Utilization Management

Organization Determinations

An organization determination is a decision we make about your benefits and coverage or about the amount we will pay for your medical services.

For example, your plan network doctor makes a favorable organizational decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You can also contact us and ask for a coverage decision if your doctor is unsure if we will cover a particular medical service or refuses to provide medical care you think that you need.

If you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare or Medicaid. If you disagree with this coverage decision, you can make an appeal.

Generally, for a standard decision, we will give you our answer within 14 days of receiving your request. We can take up to 14 more days “an extended time period” under certain circumstances. 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 an “expedited complaint” about our decision to take extra days. When you file an expedited complaint, we will give you an answer to your complaint within 24 hours. If we do not give you our answer within 14 days (or if there is an extended time period, by the end of that period), you have the right to appeal.

You can ask our plan to make a coverage decision on the medical care you are requesting. If your health needs a quick response, you should ask us to make an “expedited decision.”

To get an expedited decision, you must meet two requirements:

  • You can get an expedited decision only if you are asking for coverage for medical care you have not yet received. You cannot get an expedited decision if your request is about payment for medical care you have already received.
  • You can get an expedited decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.

Medicare Organization Determination

To request a Medicare Organization Determination, you or your provider must call or fax us:
Call: 1-718-696-0210 TTY/TDD: 1-800-662-1220| Fax to 1-855-895-0776.

Or you can write to us at:

AgeWell New York
Attn: Utilization Management Department
1991 Marcus Avenue, Suite M107 | Lake Success, New York 11042