rules for getting the care or drug, we will pay for our share of the cost. If you have already paid for the service, we will mail your reimbursement of our share of the cost to you. If you have not paid for the service yet, we will mail the payment directly to the provider. (Chapter 3 of your Evidence of Coverage explains the rules you need to follow for getting your medical services covered.)

If we decide that the medical care is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.

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

Send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records.

It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for medical services or drugs that are covered by our plan. Our plan covers up to the Medicare reimbursement rates less any copayment or coinsurance. Medicare providers are not meant to bill you for more than Medicare payment for covered Medicare services.

There may also be times when you get a bill from a provider for the full cost of medical care you have received. In many cases, you should send this bill to us instead of paying it. We will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly.

Mail your request for payment together with any bills or receipts to us at this address:
For Medical Claims:
KelseyCare Advantage
Attn: Member Services
P.O. Box 841569
Pearland, TX 77584-9832

You must submit your claim to us within 12 months of the date you received the service, item, or drug.

For more detailed coverage information, please review your Evidence of Coverage.

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

You may call Member Services if you have questions about our coverage decision process at 1-866-535-8343. If you don’t know what you should have paid, or you receive bills and you don’t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us. Calls to this number are free. From October 1 through March 31, hours are 8 a.m. to 8 p.m., seven days a week. During this period on Thanksgiving Day and Christmas Day, calls are handled by our voicemail system. From April 1 through September 30, hours are 8 a.m. to 8 p.m., Monday through Friday. During this period on Saturdays, Sundays, and holidays, calls are handled by our voicemail system. TTY 711 (This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.) Calls to this number are free. This number is available Monday – Friday from 8 a.m. to 8 p.m.

You can also write to us at:
KelseyCare Advantage
Attn: Member Services
P.O. Box 841569
Pearland, TX 77584-9832
Fax: 713-442-5450

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

If you need someone to file an organization determination, request for reimbursement, 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. Per Medicare guidelines, in order for us to process a request from a representative of a Medicare member, we require a valid Authorization of Representative (AOR) notice. To appoint a representative, you must sign, date, and complete a representative form (Form CMS-1696 Appointment of Representative or other equivalent written notice). You can find more information about the Appointment of Representative (AOR) notice here: Appointment of Representative Info and Form

What is an appeal?

An appeal is a special kind of complaint you can make if KelseyCare Advantage refuses to cover something you think should be covered. If you disagree with the plan’s initial decision (organization determination), you, your representative, or your treating physician can request an appeal, but you must make your request within 60 days from the date of the organization determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.

Requesting an appeal means asking us to reconsider—and possibly change—the decision we made. An appeal to the plan about an organization determination is called a plan “reconsideration.” Please refer to your Evidence of Coverage that discusses the five levels of appeals. When our plan is reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were being fair and following all the rules when we said no to your request. We may contact you or your doctor to get more information.

Who can file an appeal?

You, your representative, or your treating physician can ask for a standard or fast appeal. You will get a fast decision if we determine, or your physician tells us that your life or health may be at risk by waiting for a standard decision. The decision request deadlines are as follows:

How do you file an appeal?

For standard appeal requests, you or your representative, or your treating physician must make your request to us in writing if services or medication have been provided. Your written reconsideration request should include:

• Your name, address, and your member ID number.
• The items or services for which you’re asking for a reconsideration and the dates of service.
• Your signature.
• You should also include any other information that may help your case.
• If you have not received the service or medication, appeals are accepted by us in writing, in person, or over the phone.

How to contact us when you are making an appeal:

1-866-535-8343

Hours of Operation: From October 1 through March 31, hours are 8 a.m. to 8 p.m., seven days a week. During this time period on Thanksgiving Day and Christmas Day, calls are handled by our voicemail system. From April 1 through September 30, hours are 8 a.m. to 8 p.m., Monday through Friday. During this time period on Saturdays, Sundays and federal holidays, calls are handled by our voicemail system. We will return calls the next business day.

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.