An organization determination, also known as a service authorization, is our initial decision about whether we will provide the medical care or service a member requests, or pay for a service a member has received. Providers, members or a member’s appointed representative can request a service authorization by contacting the ArchCare Advantage Clinical Services Department. Organizational determinations are made as expeditiously as the member’s health condition requires, but no later than 72 hours after receipt of an expedited request or no later than 14 calendar days for a standard request for services.
Determinations of coverage are made based on Medicare regulations, the ArchCare Advantage Evidence of Coverage, local Medicare carrier policies, internal policies and procedures, and medical criteria.
Part C service authorization requests can be submitted via fax to 1‑212‑524‑5163 or 1‑646‑233‑5745. Part C service authorization requests can also be submitted by phone by calling Member Services at 1‑800‑373‑3177 (TTY/TDD: 1‑800‑662‑1220), seven days a week, 8 a.m. to 8 p.m.. Please be sure to include all supporting documents with your request.