UnitedHealthcare Community Plan
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Grievance

Grievance is a written or verbal expression of dissatisfaction about any matter other than an action. A member may file a grievance either verbally or in writing. A provider may file a grievance when acting as the member’s authorized representative.

 

The member may file a grievance by calling UnitedHealthcare Community Plan at 800-641-1902, 711 (TTY for the hearing impaired), OR

 

Writing to:

UnitedHealthcare Community Plan

Attn: Appeals and Grievances

P.O. Box 31364

Salt Lake City, UT 84131

 

We will try to get an answer in 15 working days. If that is not possible, an answer should be received no longer than 90 calendar days from the date the complaint/grievance was filed.

 

Appeals

You play an integral role in the appeal process for UnitedHealthcare Community Plan members. This includes you acting on the member’s behalf with written consent, and providing medical records and certification of the emergent nature of appeals as appropriate.

 

Appeal is a request for review of an action.

 

 

Action is when the plan:

  • Makes an adverse determination or limits authorizationof requested service(s) including the type or level ofservice;
  • Reduces, suspends or terminates a previouslyauthorized service;
  • Refuses or denies, in whole or part, payment forservices;
  • Fails to provide services in a timely manner, as definedby the state or CMS; or
  • Fails to act within the time frames required by state or CMS.

 

CMS allows UnitedHealthcare Community Plan members the right to appeal any decision regarding provision of services or claim payment whether the decision is made by UnitedHealthcare Community Plan or you. Whenever you deny a service, you are obligated, under CMS’s requirements, to provide that patient with his or her UnitedHealthcare Community Plan appeal rights. The member has the right to:

 

  • Appeal the decision by calling or writing to the Customer Service Center within 90 calendar days of the notice of action.

 

UnitedHealthcare Community Plan

Attn: Appeals and Grievances

P.O. Box 31364

Salt Lake City, UT 84131

800-641-1902 (toll-free)

TTY: 711 for the hearing impaired

(available 7:00 a.m. to 7:00 p.m. CT and 6:00 a.m. to

6:00 p.m. MT Monday through Friday.)

  • Member has the right to present the Appeal in person

Monday through Friday, 8:00 a.m. to 5:00 p.m. CT at:

UnitedHealthcare Community Plan

2717 N. 118th Street Suite #300

Omaha, NE 68164

  • Receive a copy of the rule used to make the decision
  • Ask someone (a family member, friend, lawyer, healthcare provider, etc.) to help with the appeal. The member has the right to present evidence, and allegations of fact or law, in person as well as in writing. If someone else helps the member with their appeal, the member will need to sign a form called Assignment of Record (AOR). The form grants permission to the other party to help the member on their behalf with the appeal process.
  • The enrollee or representative may review the case file, including medical records and any other documents or records, before and during the appeal process.
  • Send written comments or documents to be considered in deciding the appeal.
  • Ask for an expedited appeal if waiting for this health service would increase the risk to the patient’s health. The member or care provider has limited time (72 hours) to represent evidence and allegations of fact or law, in person and in writing.
  • Ask for continuation of services during the appeal. However, the patient may be required to pay for the Health service if the service is continued and it is decided that the patient should not have received the service.
  • Time frame that the health plan has to resolve standard appeal is 45 calendar days from the day the Health Plan receives the appeal.
  • Time frame that the health plan has to resolve an expedited appeal is 72 hours from the day the Health Plan receives the appeal. The Health Plan may extend the expedited appeal response up to 14 calendar days if any other below conditions apply:

1. Member request

2. The Health plan shows to the satisfaction of DHHS upon its request that there is need for additional information and how the delay is in the enrollee’s interest.

State Fair Hearings

State Fair Hearing is a request by a member or physician to appeal a decision made by the health plan, addressed to the state.

 

The member or his/her representative may request the state of Nebraska for a State Fair Hearing only after receiving notice that the Health plan is upholding the adverse benefit determination. Write to the state within 90 calendar days from the date of the MCO’s notice of resolution.

 

Department of Health and Human Services

Legal Services – Hearing Section

P.O. Box 98914

Lincoln, NE 68509-8914

 

  • The patient can call UnitedHealthcare Community Plan Customer Service for assistance in writing the letter as necessary
  • The patient may call the NE DHHS MLTC Legal Services at 402-471-7237. The patient may have someone else such as a family member, friend, healthcare provider, or lawyer attend with them. Note: A member or member representative may request a State Fair Hearing only after receiving notice the health plan is upholding the adverse benefit determination.

You have the same appeal rights as members.

Ask for continuation of services during the State Fair Hearing. However, the patient may be required to pay for the health service if the service is continued and it is decided that the patient should not have received the service.

Claims Administrative Appeals

Claims administrative appeals (claim reconsiderations) are ppeals of any payment decision made after the health care ervice was rendered. Some of the common reasons for claims dministrative appeals include, but are not limited to, disputes concerning the following reasons:

 

  • Failure to obtain required prior notification
  • Untimely submission of claim
  • Reimbursement disputes

Claims administrative appeals may be made for claims that are:

  • Denied in entirety
  • Denied in part
  • Paid at a rate alleged to be inconsistent with contracted rates

 

Claims administrative appeals must be filed within the time frames specified in your contract. Failure to file a claims administrative appeal within the required time frame shall be a waiver of your right to appeal in this or any other forum. You acknowledge it will not be paid for any services provided to UnitedHealthcare members regardless of the merits of the underlying claim if no appeal is filed in a timely manner. Any decision by UnitedHealthcare will be final and binding and not subject to arbitration or any adjudication in a court of law or other administrative, executive or judicial proceeding if you fail to appeal the decision. Non-Par Providers: Claims must be received within 365 days of the date services were rendered.

 

To file a claims administrative appeal (claim reconsideration), you should send a written appeal via regular mail to:

UnitedHealthcare Community Plan

Provider Claim Disputes

P.O. Box 31365

Salt Lake City, UT 84131

 

The cover letter should state that a claims administrative appeal is being made. Several claims with the same reasons for appeal may be combined in a single appeal letter, with an attached list of claims.

 

State the specific reason for denial as stated on the remittance.

 

UnitedHealthcare does not accept appeals that fail to address the reason for the denial as stated on the remittance.

 

For appeals of payment rates, state the basis for the dispute and enclose all relevant documentation, including but not limited to contract rate sheets and fee schedules