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) 197 Medicare You can also contact Medicare to get help. To contact Medicare: · You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. · You can also visit the Medicare website (www.medicare.gov). Section 3 To deal with your problem, which process should you use? If you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. The guide that follows will help. Is your problem or concern about your benefits or coverage? This includes problems about whether medical care (medical items, services and/or Part B prescription drugs) are covered or not, the way they are covered, and problems related to payment for medical care. Yes. Go on to the next section of this chapter, Section 4, “A guide to the basics of coverage decisions and appeals.” No. Skip ahead to Section 10 at the end of this chapter: “How to make a complaint about quality of care, waiting times, customer service or other concerns.” Coverage decisions and appeals Section 4 A guide to the basics of coverage decisions and appeals Section 4.1 Asking for coverage decisions and making appeals: the big picture Coverage decisions and appeals deal with problems related to your benefits and coverage for your medical care (services, items and Part B prescription drugs, including payment). To keep things simple, we generally refer to medical items, services and Medicare Part B prescription drugs as medical care. You use the coverage decision and appeals process for issues such as whether something is covered or not and the way in which something is covered. Asking for coverage decisions prior to receiving benefits A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical care. For example, if your plan network doctor refers you to a medical specialist not inside the network, this referral is considered a favorable coverage decision unless either your network doctor can show that you received a standard denial notice for this medical