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) 201 Section 5.2 Step-by-step: How to ask for a coverage decision Legal Terms When a coverage decision involves your medical care, it is called an “organization determination.” A “fast coverage decision” is called an “expedited determination.” Step 1: Decide if you need a “standard coverage decision” or a “fast coverage decision”. A “standard coverage decision” is usually made within 14 days or 72 hours for Part B drugs. A “fast coverage decision” is generally made within 72 hours, for medical services, or 24 hours for Part B drugs. In order to get a fast coverage decision, you must meet two requirements: · You may only ask for coverage for medical items and/or services (not requests for payment for items and/or services already received). · You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. · If your doctor tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision. · If you ask for a fast coverage decision on your own, without your doctor’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 asks for the fast coverage decision, we will automatically give you a fast coverage decision. - Explains that you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. Step 2: Ask our plan to make a coverage decision or 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, your doctor, or your representative can do this. Chapter 2 has contact information.