Organization Determination

(Also referred to as "coverage decision")

What is Organization determination?

Organization determination means that Blue Shield of California Promise Health Plan 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.

Organization Determination for Medical Services

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.

Here is the step-by-step process:

  • You ask our plan to make a coverage decision on the medical care you are requesting. You, your doctor, or your representative can do this by one of the options below.

    • Call Blue Shield Promise Cal MediConnect Plan Member Services at (855) 905-3825 (TTY: 711). Calls to this number are free. 8:00 a.m. to 8:00 p.m., seven days a week.
    • Write to Blue Shield of California Promise Health Plan at this address:

      Blue Shield Promise Cal MediConnect Plan
      Member Services (Coverage Decisions)
      601 Potrero Grande Drive
      Monterey Park, CA 91755
    • Fax Blue Shield Promise Cal MediConnect Plan at (323) 889-6577

    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.

  • We consider your request for medical care coverage and give you our answer

    Timeframes

    Standard 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.

    Fast coverage decision

    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 we say no to your request and you want us to reconsider and/or change our decision, or if we do not have our answer within the timeframe above (or if there is an extended time period, by the end of that period), you have the right to appeal. For information on appeals, please view our Appeals Process page.


Organization Determination for Reimbursement

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:

  • When you've received emergency or urgently needed medical care from a provider who is not in our plan's network
  • When a network provider sends you a bill you think you should not pay
  • If you are retroactively enrolled in our plan
  • When you use an out-of-network pharmacy to get a prescription filled
  • When you pay the full cost for a prescription because you don’t have your plan membership card with you
  • When you pay the full cost for a prescription in other situations

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:

  • You send us your request for payment

    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:

    Blue Shield of California Promise Health Plan
    Member Services
    PO Box 4239 Montebello, CA 90640

    You must submit your claim to us within sixty (60) calendar days of the date you received the service, item, or drug.

  • We check to see whether we should cover the service or drug and how much we owe

    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 we decide that the medical care or drug is covered and you followed all the rules for getting the care or drug, we will pay for our share of the cost. If you have already paid for the service or drug, we will mail your reimbursement of our share of the cost to you. If you have not paid for the service or drug yet, we will mail the payment directly to the provider.
    • If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision.
  • If we tell you that we will not pay for all or part of the medical care or drug, you can make an appeal

    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.



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