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) 211 CMS Model Coverage Determination Request Form, which is available on our website. Chapter 2 has contact information. To assist us in processing your request, please be sure to include your name, contact information, and information identifying which denied claim is being appealed. You, your doctor, (or other prescriber) or your representative can do this. You can also have a lawyer act on your behalf. Section 4 of this chapter tells how you can give written permission to someone else to act as your representative. · If you are requesting an exception, provide the “supporting statement,” which is the medical reasons for the exception. Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary. Step 3: We consider your request and give you our answer. Deadlines for a “fast” coverage decision · We must generally give you our answer within 24 hours after we receive your request. - For exceptions, we will give you our answer within 24 hours after we receive your doctor’s supporting statement. We will give you our answer sooner if your health requires us to. - If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. · If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal. Deadlines for a “standard” coverage decision about a drug you have not yet received · We must generally give you our answer within 72 hours after we receive your request. - For exceptions, we will give you our answer within 72 hours after we receive your doctor’s supporting statement. We will give you our answer sooner if your health requires us to. - If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. · If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal. Deadlines for a “standard” coverage decision about payment for a drug you have already bought · We must give you our answer within 14 calendar days after we receive your request.