Medicare Part C Benefits: File a Part C Organization Determination/Coverage Decision

Category: File a Part C Organization Determination

As a SCAN member you may ask for a coverage decision on the medical care you are requesting.  When a coverage decision involves your medical care, it is called an “organization determination.” You can ask for a coverage decision yourself or appoint someone to do it for you. This person you appoint would be your authorized representative. You can appoint a relative, friend, advocate, doctor, attorney, or other person to act for you. If you already have someone authorized under state law to act for you, this person can request the coverage decision on your behalf. You can download the CMS Appointment of Representation form (Form CMS-1696) from the CMS website.

Standard Coverage Decision

A standard coverage decision means we agree to part or all of what you requested and we must authorize or provide the coverage we have agreed to within 14 calendar days after we received your request.  . However, we may take up to an additional 14 more calendar days if you ask for more time, or if we determine that more time is needed make a determination on your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period.

If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. The process for making a complaint is different from the process for coverage decisions. For more information about the process for making a fast complaint, see, Medicare Part C Benefits: File an Appeal.

If we do not give you our answer within 14 calendar days (or if there is an extended time period, by the end of that period) you have the right to make an appeal.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.  For more information about the appeal process see, Medicare Part C Benefits: File an Appeal.

Fast Coverage Decision

If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. The process for making a complaint is different from the process for coverage decisions. For more information about the process for making a fast complaint, see, Medicare Part C Benefits: File an Appeal.

If we do not give you our answer within 14 calendar days (or if there is an extended time period, by the end of that period) you have the right to make an appeal.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.  For more information about the appeal process see, Medicare Part C Benefits: File an Appeal.

 A fast coverage decision means we will answer within 72 hours.  However, we may take up to an additional 14 more calendar days if we find that some information that may benefit you is missing (such as medical records from out-of-network providers), or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing. If we say no, you have the right to ask us to reconsider – and perhaps change – this decision by making an appeal. For more information about the appeal process see, Medicare Part C Benefits: File an Appeal.

To get a fast coverage decision, you must meet two requirements:

  • You can get a fast coverage decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
  • You can get a fast coverage decision only if 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 a “fast coverage decision,” we will automatically agree to give you a fast coverage decision

If your doctor tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision. If you ask for a fast coverage decision on your own, without your doctor’s support, we will decide whether your health requires that we give you a fast coverage decision.  If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).

If our answer is yes to part or all of what you requested, we must authorize or provide the medical care coverage we have agreed to provide within 72 hours after we received your request. If we extended the time needed to make our coverage decision, we will authorize or provide the coverage by the end of that extended period.

If we do not give you our answer within 72 hours (or if there is an extended time period, by the end of that period) you have the right to make an appeal.  If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.  For more information about the appeal process see, Medicare Part C Benefits: File an Appeal.

Call Member Services at 1-800-559-3500 for additional information. (TTY Users: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31.

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