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) 222 · If we say yes to your appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date. We will keep providing your covered inpatient hospital services for as long as they are medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.) · If we say no to your appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends as of the day we said coverage would end. - If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. Step 4: If our plan says no to your appeal, your case will automatically be sent on to the next level of the appeals process. Step-by-Step: Level 2 alternate appeal process Legal Term The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” The independent review organization is an independent organization hired by Medicare. It is not connected with our plan and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: We will automatically forward your case to the independent review organization. · We are required to send the information for your Level 2 appeal to the independent review organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. Section 10 of this chapter tells how to make a complaint.) Step 2: The independent review organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. · Reviewers at the Independent review organization will take a careful look at all of the information related to your appeal of your hospital discharge.