Organization Determinations
An “Organization Determination” is when Senior Care Plus, or one of its providers, makes a decision about whether services are covered or how much you have to pay for covered services. Organization determinations can also be called “coverage decisions.” The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services and prescription drugs, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.
Asking for coverage decisions – A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision 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 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 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. For more information regarding the coverage decision process please reference the below sections in your Evidence of Coverage.
| SCP Plan | Chapter | Sections |
|---|---|---|
| Value Basic (HMO) | Chapter 7 | Sections 4 & 5 |
| Value Rx (HMO) | Chapter 9 | Sections 4 & 5 |
| Value Rx Enhanced (HMO) | Chapter 9 | Sections 4 & 5 |
| Value Rx Select (HMO) | Chapter 9 | Sections 4 & 5 |
| Freedom Basic (PPO) | Chapter 9 | Sections 4 & 5 |
| Freedom Rx (PPO) | Chapter 9 | Sections 4 & 5 |
| Freedom Rx Select (PPO) | Chapter 9 | Sections 4 & 5 |
Out-of-Network / Non-Plan Providers
“Non-plan providers” are providers that are not part of Senior Care Plus. If you use non-plan providers, you may have to pay more. If you receive health care service from a plan provider, this is known as an “in-network” service. Health care received from a non-plan provider is known as “out-of-network” service. Medicare requires that we have enough in-network plan providers to give you covered services that are medically necessary.
For those members enrolled in the Value (HMO) plans, care or services received from non-plan providers will not be covered, except for ambulance services, emergency care, including post- stabilization care, urgently needed care, renal dialysis (kidney), and any services which were ordered covered through an appeals process. For those members enrolled in the Freedom (PPO) plans, you may use non-plan providers to get your covered services, although, you’re out-of- pocket costs may be higher than if you use our plan providers. For emergency care, including post stabilization care, and urgently needed care, your out-of pocket costs will be the same both in and out-of-network. For cost sharing information see your “Evidence of Coverage”.
There are special rules for out-of-network services. Certain services that we offer are not covered out-of-network. For those members enrolled in the Freedom (PPO) plans, you do not need to get a referral or prior authorization when you get out-of-network care from non-plan providers. However, before getting out-of-network service, check with your plan to see if the services you are getting are covered by your plan and are medically necessary. Although you do not need to get prior authorization for certain out-of-network services for those members enrolled in the Freedom (PPO) plans, some plans may offer a lower cost if you choose to get prior authorization. For more information, see your “Evidence of Coverage”.
Contact Us
We encourage you to contact Senior Care Plus if you have any questions or concerns regarding coverage decisions, or if you require information on how to obtain an aggregate number of grievances, appeals, and exceptions filed with Senior Care Plus. Please call Customer Service at 775-982-3112 or toll-free at 888-775-7003, 7 a.m.-8 p.m. Monday-Friday. TTY users should call the State Relay Service number at 711.
If mailing a request for a coverage decision to Senior Care Plus, please address the request to:
Senior Care Plus
10315 Professional Circle
Reno, NV 89521
You may also fax completed requests to Senior Care Plus at 775-982-3743.
