Medicare-Medicaid Appeals and Grievances Process

Your health plan must follow strict rules for how we identify, track, resolve and report all appeals and grievances. The following information applies to benefits provided by your Medicare benefit.

For information regarding your Medicaid benefit and the appeals and grievances process, please access your Medicaid Plan’s Member Handbook.

Appeals, Coverage Determinations and Grievances

Medicare Complaint Form

Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • Provide your health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting an appeal from your health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
    • Click here to find and download the CMS Appointment of Representation form.
  • Review your plan's Appeals and Grievances process in the Evidence of Coverage document.
  
  

  What is an Appeal?

  An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

  When can an Appeal be filed?

  You may file an appeal within sixty (60) calendar days of the date of the notice of the coverage determination. For example, you may file an appeal for any of the following reasons:

  • your health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
  • your health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
  • your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
  • If you think that your health plan is stopping your coverage too soon.
  
  

  Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

  Where can an Appeal be filed?

  An appeal may be filed in writing directly to us.

  UnitedHealthcare Complaint and Appeals Department

P.O. Box 6103

MS CA124-0187

Cypress, CA 90630-0023

Fax: Expedited appeals only - 1-844-226-0356

OR

Call 1-877-614-0623 TTY 711
8 a.m. - 5 p.m. PT, Monday – Friday

UnitedHealthcare Appeals and Grievances Department Part D




You may fax your written request toll-free to 1-877-960-8235.


Or Call 1-877-614-0623 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (coverage determination) that was made regarding a service or the amount of payment your health plan paid for a service. 

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize: 




If your health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request.

Medicare Complaint Form

Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

 

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office. 

When can a Grievance be filed?

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. 

Expedited Grievance

You have the right to request an expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where can a Grievance be filed?

A grievance may be filed in writing directly to us.

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Grievance, Coverage Determinations and Appeals

Filing a grievance (making a complaint) about your prescription coverage

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

Some types of problems that might lead to filing a grievance include:




If you have any of these problems and want to make a complaint, it is called "filing a grievance."

Who may file a grievance

You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.

Filing a grievance with our plan

The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number listed on the back of your member ID card. We will try to resolve your complaint over the phone.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.

UnitedHealthcare Appeals and Grievances Department Part C

UnitedHealthcare Complaint and Appeals Department

P. O. Box 6103, MS CA124-0187
Cypress, CA 90630-0023

OR

Call 1-877-614-0623 TTY 711
8 a.m. - 5 p.m. PT, Monday – Friday

UnitedHealthcare Appeals and Grievances Department Part D

Or Call 1-877-614-0623 TTY 711


8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

•  
  • your life or health, or
  • your ability to regain maximum function.
  • You may file a grievance.
  • Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
    • Provide your Medicare Advantage health plan with your name, your and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in filing a grievance from  my health plan the quality of services I have received from my provider."
    • You must sign and date the statement.
    • Your representative must also sign and date this statement.
    • You must include this signed statement with your grievance.
  • Issues with the service you receive from Customer Service.
  • If you feel that you are being encouraged to leave (disenroll from) the plan.
  • If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
  • We don't give you a decision within the required time frame.
  • We don't give you required notices.
  • You believe our notices and other written materials are hard to understand.
  • Waiting too long for prescriptions to be filled.
  • Rude behavior by network pharmacists or other staff.
  • We don't forward your case to the Independent Review Entity if we do not give you a decision on time.

If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

1. You may submit a written request for a Fast Grievance to the Medicare Part C and Part D Appeals & Grievance Dept. at PO Box 6103, MS CA124-0197 Cypress CA 90630-0023; or
2. You may fax your written request toll-free to 1-877-960-8235; or
3. You may contact UnitedHealthcare to file an expedited Grievance.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

• Or Call 1-877-614-0623 TTY 711 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

Review the Evidence of Coverage for additional details..

Medicare Complaint Form

Coverage Determination

Asking for a coverage determination (coverage decision)

An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the coverage.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug , or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier.
  • Tier exceptions are not available for drugs in the Preferred Generic Tier.
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier level that does not contain branded drugs used for your condition.
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs.
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form (PDF)(54.6 KB) – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.

Both you and the person you have named as an authorized representative must sign the representative form.

