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) 230 For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 appeal: An Administrative Law Judge or an attorney adjudicator who works for the Federal government will review your appeal and give you an answer. · If the Administrative Law Judge or attorney adjudicator says yes to your appeal, the appeals process may or may not be over. Unlike a decision at a Level 2 appeal, we have the right to appeal a Level 3 decision that is favorable to you. If we decide to appeal, it will go to a Level 4 appeal. - If we decide not to appeal, we must authorize or provide you with the medical care within 60 calendar days after receiving the Administrative Law Judge’s or attorney adjudicator’s decision. - If we decide to appeal the decision, we will send you a copy of the Level 4 appeal request with any accompanying documents. We may wait for the Level 4 appeal decision before authorizing or providing the medical care in dispute. · If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process may or may not be over. - If you decide to accept this decision that turns down your appeal, the appeals process is over. - If you do not want to accept the decision, you can continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal. Level 4 appeal: The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the Federal government. · If the answer is yes, or if the Council denies our request to review a favorable Level 3 appeal decision, the appeals process may or may not be over. Unlike a decision at Level 2, we have the right to appeal a Level 4 decision that is favorable to you. We will decide whether to appeal this decision to Level 5. - If we decide not to appeal the decision, we must authorize or provide you with the medical care within 60 calendar days after receiving the Council’s decision. - If we decide to appeal the decision, we will let you know in writing. · If the answer is no or if the Council denies the review request, the appeals process may or may not be over. - If you decide to accept this decision that turns down your appeal, the appeals process is over.