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CarePlus Organization Determination

Your Medical Care: How to Ask for an Organization Determination & Reconsiderations

What is an Organization Determination?

An "organization determination," as defined by the Centers for Medicare & Medicaid Services (CMS), is any determination (i.e., an approval or denial) made by CarePlus or its delegated entity with respect to any of the following:

  • Payment for temporarily out-of-area renal dialysis services, emergency services, post-stabilization care, and/or urgently needed services
  • Payment for any other health services furnished by a physician that the member believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by CarePlus
  • CarePlus' refusal to provide, or pay for services, in whole or in part, including the type or level of services, that the member believes should be furnished or arranged for by CarePlus
  • Discontinuation or reduction of a service that the member believes should be continued because they believe the services to be medically necessary
  • Failure of CarePlus to approve, furnish, arrange for, or provide payment for healthcare services in a timely manner, or to provide the member with timely notice of an adverse determination (denial), such that a delay would adversely affect the health of the member

How to Request an Organization Determination

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

By phone – Contact Member Services at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.

By fax – Our fax number is 1-888-790-9999.

By mail – Mail your request to:

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

Reconsideration Requests

How to Appeal an Unfavorable Organization Determination

If you have received an unfavorable organization determination, you may submit a request for reconsideration (appeal) by following the instructions provided on the determination notice or as described below.

To request an appeal, you, your appointed representative or your doctor can contact CarePlus in one of these ways:

Fax or mail your request

You may download a copy of the Grievance or Appeals Request form below and fax or mail it to CarePlus.

Fax: 1-800-956-4288

Mailing address:

CarePlus Health Plans
Attention: Grievance and Appeals
11430 NW 20th Street, Suite 300
Miami, FL 33172

Be sure to provide all supporting documentation, along with your appeal request. Any supporting documentation can be sent via fax at 1-800-956-4288. Once we receive the request, we must make a decision and provide written notice within 72 hours for expedited requests, 7 calendar days for standard Medicare Part B prescription drug requests, 30 calendar days for standard medical services requests and 60 calendar days for payment requests.

If you have any questions about our process or the status of your request, please call Member Services at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may

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 proper legal documentation. 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 can also obtain the Appointment of Representative form(link opens in new window)  via the CMS website.

If you have any questions, please call Member Services number at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m.. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.

How Long Do We Need Before Giving You a Decision?

While we review your request for an organization determination, we will use the “standard” timeframe unless the request requires “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 Part C request, or no later than 72 hours after the date CarePlus receives your Part B 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 timeframes mentioned above for a decision, you can request 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 Part C request or no later than 24 hours after we receive your Part B request if you meet the following two requirements for an expedited (fast) Organization Determination

The two requirements for an expedited (fast) organization determination include: (1) the coverage you are requesting must be coverage that you have not yet received and (2) 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, regarding your Part C request. If we decide to take extra days to make the decision, we will advise you in writing.

If you disagree with our decision to extend the time, you can file an expedited grievance by calling our Member Services department or by submitting your request in writing to the Grievance and Appeals department. 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 timeframe, 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 (which is known as requesting "prior authorization"). Your Evidence of Coverage includes a list of services for which your doctor must first get advance approval from us.

If you have any questions, please call Member Services at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.