For Coverage Determinations

OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

For Appeals

Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294

If your prescribing doctor calls on your behalf, no representative form is required.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email.
• Send the letter or the Redetermination Request Form to the Medicare Part C and Part D Appeals and Grievance Department PO Box 6103, MS CA124-0197, Cypress CA 90630-0023.You may also fax your letter of appeal to the Medicare Part D Appeals and Grievances Department toll-free at 1-877-960-8235 or call 1-877-614-0623 TTY 711. 8.a.m. – 8 p.m.: 7 days Oct-Mar; M-F Apr-Sept. You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The Medicare Part C and Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

UnitedHealthcare Coverage Determination Part C

P. O. Box 31364
Hot Springs, AR 71903-9675
Fax: Fax/Expedited appeals only – 1-501-262-7072

OR

Call 1-877-614-0623 TTY 711
8 a.m. - 5 p.m. PT, Monday – Friday

UnitedHealthcare Coverage Determination Part D

Attn: Medicare Part D Appeals & Grievance Dept.
PO Box 6103, M/S CA 124-0197
Cypress CA 90630-0023

Fax: Fax/Expedited appeals only 1-501-262-7072

Or Call 1-877-614-0623 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

2020 Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Morphine Milligram Equivalent (MME) limits
• Opioid day supply limits (7-day supply)
• Therapeutic dose limits
• Clinically significant drug interactions
  • Therapeutic duplication
  • Inappropriate or incorrect drug therapy
  • Patient-specific drug contraindications
  • Under-utilization
  • The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Appeals, Coverage Determinations and Grievances

Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.

Medicare Complaint Form

Appeals

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting an appeal from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
    • Click here to find and download the CMS Appointment of Representation form.
  • Review your plan's Appeals and Grievances process in the Evidence of Coverage document.

Medicare Complaint Form

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

When can an Appeal be filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the coverage determination. For example, you may file an appeal for any of the following reasons:

• your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
• your Medicare Advantage health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your Medicare Advantage health plan is stopping your coverage too soon.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Where can an Appeal be filed?

An appeal may be filed in writing directly to us. See the contact information below for appeals regarding services.

UnitedHealthcare Appeals and Grievances Department Part C

UnitedHealthcare Complaint and Appeals Department
P. O. Box 6103
MS CA124-0187
Cypress, CA 90630-0023

Call: 1-888-867-5511
Available 8 a.m. to 8 p.m. local time, 7 days a week
Fax/Expedited appeals only Fax: 1-844-226-0356

An appeal may be filed in writing directly to us. 

UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197
Cypress CA 90630-0023

Fax: Fax/Expedited appeals only – 1-877-960-8235

OR

Call 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (coverage determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• your life or health, or
• your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus fourteen (14) calendar days, if an extension is taken, after receiving the request.

Medicare Complaint Form

Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting a grievance from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your grievance.

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your Medicare Advantage health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When can a Grievance be filed?

You may file a grievance at any time.

Expedited Grievance

You have the right to request an expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where can a Grievance be filed?

A grievance may be filed in writing or by phoning your Medicare Advantage health plan.

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Grievance, Coverage Determinations and Appeals

Filing a grievance (making a complaint) about your prescription coverage

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

Some types of problems that might lead to filing a grievance include:

• Issues with the service you receive from Customer Service.
• If you feel that you are being encouraged to leave (disenroll from) the plan.
• If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
• We don't give you a decision within the required time frame.
• We don't give you required notices.
• You believe our notices and other written materials are hard to understand.
• Waiting too long for prescriptions to be filled.
• Rude behavior by network pharmacists or other staff.
• We don't forward your case to the Independent Review Entity if we do not give you a decision on time.

If you have any of these problems and want to make a complaint, it is called "filing a grievance."

Who may file a grievance

You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.

