Organization Determination

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 a coverage decision before you are provided 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., seven days a week.
• Utilization Management at 1-888-244-5410 (TTY 711), 8 a.m. - 5 p.m., Monday - Friday.

Fax

Fax us at 1-888-257-7960.

Write

Write us at:

First Choice VIP Care Plus
Attn: Prior Authorization of Medical Care
4390 Belle Oaks Drive
Suite 400
North Charleston, SC 29405

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