CarePlus Organization Determination

Your Medical Care: How to ask for an Organization Determination

What is an Organization Determination?

An "organization determination", as defined by the Centers for Medicare & Medicaid Services (CMS) is any determination made by CarePlus with respect to any of the following:

  • Payment for temporarily out-of-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 the health plan that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by CarePlus
  • The health plan’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 CarePlus
  • Reduction, or premature discontinuation of a previously authorized ongoing course of treatment
  • Failure of the health plan 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

How to request an Organization Determination

You, your appointed representative, or your physician may request an Organization Determination in one of the following ways:

Call us: Contact our Member Services department at 1-800-794-5907 from 8 a.m. to 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday-Friday from 8 a.m. to 8 p.m. TTY users should call 711.

Fax us: Our Toll Free Fax number is 1-800-956-4288

Write us. Mail your request to:

CarePlus Health Plans
11430 NW 20th Street, Suite 300
Miami, FL 33172
Attention: Member Services department

How to Appoint a Representative

To consider an organization determination request from someone other than you (the member) or your physician, we must have authorization. You may appoint any individual as your representative by sending us an Appointment of Representative form signed by both you and your representative. A representative who is appointed by the court or who is acting in accordance with state law may also file a request for you after sending us the legal representative form. You will not need to complete an Appointment of Representative Form if you provide an equivalent written notice or other legal representation document with your request. A request for an organization determination can only be processed with a valid Appointment of Representative form or other legal representation document on file.

Appointment of Representative Form Instructions on how to Appoint a Representative

You also can get the Appointment of Representative form(link opens in new window)  on CMS's website.

If you have any questions, please call our Member Services number at 1-800-794-5907; from 8 a.m. to 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday – Friday from 8 a.m. to 8 p.m. TTY users should call 711.

How long will it take for us to give you a decision?

While we review your request for an organization determination, we will use the “standard” timeframe unless the request was submitted for “expedited” review.

Standard Organization Determination
A standard organization determination request means we will give you an answer as fast as your health condition requires, but no later than 14 calendar days after we receive your request.

Expedited (fast) Organization Determination
If you believe that your life, health or ability to regain maximum function could be seriously harmed by waiting the standard 14 calendar days for a decision, you can ask for an expedited (fast) organization determination. We will give you an answer as fast as your health condition requires, but no later than 72 hours after we receive your request if you meet the two requirements for an expedited (fast) organization determination.

When submitting a request for an expedited organization determination, you must meet two requirements:

  • You may request an expedited organization determination if you are asking for coverage for medical care you have not yet received. (You cannot get an expedited organization determination if your request is about payment for medical care you have already received.)
  • You may request an expedited organization determination only if using the standard deadline could cause serious harm to your health or hurt your ability to regain maximum function.

If your doctor tells us that your health requires an “expedited (fast) organization determination”, we will automatically agree to review the request within the expedited review timeframe.

Extended time for a decision

We can take up to 14 more calendar days to make either a standard or expedited decision if you ask for more time, or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will advise you in writing.

If you believe we should not take extra days, you can file an expedited grievance through our Member Services department or in writing. When you file an expedited grievance, we will provide you with a response to your expedited grievance request within 24 hours.

When we tell you we will not cover a service

In some cases we might decide a service is not covered or is no longer covered by your plan. If we deny all or part of your request, we will send you a detailed written explanation of our denial and instructions on how to appeal our decision if you disagree with the determination made.

In addition, if we do not give you our answer within the standard or expedited time frame, you also have the right to appeal.

Approval from the plan before receiving an item or service

For some types of items or services, your primary care physician (PCP) may need to get approval in advance from CarePlus by requesting an organization determination (this is called getting "prior authorization"). The services for which your doctor will need to get advance approval from us are included in your Evidence of Coverage.

If you have any questions, please call our Member Services number at 1-800-794-5907; from 8 a.m. to 8 p.m., 7 days a week. From February 15th to September 30th, we are open Monday – Friday from 8 a.m. to 8 p.m. TTY users should call 711.