Filing a grievance with our plan

The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number listed on the back of your member ID card. We will try to resolve your complaint over the phone.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. Submit a written request for a grievance to Part C & D Grievances:

Part C Grievances UnitedHealthcare Community plan

UnitedHealthcare Complaint and Appeals Department
P.O. ox 6103
MS CA124-0187
Cypress, CA 90630-0023

Or you can call us at: 1-888-867-5511
TTY 711.
Available 8 a.m. - 8 p.m. local time, 7 days a week

Part D Grievances UnitedHealthcare Part D Standard Appeals
Attn: Complaint and Appeals Department
P.O. Box 6103
MS CA 124-0197
Cypress, CA 90630-0023

Or you can call us at: 1-888-867-5511
TTY 711.
Available 8 a.m. - 8 p.m.; local time, 7 days a week

If you ask for a written response, file a written grievance, or if your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

1. You may submit a written request for a Fast Grievance to the Medicare Part D Appeals & Grievance Dept. at PO Box 6103, MS CA124-0197 Cypress CA 90630-0023; or
2. You may fax your written request toll-free to 1-866-308-6296; or
3. You may contact UnitedHealthcare to file an expedited Grievance.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

Whether you call or write, you should contact Customer Service right away. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

Review the Evidence of Coverage for additional details.

Medicare Complaint Form

Coverage Determination

Asking for a coverage determination (coverage decision)

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.

An initial coverage decision about your Part D drugs is called a “coverage determination.”, or simply put, a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug , or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand copay will apply.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it. 
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier. 
  • Tier exceptions are not available for drugs in the Preferred Generic Tier. 
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that does not contain branded drugs used for your condition. 
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs. 
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug. 

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form (PDF)(54.6 KB) – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Download the representative form. 

Both you and the person you have named as an authorized representative must sign the representative form. This statement must be sent to

For Coverage Determinations
Mail: OptumRx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

For Appeals
Mail: Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294 

If your prescribing doctor calls on your behalf, no representative form is required.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email.

Send the letter or the Redetermination Request Form to the Medicare Part D Appeals and Grievance Department P.O. Box 6103 MS CA 124-097 Cypress, CA 90630-0023.  You may also fax your letter of appeal to the Medicare Part D Appeals and Grievances Department toll-free at 1-877-960-8235. You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline. Or you can call us at: 1-888-867-5511 TTY 711. Available 8 a.m. - 8 p.m. local time, 7 days a week.

• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The Medicare Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

UnitedHealthcare Coverage Determination Part C
P. O. Box 29675
Hot Springs, AR 71903-9675
Call: 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week
Fax/Expedited Fax: 1-501-262-7070

An appeal may be filed in writing directly to us.
UnitedHealthcare Coverage Determination Part D
P. O. Box 29675
Hot Springs, AR 71903-9675
Call: 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week
Fax/Expedited Fax: 1-501-262-7070

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:

We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Clinically significant drug interactions
• Therapeutic duplication
• Inappropriate or incorrect drug therapy
• Patient-specific drug contraindications
• Over-utilization and under-utilization
• Abuse or misuse
• The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Coverage Determinations, Coverage Decsions and Appeals

Your health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.

Medicare Complaint Form

Medicare Part D Prior Authorization, Formulary Exception or Coverage Determination Request(s)

Prior Authorizations /Formulary Exceptions

Medicare Part D prior authorization forms list

Prescription Drugs - Not Covered by Medicare Part D

While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare Connected®. You can view our plan's List of Covered Drugs on our website at www.myuhc.com/communityplan. Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare Connected® (Medicare-Medicaid Plan). You do not have any co-pays for non-Part D drugs covered by our plan.

Please note that our list of medications that require prior authorization, formulary exceptions or coverage determinations can change

Submit a Pharmacy Prior Authorization. Formulary Exception or Coverage Determination Request to OptumRx.

Submit a Pharmacy Prior Authorization Request, Formulary Exception or Coverage Determination electronically to OptumRx

Appeals

Who can file an Appeal?

• An appeal may be filed by any of the following:
• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  
  • Provide your health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from your health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
• Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan’s member handbook

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your health plan pays or will pay for a service or the amount you must pay for a service.

When can an Appeal be filed?

You may file a Part C/Medicaid appeal within sixty (60) calendar days of the date of the notice of the initial coverage decision. For example, you may file an appeal for any of the following reasons:

• Your health plan refuses to cover or pay for services you think your health plan should cover.
• Your health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• Your health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your health plan is stopping your coverage too soon.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

If you are appealing because you were told that a service you are getting will be reduced or stopped, you have a shorter timeframe to appeal if you want us to continue covering that service while the appeal is processing.   For more information, please see your Member Handbook.

The standard resolution timeframe for a Part C/Medicaid appeal is 30 calendar days for a pre-service appeal.   If we need more time, we may take a 14 calendar day extension.   If we take an extension we will let you know.   

