An 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 health plan pays or will pay for a service or the amount you must pay for a service. Look through the document several times and make sure that all fields are completed with the correct information. UnitedHealthcare Community Plan SHINE is an independent organization. 2023 WellMed Medical Management Inc. All Rights Reserved. Please note that our list of medications that require prior authorization, formulary exceptions or coverage determinations can change, Submit a Pharmacy Prior Authorization. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. The letter will explain why more time is needed. Your health plan must follow strict rules for how we identify, track, resolve and report all appeals and grievances. Enrollment If you are unable to use the online reconsideration and appeals process outlined in Chapter 10: Our claims process, mail or fax appeal forms to: UnitedHealthcare Appeals These special rules also help control overall drug costs, which keeps your drug coverage more affordable. You may file a verbal by calling customer service or a written grievance by writing to the plan within sixty (60) of the date the circumstance giving rise to the grievance. You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. Box 31364 Box 31364 P.O. You, your doctor or other provider, or your representative must contact us. You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email. Resource Center Expedited 1-866-308-6296, Standard 1-844-368-5888TTY 711 To inquire about the status of a coverage decision, contact UnitedHealthcare, How to appoint a representative to help you with a coverage determination or an appeal, Both you and the person you have named as an authorized representative must sign the representative form. Salt Lake City, UT 84130-0770. Our response will include our reasons for this answer. A grievance may be filed by any of the following: 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 health plan or a Contracting Medical Provider. The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. Prior Authorization Department 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.". Continue to use your standard P.O. Santa Ana, CA 92799 Lack of cleanliness or the condition of a doctors office. Submit a written request for a Part C/Medical and Part D grievance to: UnitedHealthcare Appeals and Grievances Department Part C/Medical Open the email you received with the documents that need signing. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. UnitedHealthcare Appeals and Grievances Department Part C/Medical, Part D - Grievance, Coverage Determinations and Appeals. PO Box 6106 Copyright 2013 WellMed. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required). You have the right to request an expedited grievance if you disagree with your health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your health plan's decision to process your expedited reconsideration request as a standard request. Medicare Part B or Medicare Part D Coverage Determination (B/D). Expedited Fax: 801-994-1349 If we do not agree with some or all of your complaint or dont take responsibility for the problem you are complaining about, we will let you know. Begin eSigning wellmed appeal form with our tool and join the numerous satisfied clients whove already experienced the benefits of in-mail signing. Whether you call or write, you should contact Customer Service right away. If you don't get approval, the plan may not cover the drug. If you have a complaint, you or your representative may call the phone number listed on the back of your member ID card. To find the plan's drug list go to the Find a Drug Look Up Page and download your plans formulary. 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. Complaints about access to care are answered in 2 business days. Fax: 1-844-226-0356. Part C Appeals: Write of us at the following address: Complaints related to Part D must be made within 90 calendar days after you had the problem you want to complain about. Call:1-800-290-4009 TTY 711 ", Send the letter or the Redetermination Request Form to the 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. Benefits We will also use the standard 3 business day deadline (or the 72 hour deadline for Medicare Part B prescription drugs) instead. If possible, we will answer you right away. Get Form How to create an eSignature for the wellmed provider appeal address The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. Note: PDF (Portable Document Format) files can be viewed with Adobe Reader. You can call Member Services and ask us to make a note in our system that you would like materials in Spanish, large print, braille, or audio now and in the future. P.O. Download your copy, save it to the cloud, print it, or share it right from the editor. We may give you more time if you have a good reason for missing the deadline. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. You need to call or write to us to ask for a formal decision about the coverage. P.O. This also includes problems with payment. For example: "I. If you don't get approval, the plan may not cover the drug. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. Contact # 1-866-444-EBSA (3272). A grievance is a type of complaint you make if you have a problem that does not involve payment or services by your health plan or a Contracting Medical Provider. Please refer to your plans Appeals and Grievance process located in Chapter 8: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document. If you have any problem reading or understanding this or any other UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) information, please contact our Member Services at 1-877-542-9236(TTY 711,) from 7 a.m. to 8 p.m. Monday through Friday (voice mail available 24 hours a day/7 days a week) for help at no cost to you. ATTENTION: If you speak an alternative language, language assistance services, free of charge, are available to you. Medicare patients' claims must be filed no later than the end of the calendar year following the year in which the services were provided. Cypress, CA 90630-9948 This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept, Call 1-800-290-4909 TTY 711 If we approve your request, youll be able to get your drug at the start of the new plan year. MS CA124-0187 Need Help Registering? You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information. Review your plan's Appeals and Grievances process in the Evidence of Coverage document. If you have any of these problems and want to make a complaint, it is called filing a grievance.. You may contact UnitedHealthcare to file an expedited Grievance. Complaints related to Part D can be made at any time after you had the problem you want to complain about. The legal term for fast coverage decision is expedited determination.". P.O. If your appeal is regarding a Part B drug which you have not yet received, the timeframe for completion is 7 calendar days. An appeal may be filed by calling us at 1-800-256-6533 (TTY 711) 8 a.m. to 8p.m. An appeal may be filed either in writing or verbally. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. For example: I. We will try to resolve your complaint over the phone. Contact Us - WellMed Medical Group Contact Us Your health is important to us If you are a current patient, interested in becoming a WellMed patient or have a question you would like answered, please contact our Patient Advocate Team. What to do if you have a problem or complaint (coverage decisions, appeals, complaints). 2023 UnitedHealthcare | All Rights Reserved, Healthcare Provider Administrative Guides and Manuals, Claims reconsiderations and appeals - 2022 Administrative Guide, Neighborhood Health Partnership supplement - 2022 Administrative Guide, How to contact NHP - 2022 Administrative Guide, Discharge of a member from participating providers care - 2022 Administrative Guide, Laboratory services - 2022 Administrative Guide, Capitated health care providers - 2022 Administrative Guide, Sign in to the UnitedHealthcare Provider Portal, Health plans, policies, protocols and guides, The UnitedHealthcare Provider Portal resources, Claim reconsideration and appeals process. Salt Lake City, UT 84131 0364 All you need is smooth internet connection and a device to work on. These limits may be in place to ensure safe and effective use of the drug. If your request is for a Medicare Part B prescription drug, we will give you a decision no more than 72 hours after we receive your request. P.O. Install the signNow application on your iOS device. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services. A written Grievance may be filed by writing to, Fax/Expedited appeals only 1-866-308-6294, Call1-800-290-4009 TTY 711