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) 227 What happens if the review organization says no? · It means they agree with the decision made to your Level 1 appeal. · The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by an Administrative Law Judge or attorney adjudicator. Step 4: If the answer is no, you will need to decide 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. · The Level 3 appeal is handled 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 8.5 What if you miss the deadline for making your Level 1 appeal? You can appeal to us instead As explained above, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal Legal Term A “fast” review (or “fast appeal”) is also called an “expedited appeal.” Step 1: Contact us and ask for a “fast review.” · Ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Chapter 2 has contact information. Step 2: We do a “fast” review of the decision we made about when to end coverage for your services.