Medicare Advantage Plans

Appeals and Grievances Process

Medicare Advantage Plans

The following procedures for appeals and grievances must be followed by your Medicare Advantage health plan in identifying, tracking, resolving and reporting all activity related to an appeal or grievance.

Coverage decisions and appeals

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services and prescription drugs, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.

Asking for coverage decisions

A coverage decision is a decision given in writing that we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We and/or your doctor make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Member appeals

Who can file an appeal
An appeal may be filed by any of the following:

  • You may file an appeal.
  • Someone else may file the appeal for you on your behalf.

You may appoint an individual to act as your representative to file the appeal for you by following the steps below:

  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting an appeal from your Medicare Advantage health plan and/or CMS regarding the denial or discontinuation of medical services.”
  • Provide your name, address and phone number and that of your representative, if applicable.
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal. United Behavioral Health offers an appeal process if you are not satisfied with a care advocacy or claims payment decision related to behavioral health services. There is also a complaint process if you are not satisfied with the quality of services that you received from United Behavioral Health or your behavioral health practitioner. Complaints and appeals may be filed over the phone or in writing.

What an appeal is
An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

When appeals can be filed
You may file an appeal within sixty (60) calendar days of the date of the notice of the initial organization determination. For example, you may file an appeal for any of the following reasons:

  • Your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
  • Your Medicare Advantage health plan or one of the contracting medical providers refuses to give you a service you think should be covered.
  • Your Medicare Advantage health plan or one of the contracting medical providers reduces or cuts back on services you have been receiving.
  • If you think that your Medicare Advantage health plan is stopping your coverage too soon.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Where to file an appeal
An appeal may be filed in writing or by contacting UnitedHealthcare® Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in the Summary of Benefits or Chapter Two of the Evidence of Coverage, 8 a.m. – 8 p.m., local time, 7 days a week. You may also contact UnitedHealthcare Customer Service and request the facsimile number for Appeals and Grievances.

Why you file an appeal
You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.

What to include with your appeal
You should include: your name, address, member ID number, reasons for appealing, and any evidence you wish to attach. You may send in supporting medical records, doctors' letters, or other information that explains why your plan should provide the service. Call your doctor if you need this information to help you with your appeal. You may send in this information or present this information in person if you wish.

What happens next
If you appeal, UnitedHealthcare will review the decision. If any of the services you requested are still denied after our review, Medicare will provide you with a new and impartial review of your case by a reviewer outside of our Medicare Advantage Organization or prescription drug plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

Fast decisions/expedited appeals
You have the right to request and receive expedited decisions affecting your medical treatment in “Time-Sensitive” situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

  • your life or health, or
  • your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Physician decides, based on medical criteria that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan or your Primary Care Physician will issue a decision as fast as possible, but no later than seventy-two (72) hours after receiving the request.

Member grievances

Who can file a grievance
A grievance may be filed by any of the following:

  • You may file a grievance.
  • Someone else may file the grievance for you on your behalf.

You may appoint an individual to act as your representative to file the grievance for you by following the steps below:

  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement which appoints an individual as your representative. (Note: You may appoint a physician or a Provider.) For example: “I [your name] appoint [name of representative] to act as my representative in requesting a grievance from your Medicare Advantage health plan and/or CMS regarding the denial or discontinuation of medical services.”
  • Provide your name, address and phone number and that of your representative, if applicable.
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your grievance.

What a grievance is
A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your Medicare Advantage health plan or a Contracting Medical Provider. For example, you would file a grievance if: you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When a grievance can be filed
You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance.

Expedited grievance
You have the right to request a fast review or expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan's decision to process your expedited request as a standard request. In such cases, your Medicare Advantage health plan will acknowledge your grievance within twenty-four (24) hours of receipt and notify you in writing of your Medicare Advantage health plan's conclusion within three (3) calendar days.

Where a grievance can be filed
A grievance may be filed in writing or by contacting UnitedHealthcare Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in the Summary of Benefits or Chapter Two of the Evidence of Coverage, 8 a.m. – 8 p.m., local time, 7 days a week. You may also contact Customer Service and request the facsimile number for Appeals and Grievances.

Why you file a grievance
You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Asking for coverage decisions and making appeals
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services and prescription drugs, including problems related to payment. This is the process you use for issues such as whether something is covered or not and the way in which something is covered.

A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We and/or your doctor make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.

We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

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