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) 205 Section 5.4 Step-by-step: How a Level 2 appeal is done 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: The independent review organization reviews your appeal. · We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file. · You have a right to give the independent review organization additional information to support your appeal. · Reviewers at the independent review organization will take a careful look at all of the information related to your appeal. If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2 · For the “fast appeal” the review organization must give you an answer to your Level 2 appeal within 72 hours of when it receives your appeal. · However, if your request is for a medical item or service and the independent review organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The independent review organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 2 · For a “standard appeal” if your request is for a medical item or service, the review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal. If your request is for a Medicare Part B prescription drug, the review organization must give you an answer to your Level 2 appeal within 7 calendar days of when it receives your appeal. · However, if your request is for a medical item or service and the independent review organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The independent review organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.