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, contact Customer Service.

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  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 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. 

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.

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:

•     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.

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.