Organizational Determinations

You, your physician, or someone you name may ask us for an initial determination. The person you name would be your authorized representative. You may name a relative, friend, advocate, doctor, or anyone else to act for you. Other people may already be authorized under State law to act for you. If you want someone to act for you who is not already authorized under State law, then you and that person must sign and date a statement that gives the person legal permission to be your authorized representative.

Requesting a standard coverage determination

To request a standard decision for Part C medical care or service, you, your doctor, or your authorized representative must send a request in writing by mail or fax to:

Medicare y Mucho Más

Member Services
PO BOX 71114
SAN JUAN PR 00936-8014
Fax: 787-622-0485

You may ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. (Fast decisions apply only to requests for benefits that you have not yet received. You cannot get a fast decision if you are asking us to pay you back for a benefit that you already received.)

If you are requesting a Part C medical care or service that you have not yet received, you, your doctor, or your representative may ask us to give you a fast decision by calling Member Services:

Medicare y Mucho Más

Member Services
PO BOX 71114
SAN JUAN PR 00936-8014
Fax: 787-622-0485

You can also send your request by mail or fax:

To request a standard decision for Part C medical care or service, you, your doctor, or your authorized representative must send a request in writing by mail or fax to:

Medicare y Mucho Más

Member Services
PO BOX 71114
SAN JUAN PR 00936-8014
Fax: 787-622-0485

Be sure to ask for a “fast” or “expedited” review. If your doctor requests an expedited decision for you, or supports you in asking for one, and the doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you an expedited decision.

If you are requesting an expedited decision without support from a doctor, we will decide if your health requires such a decision. If we decide that your medical condition does not meet the requirements for an expedited decision, we will send you a letter informing you that if you get a doctor’s support for an expedited review, we will automatically give you an expedited decision. The letter will also show you how to file an expedited grievance. You have the right to file an expedited grievance if you disagree with our decision to deny your request for an expedited review (for more information about expedited grievances, see your plan’s Evidence of Coverage). If we deny your request for an expedited initial determination, we will give you a standard decision.

For a decision about payment for Part C medical care or services you already received:

If we do not need more information to make a decision, we have up to 30 days to make a decision after we receive your request, although a small number of decisions may take longer. However, if we need more information in order to make a decision, we have up to 60 days from the date of the receipt of your request to make a decision. You will be told in writing when we make a decision.

If you have not received an answer from us within 60 days of your request, you have the right to appeal.

For a standard decision about Part C medical care or services you have not yet received:

We have 14 days to make a decision after we receive your request. However, we can take up to 14 more days if you ask for additional time, or if we need more information (such as medical records) that may benefit you. If we take additional days, we will notify you in writing. If you believe that we should not take additional days, you can make a specific type of complaint called a “fast grievance”.

If you have not received an answer from us within 14 days of your request (or by the end of any extended time period), you have the right to appeal.

For an expedited decision about Part C medical care or services you have not yet received:

If you receive an expedited decision, we will give you our decision about your requested medical care or services within 72 hours after we receive the request. 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 more time to prepare for this review. If we take additional days, we will notify you in writing. If you believe that we should not take any extra days, you can file a fast grievance. We will call you as soon as we make the decision.

If we do not tell you about our decision within 72 hours (or by the end of any extended time period), you have the right to appeal. If we deny your request for a fast decision, you may file a “fast grievance.”

For a decision about payment for Part C medical care or services you already received.

Generally, we must send payment no later than 30 days after we receive your request, although a small number of decisions may take up to 60 days. If we need more information in order to make a decision, we have up to 60 days from the date of the receipt of your request to make payment.

For a standard decision about Part C medical care or services you have not yet received.

We must authorize or provide your requested care within 14 days of receiving your request. If we extended the time needed to make our decision, we will authorize or provide your medical care before the extended time period expires.

For an expedited decision about Part C medical care or services you have not yet received.

We must authorize or provide your requested care within 72 hours of receiving your request. If we extended the time needed to make our decision, we will authorize or provide your medical care before the extended time period expires.

If we decide against you, we will send you a written decision explaining why we denied your request. If an initial determination does not give you all that you requested, you have the right to appeal the decision.