2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs 178 UnitedHealthcare P.O. Box 30995 Salt Lake City, UT 84130-0995 Part D prescription drug payment requests: OptumRx P.O. Box 650287 Dallas, TX 75265-0287 You must submit your Part C (medical) claim to us within 12 months of the date you received the service, item, or Part B drug. You must submit your Part D (prescription drug) claim to us within 36 months of the date you received the service, item, or drug. Section 3 We will consider your request for payment and say yes or no Section 3.1 We check to see whether we should cover the service or drug and how much we owe When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision. · If we decide that the medical care or drug is covered and you followed all the rules, we will pay for our share of the cost. If you have already paid for the service or drug, we will mail your reimbursement of our share of the cost to you. If you have not paid for the service or drug yet, we will mail the payment directly to the provider. · If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. We will send you a letter explaining the reasons why we are not sending the payment and your rights to appeal that decision. Section 3.2 If we tell you that we will not pay for all or part of the medical care or drug, you can make an appeal If you think we have made a mistake in turning down your request for payment or the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment. The appeals process is a formal process with detailed procedures and important deadlines. For details on how to make this appeal, go to Chapter 9 of this document.