2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 227 · We are required to send the information for your Level 2 appeal to the independent review organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. Section 10 of this chapter tells how to make a complaint.) Step 2: The independent review organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. · Reviewers at the independent review organization will take a careful look at all of the information related to your appeal. · If this organization says yes to your appeal, then we must pay you back for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care 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 services. · If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it. - The notice you get from the independent review organization will tell you in writing what you can do if you wish to go on to a Level 3 appeal. Step 3: If the independent review organization says no to your appeal, you choose whether you want to take your appeal further. · There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision. · A Level 3 appeal is reviewed by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 9 Taking your appeal to Level 3 and beyond Section 9.1 Appeal Levels 3, 4, and 5 for Medical Service Requests This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your appeals have been turned down. If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. The written response you receive to your Level 2 appeal will explain how to make a Level 3 appeal.