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) 200 · Section 6 of this chapter: “Your Part D prescription drugs: How to ask for a coverage decision or make an appeal of a coverage decision” · Section 7 of this chapter: “How to ask us to cover a longer inpatient hospital stay if you think you are being discharged too soon” · Section 8 of this chapter: “How to ask us to keep covering certain medical services if you think your coverage is ending too soon” (Applies only to these services: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services) If you’re not sure which section you should be using, please call Customer Service. You can also get help or information from government organizations such as your State Health Insurance Assistance Program. Section 5 Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision Section 5.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care This section is about your benefits for medical care. These benefits are described in Chapter 4 of this document: Medical Benefits Chart (what is covered and what you pay). In some cases, different rules apply to a request for a Part B prescription drug. In those cases, we will explain how the rules for Part B prescription drugs are different from the rules for medical items and services. This section tells what you can do if you are in any of the five following situations: 1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. Ask for a coverage decision. Section 5.2. 2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan. Ask for a coverage decision. Section 5.2. 3. You have received medical care that you believe should be covered by the plan, but we have said we will not pay for this care. Make an appeal. Section 5.3. 4. You have received and paid for medical care that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care. Send us the bill. Section 5.5. 5. You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health. Make an appeal. Section 5.3. Note: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read Sections 7 and 8 of this Chapter. Special rules apply to these types of care.