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) 210 · If we say no to your request, you can ask for another review by making an appeal. Section 6.4 Step-by-step: How to ask for a coverage decision, including an exception Legal Term A “fast coverage decision” is called an “expedited coverage determination.” Step 1: Decide if you need a “standard coverage decision” or a “fast coverage decision.” “Standard coverage decisions” are made within 72 hours after we receive your doctor’s statement. “Fast coverage decisions” are made within 24 hours after we receive your doctor’s statement. If your health requires it, ask us to give you a “fast coverage decision.” To get a fast coverage decision, you must meet two requirements: · You must be asking for a drug you have not yet received. (You cannot ask for fast coverage decision to be paid back for a drug you have already bought.) · Using the standard deadlines could cause serious harm to your health or hurt your ability to function. · If your doctor or other prescriber tells us that your health requires a “fast coverage decision,” we will automatically give you a fast coverage decision. · If you ask for a fast coverage decision on your own, without your doctor or prescriber’s support, we will decide whether your health requires that we give you a fast coverage decision. If we do not approve a fast coverage decision, we will send you a letter that: - Explains that we will use the standard deadlines. - Explains if your doctor or other prescriber asks for the fast coverage decision, we will automatically give you a fast coverage decision. - Tells you how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. We will answer your complaint within 24 hours of receipt. Step 2: Request a “standard coverage decision” or a “fast coverage decision.” Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You can also access the coverage decision process through our website. We must accept any written request, including a request submitted on the