An organization determination is a decision made by a Medicare plan determining authorization, the amount you’ll pay, or limits on an item or service.[1]

In some cases, you, your repetitive, or a provider may request a standard organization determination for a service, drug, or supply. This request is made to the health plan. Expedited requests may also be requested.

If your health plan denies coverage for an item or service they must tell you in writing.

TIP: If a plan provider refers you outside the network for an item or service without getting determination in advance it is called “plan directed care.” You typically won’t pay more than the usual cost-sharing for plan directed care.

TIP: When shopping for Medicare Advantage plans, or when reviewing your benefits, make sure to check which services require prior authorization and how these services are covered in-network and out-of-network to better understand how organization determination requests may impact you.

Citations

  1. Organization Determinations. CMS.Gov.