← Glossary · CMS & regulatory
Payment organization determination and payment reconsideration
A plan decision, or plan-level appeal, on paying a claim or reimbursement request, reported in Table 3.
Payment organization determinations are decisions on claims; the protocol treats a payment request as a claim or reimbursement request. Plans must pay or deny claims from non-contracted providers and enrollees within 60 calendar days. Payment reconsiderations must be paid if overturned or forwarded to the IRE if upheld within 60 calendar days (30 for DSNP-AIPs).
Source: ODAG protocol, Timeliness 1.9-1.10, PDF p. 8; Universe Table 3 guidance, PDF p. 29; Supporting Documentation, PDF p. 47.