If your appeal is regarding a Part B drug which you have not yet received, the timeframe for completion is 7 calendar days.   An extension for Part B drug appeals is not allowed.

You have the right to request and received expedited decisions affecting your medical treatment.  A situation is considered “time-sensitive”.  A time sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision making process could seriously jeopardize:

• Your life or health, or
• Your ability to regain maximum function.

If your health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request.

Where can an Appeal be filed?

An appeal may be filed by calling Member Engagement Center 1-866-633-4454, TTY 711, 8 am – 8 pm local time, 7 days a week, writing directly to us, calling us or submitting a form electronically.

How do I Start an Appeal?

For a Part C/Medical appeal

You, your doctor or other provider, or your representative must contact us.

You can call us at 1-866-633-4454 (TTY 7-1-1), 8 am – 8 pm local time, Monday – Friday

Or, you, your doctor or other provider, or your representative write us at:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 6103
MS CA124-0187
Cypress, CA 90630-0023
Fax: 1-844-226-0356

For a Part D appeal 

You, your doctor or other provider, or your representative can write us at:

Part D Appeals:

UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6106
MS CA124-0197
Cypress, CA 90630-0023
Standard Fax: 1-866-308-6296

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your health plan paid for a service.

The standard resolution timeframe for a Part C/Medicaid appeal is 30 calendar days for a pre-service appeal. If we need more time, we may take a 14 calendar day extension. If we take an extension we will let you know.

If your appeal is regarding a Part B drug which you have not yet received, the timeframe for completion is 7 calendar days. An extension for Part B drug appeals is not allowed.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• your life or health, or
• your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request.
 

Coverage decisions and Appeals

Overview

When you ask for information on coverage decisions and making Appeals, it means that you’re dealing with problems related to your benefits and coverage. This also includes problems with payment. 

What is a coverage decision?

A coverage decision is a decision we make about what services, items, and drugs we will cover for you. For example, your plan network doctor makes a (favorable) coverage decision for you whenever you receive medical care from them or if your network doctor refers you to a medical specialist.

If you or your doctor are not sure if a service, item, or drug is covered by our plan, either of you can ask for a coverage decision before the doctor gives the service, item, or drug. In other words, if youwant to know if we will cover a service, item, or drug before you receive it, you can ask us to make a coverage decision for you.

Getting help

Who can I call for help with asking for coverage decisions or making an Appeal?

There are a few different ways that you can ask for help.

• Call the Member Engagement Center at 1-866-633-4454, TTY 711.
• Call, email, write, or visit My Ombudsman.
  • Call 1-855-781-9898, Monday through Friday from 9 am - 4 pm. People who are deaf, hard of hearing, or speech disabled should use MassRelay at 711 to call 1-855-781-9898 or Videophone (VP) 339-224-6831.
  • Email info@myombudsman.org. 
  • Visit My Ombudsman online at www.myombudsman.org.
  • Write to the My Ombudsman office at 11 Dartmouth Street, Suite 301, Malden, MA 02148.
• Call the State Health Insurance Assistance Program (SHIP) for free help. In Massachusetts, the SHIP is called SHINE. SHINE is an independent organization. It is not connected with this plan. The SHINE phone number is 1-800-243-4636. TTY (for people who are deaf, hard of hearing, or speech disabled): 1-800-439-2370 (Massachusetts only).
• Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or appeal on your behalf, and act as your representative. 
• Talk to a friend or family member and ask them to act for you. You can name another person to act for you as your representative to ask for a coverage decision or make an Appeal. 
  • If you want a friend, relative, or other person beside your provider to be your representative, call the Member Engagement Center and ask for the “Appointment of Representative” form. 
  • You can also get the form here.
  • The form gives the person permission to act for you. You must give us a copy of the signed form. Your designated representative will have the same rights as you do in asking for a coverage decision or making an Appeal. You do not need to provide this form for your doctor or other health care provider to act as your representative.
• You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Our plan will not pay for you to have a lawyer. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form. 
  • However, you do not have to have a lawyer to ask for any kind of coverage decision or to make an Appeal.

Asking for a coverage decision

You have two options to request a coverage decision. You may ask your provider to send clinical information supporting the request directly to the plan. Your provider is familiar with this process and will work with the plan to review that information. Alternatively, you may discuss the request with your Care Coordinator who can communicate with your provider and begin the process.

