What is an Organization Determination?
Asking your health plan for a benefit or for them to cover a service is called an Organization Determination request. It may also be called a Prior Authorization request. An organization determination is any decision made by a Medicare health plan regarding:
- Authorization or payment for a health care item or service;
- The amount a health plan requires an enrollee to pay for an item or service; or
- A limit on the quantity of items or services
Who May Ask For an Organization Determination/Appoint a Representative?
You can ask for an organization determination yourself, your treating physician can file one for you, or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, or anyone else to act for you. Some other persons may already be authorized under State law to act for you. If you want someone to act for you, then you and that person must sign and date a CMS Appointment of Representative form (CMS-1696) or an equivalent form and include it with your request for an organization determination. This will give the person you name legal permission to act as your appointed representative. This form must be sent to us at:
Independent Care Health Plan
1555 N. RiverCenter Dr., Suite 206
Milwaukee, WI 53212
You can print this form to appoint your representative:
CMS Appointment of Representative form (CMS-1696)
You do not have to have an Appointment of Representative form completed in order for your treating physician to submit an Organization Determination (Prior Authorization) request on your behalf.
You do not need to use this specific Appointment of Representative form. You can use this form or any equivalent document that contains the same components.
You also have the right to have an attorney ask for an organization determination on your behalf. You can contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify.