Member

Medical Appeals and Grievances

UnitedHealthcare Group Medicare Advantage®

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 filing 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 that we make about your benefits and coverage or about the amount we will pay for your medical services, items or drugs. We 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.

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 file an appeal.

You can also request to receive the total number of appeals, grievances, and exceptions that members have filed against our plan in the past. To receive this information, call Member Services.

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:

Fill out the Appointment of Representative Form ; or
Provide your Medicare Advantage health plan with your name, your Medicare Beneficiary Identifier (MBI) 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 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.

What is an appeal

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding an item/service or Part B drug, 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 items/services or a Part B drug 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 an item/service or Part B drug you think should be covered.
Your Medicare Advantage health plan or one of the contracting medical providers reduces or cuts back on items/services or a Part B drug 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 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 can submit your appeal request online using the Medicare Plan Appeals & Grievances Online Form on our member website. To file an appeal in writing, please complete the Medicare Plan Appeals & Grievances Form and follow the instructions provided. You may also contact 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 or the amount of payment your Medicare Advantage health plan paid for an item/service or Part B drug.

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 item/service or Part B drug. 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 after you file your appeal

If you appeal, UnitedHealthcare will review the decision. If any of the items/services or Part B drugs 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.

Timing of the appeal answer depends on the type of request.

Type of Request	Timing of Appeal Answer
Standard Part C Pre-Service or Benefit	Within 30 calendar days after receipt of your request
Standard Part B Drug Request	Within 7 calendar days after receipt of your request
Expedited Part C Pre-Service or Benefit	Within 72 hours after receipt of your request
Expedited Part B Drug Request	Within 72 hours after receipt of your request
Reimbursement Requests	Within 60 calendar days after receipt of your request

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 provider 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 will issue a decision as fast as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request. For Part B drugs, your Medicare Advantage plan will provide a decision as fast as possible, but no later than 72 hours in Time-Sensitive situations with no allowable extensions.

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:

Fill out the Appointment of Representative Form and mail it to your Medicare Advantage plan; or
Provide your Medicare Advantage health plan with your name, your Medicare Beneficiary Identifier (MBI) 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 regarding the denial or discontinuation of medical services.”
Provide your name, address and phone number and that of your representative, if applicable.
Provide your Medicare Beneficiary Identifier (MBI) from your member ID card.
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 an 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 reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where a grievance can be filed

A grievance may be filed in writing or by contacting 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 can submit your grievance request online using the Medicare Plan Appeals & Grievances Online Form on our member website. To file a grievance in writing, please complete the Medicare Plan Appeals & Grievances Form and follow the instructions provided. You may also contact Customer Service and request the facsimile number for Appeals and Grievances.