Medicare Advantage (Part C) Coverage Decisions, Appeals and Grievances

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 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.

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.

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 (PDF) and mail it to your Medicare Advantage plan; or
• 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 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 Indentifier (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 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 regarding an item/service or Part B drug:

• when you want a reconsideration of a decision (determination) that was made
• or the amount of payment your Medicare Advantage health plan pays or will pay
• or the amount you must pay.

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 UnitedHealthcare Customer Service. To file an appeal in writing, please complete the Medicare Plan Appeal & Grievance Form (PDF) (760.99 KB) and follow the instructions provided.

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
• your address
• your Medicare Beneficiary Identifier (MBI) from your member ID card
• 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 next

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.

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 24 hours in Time-Sensitive situations with no allowable extensions.

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 (PDF) and mail it to your Medicare Advantage plan; or
• 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 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 Indentifier (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 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 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. To file a grievance in writing, please complete the Medicare Plan Appeal & Grievance Form (PDF) (760.99 KB) and follow the instructions provided.

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.

If you would like to provide feedback regarding your Medicare plan, you can contact Customer Service toll-free at FED TFN (TTY 711), 8 a.m. – 8 p.m., 7 days a week or you can provide feedback directly to Medicare through their Complaint Form about your Medicare health plan or prescription drug plan.