Organization determination means that Care1st would be making a decision about whether items or services are covered or how much you have to pay for covered items or services. Also included are requests for reimbursement of medical service or prescription drug costs.
Do you want to find out whether we will cover the medical care or services you want? You can ask us to make a coverage decision (organization determination) for you.
If your health requires a quick response, you should ask us to make a "fast coverage decision." To get a fast coverage decision, you must meet two requirements: (1) only if you are asking for coverage for medical care you have not yet received, and (2) only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
For expedited requests, please call or fax using the contact numbers above.
NOTE: If your doctor tells us that your health requires a "fast coverage decision," we will automatically agree to give you a fast coverage decision.
Generally we use the standard deadlines for giving you our decision. A standard coverage 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 from out-of-network providers) 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.
A fast coverage 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 (such as medical records from out-of-network providers), 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. If you believe we should not take extra days, you can file a "fast complaint" about our decision to take extra days.
If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide.
Do you want to ask us to pay you back for medical care, services and prescription drugs you have already received and paid for?
Here are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received:
All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision.
Here is the step-by-step process:
Send us your request for payment, along with your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records.
Mail your request for payment together with any bills or receipts to us at this address:Care1st Health Plan
You must submit your claim to us within sixty (60) calendar days of the date you received the service, item, or drug.
When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision.
If you think we have made a mistake in turning down your request for payment or you don't agree with the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment. For information on appeals, please view our Appeals Process page.
You may also read information on the Organization Determination process in Chapter 9, Sections 1-10 of the Evidence of Coverage document for your plan. Visit the Evidence of Coverage page for more information.