Organization Determination

What is an organization determination?

An organization determination is a coverage decision we make about your medical services or long-term services and supports (LTSS). If you or your health care provider are not sure if a medical service or LTSS service is covered, either you, your provider, or someone you name can ask for a coverage decision before your provider gives the medical service or LTSS service.

The person you name would be your appointed representative. Complete an Appointment of Representative Form (PDF) and return it to us to have an appointed representative ask for a coverage decision for you.

How to ask for a coverage decision to get medical care or LTSS

You, your representative, or your provider may call, write, or fax us to ask us for a coverage decision.

Call

• Member Services at 1-888-667-0318 (TTY 711).
• Utilization Management at 1-866-263-9011.

Fax

Fax us at 1-866-263-9036.

Write

Write us at:

AmeriHealth Caritas VIP Care Plus
Prior Authorization Department
PO Box 7075
London, KY 40742-7075

You can also request an organization determination (PDF) through your care coordinator.

Coverage decisions for behavioral health, intellectual/developmental disability, and substance use disorder services and supports

Your Prepaid Inpatient Health Plan (PIHP) will make coverage decisions for behavioral health, intellectual/developmental disability, and substance use disorder services and supports. Contact your PIHP for more information.

• Wayne County PIHP General Information Line
  Call 1-855-996-2264 (TTY 1-800-630-1044), toll-free, Monday thru Friday, 8 a.m. to 4:30 p.m. 
• Macomb County PIHP General Information Line
  Call 1-855-996-2264 (TTY 844-578-6563), toll-free, Monday through Friday, 8 a.m. to 4:45 p.m.