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) 228 · During this review, we take another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan’s coverage for services you were receiving. Step 3: We give you our decision within 72 hours after you ask for a “fast review”. · If we say yes to your appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.) · If we say no to your appeal, then your coverage will end on the date we told you and we will not pay any share of the costs after this date. · If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end, then you will have to pay the full cost of this care. Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals process. Legal Term The formal name for the “independent review organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step-by-Step: Level 2 Alternate Appeal Process During the Level 2 appeal, the independent review organization reviews the decision we made to your “fast appeal.” This organization decides whether the decision should be changed. The independent review organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the independent review organization. Medicare oversees its work. Step 1: We automatically forward your case to the independent review organization.