You or your provider can get a decision, either orally or in writing, from your plan in advance to see if it covers a service, drug, or supply. You can also find out how much you’ll have to pay. This is called an “organization determination.” Sometimes you have to do this as prior authorization for your plan to cover the service, drug, or supply.
You, your representative, or your doctor can request an organization determination. The requested organization determination can be either oral or written. Based on your health needs, you, your representative, or your doctor can ask for a fast decision on your organization determination request. If your plan denies coverage, the plan must tell you in writing, and you have the right to appeal.
If a plan provider refers you for a covered service or to a provider outside the network, but doesn’t get an organization determination in advance, this is called “plan directed care.” In most cases, you won’t have to pay more than the plan’s usual cost sharing. Check with your plan for more information about this protection.