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UnitedHealthcare Community Plan
UnitedHealthcare Community Plan

Healthy Louisiana Plan

Grievance and Appeals

If you have a concern or question regarding care or coverage, you should contact Member Services at 1-866-675-1607 (TTY: 711). A Member Service Representative will answer any questions or concerns you may have. They can also assist you to file a grievance or appeal. Your provider can also file a grievance or appeal on your behalf with your written permission. We will not take any negative action against your provider for assisting you or filing your grievance or appeal for you.

Quick Forms:

 

Grievance and Appeals Form                 
English (PDF 131.83 KB) | Espanol (PDF 141.22 KB) | Vietnamese (PDF 30.21 KB)


State Fair Hearing Form
English (PDF 155.75 KB)| Espanol (PDF 170.5 KB) | Vietnamese (PDF 38.43 KB)

 

How to file a grievance

If you have an expression of dissatisfaction or not happy with service UnitedHealthcare Community Plan has provided, you can file a grievance. Possible subjects for a grievance include, but are not limited to, access to care, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, medical transportation issues or failure to respect your rights.   

You can file a grievance by calling Member Services or using the Grievance and Appeals Form. You can also find a copy of the Grievance and Appeals Form on page 61 of the Member Handbook. You can send us the form or a written letter to the address below:

UnitedHealthcare Community Plan
Appeals and Grievance Unit
P.O. Box 31364
Salt Lake City, Utah 84131

If you choose to send a letter, we ask you have the following information: your name, your member ID number, your contact information (telephone number and address), and the reason for your grievance.

You have 30 days to file your grievance from the date of the event that caused you to be unhappy. We will tell you that we have your grievance. We will finish reviewing your case within 90 days. We will let you know if we need an extra 14 (calendar) days to look at your case. We will only take more time if it could help you or if you ask us.

How to appeal an action

If we deny, reduce, limit or terminate a request for a service you or your doctor makes, that is considered a “plan action” and you may appeal our decision.

You or someone acting on your behalf (provider, family member, etc.) can file an appeal by calling Member Services at 1-866-675-1607 (TTY: 711) or using the Grievance and Appeals Form. You can also find a copy of the Grievance and Appeals Form on page 61 of the Member Handbook. You can send us the form or a written letter to the address below:

UnitedHealthcare Community Plan
Appeals and Grievance Unit
P.O. Box 31364
Salt Lake City, Utah 84131

If you file your appeal by calling us, we will send you a letter acknowledging your appeal has been received.

You must file your appeal within 30 calendar days of receiving UnitedHealthcare’s Notice of Action. If you need help writing or filing an appeal, call Member Services at 1-866-675-1607 (TTY: 711).

You may request to continue to receive benefits during your appeal. If you wish to have your benefits continue at their current level, you must request the appeal before your benefits end. If you receive our decision letter less than 15 days before your services end, you can have 15 days from the date on our decision letter to make your request.

If you request an appeal during the period between the date of the Notice of Adverse Action and the date the action will be taken, your services must be continued or reinstated unless:

1. You indicate in writing that you do not want your benefits continued; or

2. A determination is made that the sole issue is one of an existing or change in State or Federal law; or

3. A change unrelated to the appeal issue affecting your eligibility for Medicaid occurs while the decision is pending and you do not request a State Fair Hearing after receiving the notice of change; or

4. Benefits are reduced or terminated as a result of a mass change.

Your benefits or services will continue at their prior level until your Medicaid eligibility ends or until the resolution of the appeal, whichever occurs first. If we determine our initial decision we made in your case is correct, that is, we rule against your appeal, you may be required to repay the amount of any benefits you received during the process.

If someone else is going to file an appeal for you, we must have your written permission for that person to file your appeal. Parties to the appeal may include a legal representative of a deceased member’s estate.

We will send you a letter telling you we received your appeal. We will review your appeal and send you our decision within 30 calendar days of receiving your appeal.

This timeframe may be extended up to 14 days if you ask for the extension or we show that there is need for additional information and the delay is in your interest. If we ask for an extension, we will give you written notice of the reason for the delay.

You will receive a letter telling the reason for our decision and what to do if you don’t like the decision.

UnitedHealthcare will resolve an appeal and provide written notice of the resolution within 30 calendar days. UnitedHealthcare may extend this time frame by up to 14 calendar days upon a member’s request or if UnitedHealthcare demonstrates the need for more information and that a delay in rendering the decision is in the member’s best interest.

