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.
The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for a medical item/service and Part B 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 given in writing that we make about your benefits and coverage or about the amount we will pay for your medical items/services or Part B 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 item/service or Part B drug before you receive it, you can ask us to make a coverage decision for you.
Timing of the organization decision depends on the type of request.
Standard Part C pre-service or benefit
Within 14 calendar days after receipt of your request
Standard Part B drug request
Within 72 hours after receipt of your request
Expedited request for Part C benefit – if you or your doctor believe your health will be harmed by waiting 14 calendar days
Within 72 hours after receipt of your request
Expedited request for Part B drug – if you or your doctor believe your health will be harmed by waiting 72 hours
Within 24 hours after receipt of your request
Reimbursement requests
Within 30-60 calendar days, if not earlier, after receipt of your request
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 will 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.
An appeal may be filed by any of the following:
You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
An appeal is a type of complaint you make regarding an item/service or Part B drug:
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:
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.
An appeal may be filed in writing or by contacting UnitedHealthcare Customer Service. To file an appeal in writing, please complete the Medicare plan appeal and grievance form (PDF) (760.99 KB) and follow the instructions provided.
Mail a written request for an appeal to the UnitedHealthcare Appeals and Grievances Department at the address listed in your Evidence of Coverage. To find your Evidence of Coverage, visit the Plan Summary page and enter your ZIP code. On the page that appears, look for a section titled Plan Documents.
Fax your written request to the fax number listed in your Evidence of Coverage. To find your Evidence of Coverage, visit the Plan Summary page and enter your ZIP code. On the page that appears, look for a section titled Plan Documents.
Call 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 or contact UnitedHealthcare. To find your Evidence of Coverage, visit the Plan Summary page and enter your ZIP code. On the page that appears, look for a section titled Plan Documents.
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.
You should include:
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.
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.
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
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:
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 24 hours in Time-Sensitive situations with no allowable extensions.