Preauthorization and Organization Determinations
Learn how and when you or your doctor can ask CarePlus to pay for certain medical services
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Medical and Medication Preauthorizations

Sometimes, your doctor may recommend items, services, or medication that require a preauthorization per your plan’s rules. A list of items, services, and medication that require preauthorization can be found in your Evidence of Coverage (EOC) or in one of our Preauthorization Lists.

  • Organization Determinations for Medical Services and Items

    You have the right to ask CarePlus to pay for items, services, or medication you think should be covered.

    Certain items, services, or medication may require review and approval by our plan (this is called getting "preauthorization") before you can get them.

    An organization determination (also commonly referred to as a coverage decision) is a decision (i.e., an approval or denial), CarePlus or its delegated entity makes about your benefits and coverage and whether we will pay, in whole or part, for the items, services, or medication you, your representative, or your doctor have requested.

  • When to Request an Organization Determination

    Asking for an organization determination means asking CarePlus for a decision on whether we will pay for certain items, services, or medication. Here are a few cases when you might want to request a determination:

    • If your doctor isn’t sure a service will be covered. You can ask CarePlus for a decision before you receive the service.
    • If your doctor refuses to provide care you need or says it will not be covered. You can ask CarePlus to decide if it can be covered.

    Certain items, services, or medications are only covered if you, your representative, or your doctor first requests preauthorization and we approve it.

How to Request a Coverage Decision

In many cases, your doctor will request a coverage decision on your behalf. However, if that is not the case and you or your representative need to request it from us directly, please call CarePlus Member Services with your request:

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.

If a representative is going to call on your behalf, please make sure you have completed an Appointment of Representative Form. Otherwise, we will not be able to process your request.
 

How Long Does It Take?

Standard Timeframe

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 medical service or item request or within 72 hours after we receive your Part B request.

Expedited (fast) Timeframe

When medically needed, we will give you an answer within 72 hours after we receive your Part C medical service or item request or within 24 hours after we receive your Part B request.

Please request a fast decision if you believe you could be seriously harmed by waiting up to the standard 14 calendar days for a decision. If your doctor tells us your health requires a fast decision, we will use the expedited timeframe. If you request a fast decision on your own (without your doctor), we will review to decide if the expedited timeframe is medically needed.

Extended (longer) Timeframe

We will send you a letter to let you know if our decision will take longer than the standard 14 calendar day timeframe. We may take up to 14 more days if we need medical records from out-of-network doctors or other information that could help us decide we will cover your requested Part C medical services or items.

If you disagree with our decision to take longer, you can file an expedited grievance. When you file an expedited grievance, we will provide you with a response to your expedited grievance request within 24 hours.

What if We Determine a Service is Not Covered?

In some cases, CarePlus may decide a service is not covered by your plan. If we deny all or part of your request, we will send you a detailed written explanation and instructions on how to appeal our decision if you disagree.

If you appeal (and ask us to reconsider our decision), please be sure to provide all supporting documentation such as medical records, medical bills, or a letter from your provider along with your appeal request.

Once we receive the request, we will 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 service and item requests, or 60 calendar days for payment requests

If you have questions about our process or the status of your request, please call Member Services.

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Last Updated:

10/01/2024

Questions?

If you have questions about our process or the status of your request, please call Member Services.