You can reach your Care Coordinator at:
Phone: 1-866-633-4454, TTY 711

Your provider can reach the health plan at:
Phone: 1-877-790-6543, TTY 711

Portal: www.UHCprovider.com

Mail: UnitedHealthcare Community Plan
P.O. Box 30770
Salt Lake City, UT 84130-0770

How long does it take to get a coverage decision?

It usually takes up to 14 calendar days after you ask unless your request is for a Medicare Part B prescription drug. If your request is for a Medicare Part B prescription drug, we will give you a decision no more than 72 hours after we receive your request. If we don’t give you our decision within 14 calendar days (or 72 hours for a Medicare Part B prescription drug), you can appeal.

Sometimes we need more time, and we will send you a letter telling you that we will take up to 14 more calendar days. The letter will explain why more time is needed. We can’t take extra time to give you a decision if your request is for a Medicare Part B prescription drug.

Can I get a coverage decision faster?

Yes. If you need a response faster because of your health, ask us to make a “fast coverage decision.” If we approve the request, we will notify you of our decision within 72 hours (or within 24 hours for a Medicare Part B prescription drug).

However, sometimes we need more time, and if that happens, we will send you a letter telling you that we will take up to 14 more calendar days. The letter will explain why more time is needed. We can’t take extra time to give you a decision if your request is for a Medicare Part B prescription drug.

The legal term for “fast coverage decision” is “expedited determination." 

To ask for a fast coverage decision:

• Start by calling our plan to ask us to cover the care you want.
• You can call us at 1-866-633-4454. For details on how to contact us, go to Chapter 2 in the EOC Member Handbook.
• You can also have your provider contact us through the portal or your representative can call us.

What are the rules for asking for a fast coverage decision?

You can get a fast coverage decision only if you meet the following two requirements:

1. You are asking about care you have not yet received. (You cannot ask for a fast coverage decision if your request is about care you already got.)
2. The usual 14 calendar day deadline (or the 72 hour deadline for Medicare Part B prescription drugs) could cause serious harm to your health or hurt your ability to function.

• If your provider says that you need a fast coverage decision, we will automatically give you one.
• If you ask for a fast coverage decision without your provider’s support, we will decide if you get a fast coverage decision.
  • If we decide not to give you a fast coverage decision, we will use the standard 14 calendar day deadline (or the 72 hour deadline for Medicare Part B prescription drugs) instead. We will also send you a letter.
  • This letter will tell you that if your provider asks for the fast coverage decision, we will automatically give you one.
  • The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of a fast coverage decision. For more information about the process for making complaints, including fast complaints, refer to Section J on page 179 in the EOC/Member Handbook.

How will I find out the plan’s answer about my coverage decision?

The plan will send you a letter telling you whether or not we approved coverage.

What if the coverage decision is No?

If the answer is No, the letter we send you will tell you our reasons for saying No.

• If we say No, you have the right to ask us to change this decision by making an Appeal. Making an Appeal means asking us to review our decision to deny coverage.
• If you decide to appeal the coverage decision, it means you are going on to Level 1 of the appeals process (read the next section for more information).

Coverage Determination

Asking for a coverage determination (coverage decision)

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.

An initial coverage decision about your Part D drugs is called a “coverage determination.”, or simply put, a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. And some drugs may require a coverage determination to verify whether they are covered by the Medicare Part D plan. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to the ‘Find a Drug’ Look Up Page and download your plan’s formulary.

Some drugs covered by the Medicare Part D plan have “limited access” at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)
The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)
There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply. 

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition
  • Tier exceptions are not available for drugs in the Specialty Tier.
  • Tier exceptions are not available for drugs in the Preferred Generic Tier.
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that does not contain branded drugs used for your condition.
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs.
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2022 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

If you have questions, please call UnitedHealthcare Connected® One Care at 1-866-633-4454 (TTY 7-1-1), 8 a.m. – 8 p.m. local time, Monday – Friday.

For Part C coverage decision:

Write: UnitedHealthcare Connected® One Care
PO Box 6103
MS CA124-0187
Cypress, CA 90630-0023
Fax: 1-844-226-0356 

For Part D coverage decision:

Write: OptumRx
Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form 
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form  or the Prior Authorization Request Forms listed below. The Prior Authorization Department will accept both request forms.
• Specialty Pharmacy Prior Authorization Request Forms 
• Note: PDF (Portable Document Format) files can be viewed with Adobe® Reader®. If you don't already have this viewer on your computer, download it free from the Adobe website.
  

