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Part C Pre-Authorizations, Organization Determinations, and Reconsiderations (Appeals)

Information Last Updated: 11/13/2018

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Pre-authorizations and Organization Determinations

 

As a Brand New Day member you can request a self-referral (pre-authorization) to see a specialist or receive medical services and items. Typically, your provider will do this for you.

When you or your provider send a pre-authorization, Brand New Day reviews and makes an organization determination. An organization determination is the first decision Brand New Day makes about covering a medical service or item you’ve requested.

If the pre-authorization is a standard request, we will notify you of a decision within 14 calendar days.

There are times where you or your provider may submit an expedited pre-authorization for a fast organization decision. An expedited pre-authorization qualifies for a fast decision if we determine that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard request.

If the pre-authorization is an expedited request, we will notify you of a decision within 72 hours.

 

Where do I send my pre-authorization and/or request for an organization determination?

 

Please see below how you or your provider can submit a pre-authorization for an organization determination on medical services and items.

Brand New Day Member Services Department contact information
Call: 1-866-255-4795
TTY: 711
Hours of Operation: Year-Round
Monday – Friday, 8 a.m. – 8 p.m.

October 1 – March 31
Monday – Sunday, 8 a.m. – 8 p.m.
Mail: Brand New Day
Attn: Utilization Management
PO Box 93122
Long Beach, CA 90806
Fax: 1-657-400-1204
 

Appeals (Reconsiderations)

If you don’t agree with our decision on your denied pre-authorization, you have the right to file an Appeal. For more information on how to file an appeal please visit the How to File an Appeal site page under Members.