Learn how to request an organization determination (the process to determine if an item or medical service is covered).
Understanding Coverage Decisions (Organization Determinations)
You have the right to request a coverage decision if you want us to provide or pay for an item or service that you believe should be covered. A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services.
To request a coverage decision, start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this.
When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard decision means we will give you an answer within 14 days after we receive your request. However, we can take up to 14 more calendar days if you ask for more time, or if we need information (such as medical records) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.
If your health requires it, ask us to give you a "fast decision". A fast decision means we will answer within 72 hours. However, we can take up to 14 more calendar days if we find that some information that may benefit you is missing, or if you need time to get information to us for the review. If we decide to take extra days, we will tell you in writing.
To get a fast decision, you must meet two requirements:
- You can get a fast decision only if you are asking for coverage for medical care you have not yet received. (You cannot get a fast decision if your request is about payment for medical care you have already received.)
- You can get a fast decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor tells us that your health requires a "fast decision," we will automatically agree to give you a fast decision. If you ask for a fast decision on your own, without your doctor’s support, we will decide whether your health requires that we give you a fast decision.
COVERAGE DECISIONS FOR MEDICAL CARE
Calls to this number are free.
Hours of operation: 8:00a.m. - 5:00 p.m., Monday through Friday.
This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free.
Hours of operation: 8:00 a.m. - 5:00 p.m., Monday through Friday.
Attn: Medicare Utilization Management
P.O. Box 4050
Farmington, CT 06034-4050