2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 231 - If you do not want to accept the decision, you may be able to continue to the next level of the review process. If the Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 appeal and how to continue with a Level 5 appeal. Level 5 appeal: A judge at the Federal District Court will review your appeal. · A judge will review all of the information and decide yes or no to your request. This is a final answer. There are no more appeal levels after the Federal District Court. Section 9.2 Appeal Levels 3, 4, and 5 for Part D Drug Requests This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your appeals have been turned down. If the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to your Level 2 appeal will explain who to contact and what to do to ask for a Level 3 appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 appeal: An Administrative Law Judge or an attorney adjudicator who works for the Federal government will review your appeal and give you an answer. · If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge or attorney adjudicator within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision. · If the answer is no, the appeals process may or may not be over. - If you decide to accept this decision that turns down your appeal, the appeals process is over. - If you do not want to accept the decision, you can continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal. Level 4 appeal: The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the Federal government. · If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that was approved by the Council within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision. · If the answer is no, the appeals process may or may not be over.