Requesting a Medicare pre-service organization determination (PSOD)

If you want to obtain a pre-service organization determination (PSOD):

• Use the Medical Prior Authorization form to request the decision.
• Fax it to us at 888.647.6152.
• If you have questions, call the Provider Helpline at 800.942.4765.

Decision time frame:

Under CMS rules, Priority Health has 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 haven't received the information necessary to make a decision. We'll 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 isn't covered, we send a Notice of Denial of Medicare Coverage (CMS-10003) to the member, informing them that the service is not covered and what their appeal rights may be. You'll receive a copy as well.

For more information about standard organization determinations, see Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance.

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 frame 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 the time of request for a fast decision.

For more information about expedited organization determinations see Part C & D Enrollee Grievances, Organizations/Coverage Determinations, and Appeals Guidance. 

Decision time frame of expedited decisions:

Priority Health has 72 hours from time of receipt of the request to make a decision. The clock starts when the appropriate department has received the request. The member must be notified verbally within this 72-hour window. Priority Health will also send a written notification within three calendar days of the verbal notification.

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 if it's determined not to be an expedited request. The 14-day period begins when the request for the expedited determination is received.

We notify both the member and the provider verbally, as well as with written notification, if the request is changed from an expedited request to a standard request.

Member receives a Notice of Denial of Medicare Coverage

Advise the member they have the right to appeal this denial and offer to assist.

If the member refuses your offer to appeal:

1. Tell the member they 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.