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) 214 · If our answer is yes to part or all of what you requested, we must provide the coverage as quickly as your health requires, but no later than 7 calendar days after we receive your appeal. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision. Deadlines for a “standard appeal” about payment for a drug you have already bought · We must give you our answer within 14 calendar days after we receive your request. - If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. · If our answer is yes to part or all of what you requested, we are also required to make payment to you within 30 calendar days after we receive your request. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal. Step 4: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal. · If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process. Section 6.6 Step-by-step: How to make a Level 2 appeal Legal Term The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” The independent review organization is an independent organization hired by Medicare. It is not connected with us and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: You (or your representative or your doctor or other prescriber) must contact the independent review organization and ask for a review of your case. · If our plan says no to your Level 1 appeal, the written notice we send you will include instructions on how to make a Level 2 appeal with the independent review organization. These instructions will tell who can make this Level 2 appeal, what deadlines you must follow, and how to reach the review organization. If, however, we did not complete our review within the applicable timeframe, or make an unfavorable decision regarding “at-risk” determination under our drug management program, we will automatically forward your claim to the IRE.