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) 223 · If this organization says yes to your appeal, then we must pay you back for our share of the costs of hospital care you received since the date of your planned discharge. We must also continue the plan’s coverage of your inpatient hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services. · If this organization says no to your appeal, it means they agree that your planned hospital discharge date was medically appropriate. The written notice you get from the independent review organization will tell how to start a - Level 3 appeal with the review process, which is handled by an Administrative Law Judge or attorney adjudicator. Step 3: If the independent review organization turns down your appeal, you choose whether you want to take your appeal further. · There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 appeal, you decide whether to accept their decision or go on to Level 3 appeal. · Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon Section 8.1 This section is only about three services: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services When you are getting covered home health services, skilled nursing care, or rehabilitation care (Comprehensive Outpatient Rehabilitation Facility), you have the right to keep getting your services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. When we decide it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, we will stop paying our share of the cost for your care. If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal. Section 8.2 We will tell you in advance when your coverage will be ending