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) 225 Act quickly: · You must contact the Quality Improvement Organization to start your appeal by noon of the day before the effective date on the Notice of Medicare Non-Coverage. · If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to file an appeal, you must make an appeal directly to us instead. For details about this other way to make your appeal, see Section 8.5. Step 2: The Quality Improvement Organization conducts an independent review of your case. Legal Term “Detailed Explanation of Non-Coverage.” Notice that provides details on reasons for ending coverage. What happens during this review? · Health professionals at the Quality Improvement Organization (“the reviewers”) will ask you, or your representative, why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. · The review organization will also look at your medical information, talk with your doctor, and review the information that our plan has given to them. · By the end of the day the reviewers tell us of your appeal, you will get the Detailed Explanation of Non-Coverage from us that explains in detail our reasons for ending our coverage for your services. Step 3: Within one full day after they have all the information they need; the reviewers will tell you their decision. What happens if the reviewers say yes? · If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as it is medically necessary. · You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). There may be limitations on your covered services. What happens if the reviewers say no? · If the reviewers say no, then your coverage will end on the date we have told you. · If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself.