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) 202 Step 3: We consider your request for medical care coverage and give you our answer. For standard coverage decisions we use the standard deadlines. This means we will give you an answer within 14 calendar days after we receive your request for a medical item or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request. · However, if you ask for more time, or if we need more information that may benefit you we can take up to 14 more days if your request is for a medical item or service. If we take extra days, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. · If you believe we should not take extra days, you can file a “fast complaint”. We will give you an answer to your complaint as soon as we make the decision. (The process for making a complaint is different from the process for coverage decisions and appeals. See Section 10 of this chapter for information on complaints.) For Fast Coverage decisions we use an expedited timeframe A fast coverage decision means we will answer within 72 hours if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours. · However, if you ask for more time, or if we need more information that may benefit you we can take up to 14 more days. If we take extra days, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. · If you believe we should not take extra days, you can file a “fast complaint.” (See Section 10 of this chapter for information on complaints.) We will call you as soon as we make the decision. · 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. Step 4: If we say no to your request for coverage for medical care, you can 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 medical care coverage you want. If you make an appeal, it means you are going on to Level 1 of the appeals process. Section 5.3 Step-by-step: How to make a Level 1 appeal Legal Terms An appeal to the plan about a medical care coverage decision is called a plan “reconsideration.”