Organization Determinations

An organization determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services.  We and/or your provider make a coverage decision for you whenever you see your provider for medical care. You can also contact the plan and ask for a coverage decision.  For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

If you wish to request a coverage decision for medical care, please contact Healthfirst Medicare Plan:
 
Call: 1-888-394-4327
TDD/TTY: 1-888-542-3821
Monday through Friday, 8:30am-5:30pm
 
Fax: 1-646-313-4603
 
Write: 
Healthfirst Medicare Plan
Medical Management Department
P.O. Box 5166
New York, NY 10274
 
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 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 you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days.
 
When you file a fast complaint, we will give you an answer to your complaint within 24 hours.
 


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 days if we find that some information is missing that may benefit you, or if you need to get information to us for the review. If we decide to take extra days, we will tell you in writing.
 
If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days.
 
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 provider’s support, our plan will decide whether your health requires that we give you a fast decision.
 
For further information, please refer to Chapter 9 of your Evidence of Coverage with links provided at the bottom of this page.