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 TTY 711, 8 a.m. – 8 p.m. local time, 7 days a week, for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2022 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMP Appointment and Representation form.

Both you and the person you have named as an authorized representative must sign the representative form. This statement must be sent to

For Coverage Determinations

Mail:  OptumRx Prior Authorization Department
          P.O. Box 25183
          Santa Ana, CA 92799
 Fax:  1-844-403-1028

For Part D Appeals

Mail: Medicare Part D Appeals and Grievance Department
         PO Box 6106
         MS CA124-0197
         Cypress, CA 90630-0023

Fax: 1-866-308-6296
If your prescribing doctor calls on your behalf, no representative form is required.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

To file an appeal:

Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email.

Part D Appeals:
UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
PO Box 6103
MS CA124-0197
Cypress, CA 90630-0023
Fax: 1-866-308-6296

• You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The Medicare Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard appeal review for a Medicare Part D drug you have not yet received, we will give you our decision within 7 calendars days of receiving the appeal request.

For a standard appeal review regarding reimbursement for a Medicare Part D drug you have paid for and received, we will give you your decision within 14 calendar days.

If we do not give you our decision within 7 or 14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Clinically significant drug interactions
• Therapeutic duplication
• Inappropriate or incorrect drug therapy
• Patient-specific drug contraindications
• Over-utilization and under-utilization
• Abuse or misuse

The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting a grievance from your Medicare Advantage health plan regarding the denial or discontinuation of medical services.
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When can a Grievance be filed?

Complaints related to Part D can be made at any time after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid Issue can be made any time after you had the problem you want to complain about.   If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that.

Expedited Grievance

You have the right to request an expedited grievance if you disagree with your health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your health plan's decision to process your expedited reconsideration request as a standard request. In such cases, health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where can a Grievance be filed?

Call Member Engagement Center 1-866-633-4454, TTY 711, 8 a.m. – 8 p.m. local time, 7 days a week.               

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Grievance, Coverage Determinations and Appeals

Filing a grievance (making a complaint) about your prescription coverage

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

Some types of problems that might lead to filing a grievance include:

• Issues with the service you receive from Customer Service.
• If you feel that you are being encouraged to leave (disenroll from) the plan.
• If you disagree with our decision not to give you a “fast” decision or a “fast” appeal.
• We don't give you a decision within the required time frame.
• We don't give you required notices.
• You believe our notices and other written materials are hard to understand.
• Waiting too long for prescriptions to be filled.
• Rude behavior by network pharmacists or other staff.
• We don't forward your case to the Independent Review Entity if we do not give you a decision on time.

If you have any of these problems and want to make a complaint, it is called “filing a grievance.”

Who may file a grievance

You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.

Filing a grievance with our plan

The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.

Submit a written request for a grievance to Part C & D Grievances:  

Attn: Complaint and Appeals Department
P.O. Box 6106
MS CA124-0187
Cypress, CA 90630-0023
Or
Expedited Fax: 1-866-308-6296

If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

1. You may fax your expedited written request toll-free to 1-866-308-6296; or
2. You may contact UnitedHealthcare to file an expedited Grievance.

Please be sure to include the words “fast”, “expedited” or “24-hour review” on your request.

Whether you call or write, you should contact Customer Service right away. Complaints related to Part D can be made any time after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid issue can be made any time after you had the problem you want to complain about.  If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan’s member handbook.

This section details a brief summary of your health plan's processes for appeals, grievances, and Part D (prescription drug) coverage determinations. Because your plan is integrated with a Medicare Dual Special Needs Plan (D-SNP) and Medical Assistance (Medicaid) coverage, the appeals follow an integrated review process that includes both Medicare and Medical Assistance. Your appeal decision will be communicated to you with a written explanation detailing the outcome. Brief summaries of these processes can be found by clicking the quick links below for each section and full information regarding all of your plan's processes for appeals, grievances, and coverage determinations can be found in Chapter 9 of your plan's Member Handbook or Evidence of Coverage (EOC). You may also contact Member Services at 1-844-368-5888 TTY 711 for more information regarding your plan. 

