Either you or your healthcare professional can seek a judgment ahead of time, through verbal or written communication, from your health plan to verify if a particular service, medication, or item is covered. Additionally, it’s possible to determine your share of the cost. This process is known as an “organization determination.” Often, this step must be taken for prior approval, ensuring that the plan will provide coverage for the service, medication, or item.
Whether it’s you, someone acting on your behalf, or your physician, any of you can file for an organization determination. This request for an organization determination may be made via speech or in text format. Depending on your medical necessity, you, your appointee, or your physician has the capacity to request an expedited review of your organization determination. In the event that your plan rejects the coverage, it is obligated to inform you of this decision in written form, and you are then entitled to challenge their decision.
When a network associate from your plan sends you to receive a service covered by the plan or to see a healthcare provider outside of the established network, without securing an organization determination beforehand, it is referred to as “plan directed care.” Typically, under such circumstances, you will not be required to pay more than what your plan typically charges for co-sharing. For additional details on this safeguard, consult with your health plan.
