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Organization Determinations

What is an Organization Determination?

An organization determination is a decision Commonwealth Care Alliance makes about whether medical items or services are covered or how much you have to pay for covered items or services. Organization determinations are also called coverage decisions.

Asking for an Organization Determination

You, your doctor, or your representative can contact Commonwealth Care Alliance and ask for an organization determination if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make an organization determination for you.

In some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.


Last Updated 07/30/2013