You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. 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. If your 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 expeditiously as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request.Ī grievance may be filed by any of the following:Ī grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your health plan or a Contracting Medical Provider. 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: You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. You may use the appeal procedure when you want a reconsideration of a decision (coverage determination) that was made regarding a service or the amount of payment your health plan paid for a service. You may fax your written request toll-free to 1-87. UnitedHealthcare Appeals and Grievances Department Part D UnitedHealthcare Complaint and Appeals Department Include in your written request the reason why you could not file within the sixty (60) day timeframe.Īn appeal may be filed in writing directly to us. Note: The sixty (60) day limit may be extended for good cause. If you think that your health plan is stopping your coverage too soon.your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.your health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.your health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.For example, you may file an appeal for any of the following reasons: You may file an appeal within sixty (60) calendar days of the date of the notice of the coverage determination. Review your plan's Appeals and Grievances process in the Evidence of Coverage document.Īn appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, 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.
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