For any extension not requested by the member, UnitedHealthcare will give the member written notice of the reason for delay.

What can I do if I need immediate care?

If you or your doctor wants a fast decision because your health is at risk, call Member Services at
1-866-675-1607 (TTY: 711) for an expedited review of an Action. UnitedHealthcare Community Plan will call you with our decision within 72 hours of getting your request for an expedited review. This timeframe may be extended up to 14 days if you ask for the extension or we show that there is need for additional information and the delay is in your interest. If we ask for an extension, we will give you written notice of the reason for the delay. You will receive a letter telling the reason for our decision and what to do if you don’t like the decision.

How to request a State Fair Hearing
If you are not happy with our appeal decision, you can request a State Fair Hearing. This can be done by telephone, fax, in writing or on the website for the Division of Administrative law, http://www.adminlaw. state.la.us/HH.htm. You can use the State Fair Hearing Form to request a State Fair Hearing.  You can also find a copy of the State Fair Hearing Form on page 61 of the Member Handbook.  You or a representative of your choice, or a provider, acting on your behalf with your written consent may file a State Fair Hearing request within 30 days from the date shown on our decision letter. If you wish to have your benefits continue at their current level, you must request the State Fair Hearing before your benefits end. For any benefits that were previously authorized and are now being reduced, our decision letter must be issued at least 10 days prior to the date of the action.

If someone else is going to file a State Fair Hearing for you, we must have your written permission for that person to file your request. Parties to the State Fair Hearing may include a legal representative of a deceased member’s estate.

A Healthy Louisiana member who exercises the right to a State Fair Hearing is called a claimant/appellant. The claimant/appellant may represent himself at the State Fair Hearing or be represented by any authorized representative such as a friend, relative, provider, legal counsel or other spokesperson.

An Authorized Representative refers to any authorized person acting on behalf of a claimant/appellant. This can be the claimant/appellant’s friend, relative, attorney, paralegal, legal guardian, provider or any person the claimant/appellant chooses. The authorized representative must be acting with the permission of the claimant/appellant unless the claimant/appellant is under an order of interdiction.

Other Plan Details

You have the right to ask someone to represent you at the hearing. If you request a State Fair Hearing during the period between the date of the Notice of Adverse Action and the date the action will be taken, your services must be continued or reinstated unless:

1. You indicate in writing that you do not want your benefits continued; or

2. A determination is made that the sole issue is one of an existing or change in State or Federal law; or

3. A change unrelated to the appeal issue affecting your eligibility for Medicaid occurs while the State Fair Hearing decision is pending and you do not request a State Fair Hearing after receiving the notice of change; or

4. Benefits are reduced or terminated as a result of a mass change.

Your benefits or services will continue at their prior level until your Medicaid eligibility ends or until the resolution of the State Fair Hearing, whichever occurs first. If the State Fair Hearing judge finds the decision we made in your case is correct, that is, rules against your appeal, you may be required to repay the amount of any benefits you received during the State Fair Hearing process.

You may file the request for a State Fair Hearing either orally or in writing to:

Division of Administrative Law Health and Hospitals Section
P.O. Box 4189
Baton Rouge, LA 70821-4189

Fax:       225-219-9823
Phone:  225-342-5800 or 225-342-0443
Online:  http://www.adminlaw. state.la.us/HH.htm

In a State Fair Hearing, the Division of Administrative Law shall make the recommendation to the Secretary of the DHH who has final authority to determine whether services must be provided.

What if I want to choose a different plan?

You may change your plan for any reason during the first 90 calendar days after the date of your first enrollment; or when we receive notice of your enrollment, whichever is later. After the 90 calendar days you will be locked into your health plan until open enrollment. Contact Healthy Louisiana at 1-855-Bayou4U (1-855-229-6848) or online at www.bayouhealth.com.

How do I request disenrollment from my managed care plan, before my 12-month re-enrollment period?

You may request to be disenrolled from the Plan with cause such as: moving out of state; poor quality of care; unable to get access to care or the providers you need for your health care needs. Please call BAYOUHEALTH at 1-855-BAYOU4U (1-855-229-6848) TTY: 1-855-LAMed4Me (1-855-526-3346).

Questions?

Ready to get started?

Call Us:
1-866-675-1607
TTY: 711

Monday – Friday
7 a.m. – 7 p.m.

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