Member Resources

Organization Determinations

Learn about how decisions are made regarding your benefits and coverage, and how to appeal those decisions if you disagree.

Contents:

About Organization Determinations

An organization determination is a decision we make about your benefits or coverage, or about the amount we pay, or you pay, for your medical services. You have the right to request an organization determination or appeal a decision we make about your benefits.

How to Request an Organization Determination

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By Phone

Toll-Free: 1-866-901-8000
TTY: 1-877-454-8477
Fax: 215-849-7096

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By Mail

You can also mail to:

ATTN: Medical Management Department
Jefferson Health Plans Medicare
1101 Market Street, Suite 3000
Philadelphia, PA 19107

You can expedite your request if the care need is urgent, which requires us to make the decision in 72 hours. Otherwise, we will review your request for medical care coverage and give you our answer, generally within 14 days from when we receive your request.

  • If our answer is yes to part or all of what you requested, we will authorize or provide the services we have agreed to provide within 14 days from when we received your request - if we need more time, we will notify you.
  • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.

Appealing an Organization Determination

If we decline your request, you have the right to request an appeal. You can click here for more information on our appeals process.

Page last updated: 10/1/2024 - Y0170_MCE‐220S05‐4991_M