Requesting a Medicare pre-service organization determination (PSOD)

If you or the member wants to obtain a pre-service organization determination (PSOD):

Speed of decisions:

Priority Health has, under CMS rules, 14 calendar days from the time of the receipt of a request to make a standard decision and notify the member and provider.

Extensions: Priority Health may extend this time frame for up to an additional 14 calendar days if we have not received the information necessary to make a decision. Priority Health will issue a letter whenever an extension is being made.

Notification of denial:

When Priority Health completes the organization determination process and finds that the item or service is not covered, we send a Notice of Denial of Medicare Coverage (CMS-10003) to the member within three days, informing them that the service is not covered and what their appeal rights may be. You will receive a copy as well.

For more information about standard organization determinations see Chapter 13, Medicare Managed Care Manual.

Requesting an expedited decision

You may request a fast or expedited organization determination decision if you believe waiting for a decision under the standard time frames could place your patient's life, health, or ability to regain maximum function in serious jeopardy. Requests for expedited organization determinations require submission of medical records at time of the request for a fast decision.

For more information about expedited organization determinations see Chapter 13, Medicare Managed Care Manual.

Speed of expedited decisions:

Priority Health has 72 hours from time of receipt of the request to make a decision. The member must be notified orally as well as receive a written notification within 72 hours.

Denied requests for expedited decisions

Priority Health will automatically transfer the request to the standard time frame and make the decision in 14 calendar days. The 14-day period begins when the request for the expedited determination is received.

We notify the member of the denial verbally and receives a letter within 3 calendar days of the denial. We also notify providers within these time frames.

Member receives a Notice of Denial of Medicare Coverage

Advise the member he/she has the right to appeal this denial and offer to assist.

If the member refuses your offer to appeal:

  1. Tell the member he/she may be responsible for 100% of the cost of the service. Under Part C Medicare, it's not necessary to have the member sign a financial liability form.
  2. Explain that you'll send a claim to Priority Health and if the claim is denied, the member can appeal at that time.
  3. Document the discussion. No form is necessary.
  4. Bill with a GA modifier to keep the claim from going to provider liability.

Remember: you may not balance bill the member until we make a post-service payment decision.