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) 215 · We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file. · You have a right to give the independent review organization additional information to support your appeal. Step 2: The independent review organization reviews your appeal. Reviewers at the independent review organization will take a careful look at all of the information related to your appeal. Deadlines for “fast” appeal · If your health requires it, ask the independent review organization for a “fast appeal.” · If the organization agrees to give you a “fast appeal,” the organization must give you an answer to your Level 2 appeal within 72 hours after it receives your appeal request. Deadlines for “standard” appeal · For standard appeals, the review organization must give you an answer to your Level 2 appeal within 7 calendar days after it receives your appeal if it is for a drug you have not yet received. If you are requesting that we pay you back for a drug you have already bought, the review organization must give you an answer to your Level 2 appeal within 14 calendar days after it receives your request. Step 3: The independent review organization gives you their answer. For “fast” appeals · If the independent review organization says yes to part or all of what you requested, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization. For “standard” appeals · If the independent review organization says yes to part or all of your request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization. · If the independent review organization says yes to part or all of your request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization. What if the review organization says no to your appeal? If this organization says no to part or all of your appeal, it means they agree with our decision not to approve your request (or part of your request). (This is called “upholding the decision.” It is also called “turning down your appeal.”) In this case, the independent review organization will send you a letter: