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Appeals and Grievances Process
UnitedHealthcare® Senior Supplement®
The following procedures for appeals and grievances must be followed by your Senior Supplement health plan in identifying, tracking, resolving and reporting all activity related to an appeal or grievance.
I. Appealing a Decision Relating to Benefits
A Covered Person and the Company may not always agree that a Claim or request for services has been reviewed properly. When this happens, the Covered Person is encouraged to call the Company’s Customer Service Department. The Company’s Customer Service Department coordinator will assist the Covered Person and attempt to find a solution to the Covered Person’s problem or grievance.
If the Covered Person feels that his/her problem or grievance requires additional action, the Covered Person may file a formal appeal. The Company’s appeals procedures are designed to deliver a timely response and resolution to a Covered Person’s problem or grievance. This is done through a process that includes a thorough and appropriate investigation, as well as an evaluation of the problem or grievance.
The Covered Person may submit written comments, documents, records, and any other information relating to the appeal, regardless of whether this information was submitted or considered in the initial determination. The Covered Person may designate a representative to file an appeal on their behalf by providing written notice that includes the issue in dispute, the Covered Person’s signature and the representative’s signature.
The appeal will be reviewed by an individual who is neither the individual who made the initial determination that is the subject of the appeal nor the subordinate of that person. If the appeal involves a clinical issue, the necessity of treatment, or the type of treatment or level of care proposed or utilized, the determination will be made by a medical reviewer who has the education, training and relevant expertise in the field of medicine necessary to evaluate the specific clinical issues that serve as the basis of the appeal.
For appeals involving a decision based on Medical Necessity, the Company’s written response will describe the criteria or guidelines used and the clinical reasons for its decision and the option to request external review. For determinations that the services are not Covered Services, the response will specify the provisions in the Certificate that exclude that coverage.
The Covered Person may obtain, upon request and free of charge, copies of all documents, records and other information relevant to the appeal.
II. The Appeals Process
If the Covered Person disagrees with a Company decision regarding an authorization or a claim, the dispute shall be directed to the Company either by telephone or in writing. The appeal must be filed within 180 days of receiving a denial notice or explanation of benefits. To initiate the standard appeal, the Covered Person may call the Company’s Customer Service Department to request an appeal form or write the Appeals Department at the address below:
Appeals Department
P.O. Box 6103, M/S CA 124-0197
Cypress, CA 90630-0023
Fax: 1-866-704-3420
Urgent Appeal: Appeals involving an imminent and serious threat to the Covered Person’s health including, but not limited to, severe pain or the potential loss of life, limb or major bodily function, will be immediately referred to the Company’s clinical review personnel. Urgent appeal requests may be initiated by calling Customer Service or faxing a written request to the Appeals Department. If the request does not meet the criteria for an Urgent Appeal, it will be reviewed under the standard appeal process. If the appeal requires urgent review, the Company will make a determination not later than 72 hours of the Company’s receipt of the appeal.
Standard Appeal: If the appeal does not qualify as an urgent appeal, it will be reviewed as a standard appeal. The Appeals Department will provide a written response regarding the outcome within 30 calendar days from receipt of the appeal for an authorization denial and within 60 calendar days from receipt of an appeal for a claim denial.
Quality of Care/Quality of Service Review
All quality of clinical care and quality of service complaints are investigated by the Company. The Company conducts reviews by investigating the complaint and consulting with treating Providers and other UnitedHealthcare internal departments. Medical records are requested and reviewed as necessary and, as such, the Covered Person may need to sign an authorization to release medical records. The Company will notify the Covered Person in writing regarding the disposition of the complaint within 30 days of receipt of the complaint. Please be aware that the results of the quality of clinical care review are confidential and protected from legal discovery in accordance with state law.
III. Statement of ERISA Rights
Contact your employer’s Benefit Administrator to learn whether your plan is an employee welfare benefit plan as defined by the Employee Retirement Income Security Act of 1974 (ERISA). If you participate in an ERISA employee welfare benefit plan, ERISA provides you with certain rights and protections.
- All benefit determination or claim procedures are described for you in your summary plan description.
- If you receive an adverse benefit determination, a determination notice will be forwarded to you, electronically or in writing, within a reasonable time not to exceed 90 days of the date the Claim is submitted.
- You may appeal any adverse benefit determination. ERISA provides you with at least 180 days from the day you receive notice of an adverse benefit determination to appeal it. You will be provided an opportunity to submit relevant information in support of your appeal.
- ERISA provides for up to 2 mandatory appeal levels for any adverse determination. You have a right to bring a civil action on any adverse determination that you believe, after participating in the mandatory appeal process, was incorrectly made under your plan.
- ERISA provides that, in connection with any appeal of an adverse benefit determination, You have the right to request access to and receive a free copy of any and all documents, records, and other information, as follows:
- Relied on in making your benefit determination;
- Submitted, considered, or generated in the course of making your benefit determination;
- Which demonstrates compliance with administrative safeguards concerning consistent application of the plan document among similar claims; and
- Any plan Policy statement or guidance regarding your diagnosis.
- ERISA provides that most benefit appeal determination notices will be forwarded to you, in writing, within a reasonable period not to exceed 60 days from the date of the plan’s receipt of the benefit appeal request.
- Your participation in a voluntary appeal level does not affect your legal review rights, or any rights you have under your plan. Any statute of limitations will be tolled during the time you participate in a voluntary review level.
- You and Your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your state insurance regulatory agency.