Organization Determination

What is an Organization Determination (Initial Determination)? 

An Organization Determination (initial determination) is a decision UCLA Health Medicare Advantage Plan and your medical group make about your benefits and coverage, or about the amount paid for your medical items/services or Part B drugs.

UCLA Health Medicare Advantage Plan, your provider, and your provider’s assigned medical group make a coverage decision whenever you go see your provider for medical care. 

How to Request an Organization Determination

Your doctor can request an organization determination (initial determination) for you, or you can request an organization determination for yourself. You can contact the assigned medical group directly and ask for a coverage decision.  The contact information for your assigned medical group can be found on the front of your plan ID card.  For example, if you want to know if a medical item/service or Part B drug is covered before you receive it, you can ask the assigned medical group to make a coverage decision for you. You may appoint an authorized representative to act on your behalf by filling out the Appointment of Representative Form (PDF) and mailing the form back to UCLA Health Medicare Advantage Plan.  The plan will ensure your assigned medical group has a copy of your submitted Appointment of Representative Form.

To Have Your Provider Make a Request

Your provider can submit a request directly to your assigned medical group by contacting the medical group at the number printed on the front of your plan ID card. 

Your provider may also submit a request via fax to UCLA Health Medicare Advantage Plan at 1-424-234-7893 to connect with the Prior Authorization Department. The decision on your request will be provided to you by telephone and/or mail. In addition, the initiator of the request (your provider) will be notified by telephone and/or fax.

Questions regarding the Organization Determination Process

Call Us

Contact UCLA Health Medicare Advantage Plan by calling 1-833-627-8252 for additional information. (TTY users should call 711). Hours of Operation: From April 1st through September 30th, you can call 8:00 a.m. to 8:00 p.m. Monday through Friday. From October 1st through March 31st, you can call 8:00 a.m. to 8:00 p.m. seven days a week. This call is free. 

Mail/Fax Us

Feel free to download the Pre-Authorization form and mail or fax it to UCLA Health Medicare Advantage Plan. 

Mail:  UCLA Health Medicare Advantage Plan
           PO Box 211622
           Eagan, MN 55121 
Fax:    1-424-234-7893

We will ensure your assigned medical group has a copy of your submitted Prior Authorization form.

When to Expect a Decision from UCLA Health Medicare Advantage Plan 

Receiving an answer from the health plan depends on the type of request submitted.

The plan and your assigned medical group make a coverage decision for you whenever it is decided what is covered for you and how much will be paid for services rendered. In some cases, a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

What is an Appeal/Reconsideration?

An appeal is a request for the health plan to review or revisit a decision or denial for health care services, benefits, or Part B drug:

• When you want a reconsideration of a decision (determination) that was made
• or the amount of payment the health plan pays or will pay
• or the amount you must pay

Who Can File an Appeal/Reconsideration?

 An appeal may be filed by any of the following:

• You may file an appeal.
• You may authorize someone to file an appeal on your behalf.

You may appoint an individual to act on your behalf to file the appeal for you by following the steps below:

• Fill out the Appointment of Representative Form (PDF) and mail it to UCLA Health Medicare Advantage Plan; or
• Provide UCLA Health Medicare Advantage Plan with your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from UCLA Health Medicare Advantage Plan regarding the denial or discontinuation of medical services.”
• Provide your name, address, subscriber number as well as phone number and that of your representative, if applicable.
• You must sign and date the form or statement.
• Your appointed representative must also sign and date this statement.
• You must include the signed form or statement with your appeal. 

Complaints and expedited appeals may be filed over the phone or in writing. All standard appeals must be submitted in writing.

When Appeals/Reconsiderations Can be Filed

You may file an appeal within sixty-five (65) calendar days of the date of the notice of the initial organization determination. For example, you may file an appeal for any of the following reasons:

• The health plan refuses to cover or pay for items/services or a Part B drug you think you’re the health plan should cover.
• The health plan or one of the contracting medical groups or providers refuses to give you an item/service or Part B drug you think should be covered.
• The health plan or one of the contracting medical groups or providers reduces or cuts back on items/services or a Part B drug you have been receiving.
• If you think that the health plan is stopping your coverage too soon.

Note: The sixty-five (65) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty-five (65) calendar days timeframe.

Where to File an Appeal/Reconsideration

An appeal may be filed in writing or by contacting UCLA Health Medicare Advantage Plan Member Services. To file an appeal in writing, please complete the Appeals and Grievance Form and follow the instructions provided.

Mail/Fax

Download and complete the Appeals and Grievance form and mail or fax it to UCLA Health Medicare Advantage Plan.

Mail:  UCLA Health Medicare Advantage Plan
           PO Box 211622
           Eagan, MN 55121 
Fax:    1-424-320-7897
 

Phone

Contact UCLA Health Medicare Advantage Plan by calling 1-833-627-8252 to file an expedited appeal. Standard appeals must be submitted in writing.  (TTY users should call 711). Hours of Operation: From April 1st through September 30th, you can call 8:00 a.m. to 8:00 p.m. Monday through Friday. From October 1st through March 31st, you can call 8:00 a.m. to 8:00 p.m. seven days a week. This call is free. 

Email

Expedited appeals may be submitted in writing via email.  Contact UCLA Health Medicare Advantage Plan by emailing [email protected] to file an expedited appeal.

What to Include in Your Appeal/Reconsideration

You should include:

• Your name
• Your address
• Your subscriber number from your member ID card
• The reason (s) for your appeal, and
• Evidence that supports your appeal

You may send in supporting medical records, doctors' letters, or other information that explains why your plan should provide the item/service or Part B drug. Call your doctor if you need this information to help you with your appeal. You may send in this information.

What Happens Next

If you appeal, UCLA Health Medicare Advantage Plan will 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 plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

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 UCLA Health Medicare Advantage 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, UCLA Health Medicare Advantage Plan will issue a decision as fast as possible, but no later than seventy-two (72) hours — plus 14 calendar days, if an extension is taken — after receiving the request. For Part B drugs, UCLA Health Medicare Advantage Plan will provide a decision as fast as possible, but no later than 72 hours in time-sensitive situations with no allowable extensions.

Receiving an answer from the health plan depends on the type of request submitted.