Expedited Organization Determination Rules

The following rules govern the expedited organization determination (EOD) process:

• The Medicare Advantage (MA) member, authorized member representative, Appointment of Representation (AOR), or participating provider may request an EOD through the MA organization (MAO) orally or in writing.
• Requests for EODs may not be filed with the Social Security Administration District Offices or the Railroad Retirement Board.
• The member or member's representative does not have to make a specific request for an EOD. The plan reviews all requests for service to determine whether they meet the following established criteria:
  • Requests by a participating provider for a time-sensitive determination.
  • Requests for continued rehabilitation hospital stay.
  • Requests for continued skilled nursing facility (SNF) stay, even if the member has reached the maximum limit.
  • Requests for continued home health services.
  • First requests for physical therapy within four months of a CVA, head injury or surgery, or other acute trauma.
  • Requests for continued physical therapy within six months of a CVA, head injury or surgery, or other acute trauma.
  • First requests for physical therapy within four months of a major joint surgery (for example, hip or total knee).
  • Requests for continued physical therapy within six months of a major joint surgery.
  • Requests for medication, chemotherapy, radiation therapy, or proposed surgical treatment of a known malignancy.
  • Requests for proposed AIDS therapy.
  • Requests for proposed experimental treatment for a terminal member.
  • Requests concerning a refusal by the provider to proceed with a scheduled service or test because the provider failed to give an authorization for a service that was scheduled (for example, surgery scheduled, but no authorization issued on which to proceed). This applies to requests for a referral that has already been submitted.
  • Requests for service concerning any life- or limb-threatening condition.

  Health Net considers other requests for EODs if the member complains of severe pain by considering whether delaying care could seriously jeopardize the life or health of the member or the member's ability to regain maximum function.