SNBC (H7778-001-000): Minnesota Special Needs BasicCare (SNBC): Medicare & Medical Assistance (Medicaid)
MSHO (H7778-002-000): Minnesota Senior Health Options (MSHO): Medicare & Medical Assistance (Medicaid)

Coverage Determination

Appeals

Grievances

Coverage Determination

Asking for a coverage determination (coverage decision)

The process for coverage decisions deals with problems related to your benefits and coverage for benefits and prescription drugs, including problems related to payment. This is the process you use for issues such as whether a service or drug is covered or not and the way in which the service or drug is covered.

An initial coverage decision about your services or Part D drugs (prescription drugs) is called a "coverage determination." A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your service or prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

For more information regarding the process when asking for a coverage determination, refer to Chapter 9: "What to do if you have a problem or complaint (coverage decisions, appeals, complaints of the Member Handbook/Evidence of Coverage (EOC).

SNBC (H7778-001-000): Minnesota Special Needs BasicCare (SNBC): Medicare & Medical Assistance (Medicaid)
MSHO (H7778-002-000): Minnesota Senior Health Options (MSHO): Medicare & Medical Assistance (Medicaid)

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You may find the form you need here. You may find the form you need here.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug , or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand copay will apply.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it. 
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier. 
  • Tier exceptions are not available for drugs in the Preferred Generic Tier. 
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that does not contain branded drugs used for your condition. 
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs. 
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug. 

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Download the representative form. 

Both you and the person you have named as an authorized representative must sign the representative form. This statement must be sent to

For Coverage Determinations
Mail: OptumRx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

For Appeals
Mail: Medicare Part D Appeals and Grievance Department
PO Box 6106, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294 

If your prescribing doctor calls on your behalf, no representative form is required.

Making an appeal for your prescription drug coverage

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email.

Send the letter or the Redetermination Request Form to the Medicare Part D Appeals and Grievance Department P.O. Box 6106 MS CA 124-097 Cypress, CA 90630-0023.  You may also fax your letter of appeal to the Medicare Part D Appeals and Grievances Department toll-free at 1-877-960-8235. You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline. Or you can call us at: 1-888-867-5511 TTY 711. Available 8 a.m. - 8 p.m. local time, 7 days a week.

• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The Medicare Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

UnitedHealthcare Coverage Determination Part C
P. O. Box 29675
Hot Springs, AR 71903-9675
Call: 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week
Fax/Expedited Fax: 1-501-262-7070

An appeal may be filed in writing directly to us.
UnitedHealthcare Coverage Determination Part D
P. O. Box 29675
Hot Springs, AR 71903-9675
Call: 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week
Fax/Expedited Fax: 1-501-262-7070

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:

We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Clinically significant drug interactions
• Therapeutic duplication
• Inappropriate or incorrect drug therapy
• Patient-specific drug contraindications
• Over-utilization and under-utilization
• Abuse or misuse
• The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Appeals

Your health plan must follow strict rules for how it identifies, tracks, resolves and reports all appeals and grievances. The following information provides an overview of the appeals and grievances process. More information is located in the Evidence of Coverage.

What is an Appeal?

A health plan appeal is your request for us to review a decision we made regarding a service or drug coverage, or the amount of payment your health plan pays or will pay for a service or the amount you must pay. You can file an appeal for any of the following reasons:

• Your health plan refuses to provide or pay for services or drugs you think should be covered by your health Plan.
• Your health plan or one of the Contracting Medical Providers refuses to give you a service or drug you think should be covered.
• Your health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think your health plan is stopping your coverage too soon. 

When can an Appeal be filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of coverage determination. The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file your appeal within the sixty (60) calendar day timeframe. 

Who can file an Appeal?

An appeal may be filed by any of the following:

• Appeal can come from a physician without being appointed representative.
• You may file an appeal
• Your attending Health Care provider may appeal a utilization review decision (no signed consent needed).
• Someone else may file an appeal for you or on your behalf. You may appoint an individual to act as your representative to file an appeal for you by following the steps below.
  • Provide your health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a provider other than your attending Health Care provider).  For example: I, your name appoint name of representative to act as my representative in requesting an appeal from your health plan regarding the denial or discontinuation or medical services.”
  • You must sign and date the statement
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
• You can also use the CMS Appointment of Representative form (Form 1696). Click here to download the form. 

