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) 212 · 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 14 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 coverage request, you can make an appeal. · If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking again to get the drug coverage you want. If you make an appeal, it means you are going on to Level 1 of the appeals process. Section 6.5 Step-by-step: How to make a Level 1 appeal Legal Terms An appeal to the plan about a Part D drug coverage decision is called a plan “redetermination.” A “fast appeal” is also called an “expedited redetermination.” Step 1: Decide if you need a “standard appeal” or a “fast appeal.” A “standard appeal” is usually made within 7 days. A “fast appeal” is generally made within 72 hours. If your health requires it, ask for a “fast appeal” · If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.” · The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision” in Section 6.4 of this chapter. Step 2: You, your representative, doctor or other prescriber must contact us and make your Level 1 appeal. If your health requires a quick response, you must ask for a “fast appeal.” · For standard appeals, submit a written request. Chapter 2 has contact information.