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Organization Determinations

What is an organization determination?

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

See how you can appoint a representative to ask for a coverage decision for you, and then complete an Appointment of Representative Form (PDF) and return it to us.

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

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

Call

  • Member Services at 1-888-978-0862 (TTY 711), 8 a.m. - 8 p.m., 7 days a week.
  • Utilization Management at 1-888-244-5410.

Fax

Fax us at 1-888-257-7960.

Write

Write us at:

First Choice VIP Care Plus
Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113

You can also request an organization determination through your Care Coordinator.

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