Members Resources

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Organization Determination

What is an organization determination?

An organization determination (OD) is a decision made by the Medicare Health Plan regarding:

  • Receipt of, or payment for, managed care item or service;
  • The amount a health plan requires an enrollee to pay for an item or service; or
  • A limit on the number of items or services.

This means Align Senior Care will authorize, provide, or pay for medical services.

An enrollee, or any physician regardless of whether the physician is affiliated with the Plan may request for an Expedited Organization Determination (EOD) when an enrollee or his/her physician believes that waiting for a decision under the standard timeframe could place the enrollee life, health, or ability to regain maximum function is in serious jeopardy.

Who can request an organization determination?

An enrollee, an enrollee’s representative, or any provider that furnishes, or intends to furnish, services to an enrollee, may request a standard organization determination by filing an oral or written request with the Plan.  

Expedited requests may be requested by an enrollee, an enrollee’s representative, or any physician, regardless of whether the physician is affiliated with Align Senior Care.

If you want someone to act for you as your appointed representative, then you and the person must sign and date the Appointment of Representative (AOR) form that legally allows that person to act as your appointed representative. This form does not need to be filled out if your doctor is sending a request. The AOR must be faxed or mailed to us at

Fax: 1-833-610-2399

Mail:   

Align Senior Care

PO Box 4440

Glen Allen, VA 23058-4440

Where can an organization determination be filed?

To start an organization determination, you must file a Preservice Organization Determination, also known as a Prior Authorization Request, by phone, mail, or fax.

Phone:

  • California: 1-844-305-3879 (TTY 711)
  • Florida: 1-844-788-8935 (TTY 711)
  • Michigan: 1-855-855-0336 (TTY 711)
  • Virginia/Massachusetts: 1-855-855-0489 (TTY 711)

Calls to this number are free.

8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30

Fax: 1-833-610-2399

Mail: 

Align Senior Care

PO Box 4440

Glen Allen, VA 23058-4440

Once Align Senior Care receives the request, it must make its decision and notify the enrollee of the decision as quickly as the enrollee’s health requires but no later than 14 days for standard medical requests, 72 hours for standard Part B medication requests, 72 hours for expedited medical requests, and 24 hours for expedited Part B medication requests.

 

When can an organization determination be requested?

An organization determination made by Align Senior Care can be requested with respect to any of the following:

  • Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services;
  • Payment for any other health services furnished by a provider other than Align Senior Care that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Align Senior Care;
  • Align Senior Care’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by Align Senior Care;
  • Reduction, or premature discontinuation of a previously authorized ongoing course of treatment; or
  • Failure of Align Senior Care to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.
Important things to know about asking for an organization determination
  • Emergency services are excluded from prior authorization requirements.
  • Our plan can approve or deny your request. If we approve your request, our approval is valid until the end of the period stated in the approval notice.

If you do not agree with an organization determination you have the right to appeal our decision. More information on the appeal process and how to file an appeal can be found on the File an Appeal page.