Types of Appeals

Standard Appeals

A standard appeal is an appeal which is not considered “time-sensitive”. Your health plan will issue a written decision as expeditiously as possible but no later than the following timeframes:

• Medical appeals – 30 calendar days or 44 calendar days if an extension is taken.
• Part D appeals – 7 calendar days or 14 calendar days if an extension is taken. If your appeal is regarding a drug which has already been received by you, the timeframe is 14 calendar days.
• Part B appeals – 7 calendar days. Part B appeals are not allowed extensions.

Expedited/Fast Appeals

You have the right to request and receive an expedited decision regarding your medical treatment in “time-sensitive” situations. A “time-sensitive” situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• Your life or health, or
• Your ability to regain maximum function

If your health plan or your Primary Care Provider decides, based on medical criteria, that your situation is time-sensitive or if any physician calls or writes in support of your request for an expedited review, your health plan will issue a decision as expeditiously as possible but no later than seventy-72 hours plus fourteen (14) calendar days, if an extension is taken, after receiving the request.

Where can an Appeal be filed?

An appeal may be filed either in writing or verbally.   See the contact information below: 

• Medical/Part B appeals 

UnitedHealthcare Complaint and Appeals Department
P. O. Box 6106
MS CA 124-0187
Cypress, CA  90630-0023

Fax:
Standard – 1-888-517-7113
Expedited - 1-866-373-1081

Or

Call: 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week.

• Prescription Drug/Part D appeals 

UnitedHealthcare Appeals and Grievances Department, Part D
P. O. Box 6106
MS CA 124-0197
Cypress, CA  90630-0023

Fax:
Standard – 1-866-308-6294
Expedited – 1-866-308-6296

Call:

Standard – 1-844-368-5888 TTY 711
Expedited – 1-855-409-7041

Available 8 a.m. to 8 p.m. local time, 7 days a week.

Grievances

What is a Grievance?

A grievance is a type of complaint you make if you have a problem that does not involve payment or services by your health plan or a Contracting Medical Provider.  

Some examples of problems that might lead to filing a grievance include:

• Issues with the service you receive from Customer Service
• If you feel you are being encouraged to leave (disenroll from) the Plan
• If you disagree with your health plan’s decision not to give you a “fast” decision or a “fast” appeal.
• Your health plan did not give you a decision within the required time frame.
• Your health plan doesn’t give you required notices
• You believe our notices and other written materials are hard to understand
• Waiting too long for prescriptions to be filled
• Waiting too long in the waiting room or the exam room
• Rude behavior by network pharmacists or other staff
• Your health plan doesn’t forward your case to the Independent Review Entity if you do not receive an appeal decision on time.  (For more information regarding the Independent Review Entity, please refer to your Evidence of Coverage.)
• Lack of cleanliness or the condition of a doctor’s office.
• The quality of care you received during a hospital stay.  

When can a Grievance be filed?

You may file a grievance at any time.

Who can file a grievance?

• You may file a grievance
• Someone else may file a grievance for you or on your behalf. You may appoint an individual to act as your representative to file a grievance for you by following the steps below.
  • Provide your health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a provider other than your attending Health Care provider). For example: “I, your name appoint name of representative to act as my representative in filing a grievance with your health plan.
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your grievance.

You can also use the CMS Appointment of Representative form (Form 1696).  Click here to download the form. 

Types of Grievances 

Standard Grievances

All other grievances will use the standard process. Grievances are responded to as expeditiously as possible, within 30 calendar days. Grievances submitted in writing or quality of care grievances are responded to in writing. If, when filing your grievance on the phone, you request a written response, we will provide you one.  

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.   If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include the reasons for our answer. We must respond whether we agree with your complaint or not. 

• Medical/Part B grievances

UnitedHealthcare Complaint and Appeals Department
P. O. Box 6106
MS CA 124-0187
Cypress, CA  90630-0023

Fax:
Standard – 1-888-517-7113
Expedited - 1-866-373-1081

Or

Call: 1-888-867-5511 TTY 711
Available 8 a.m. to 8 p.m. local time, 7 days a week.

• Prescription Drug/Part D grievances

UnitedHealthcare Appeals and Grievances Department, Part D
P. O. Box 6106
MS CA 124-0197
Cypress, CA  90630-0023

Fax:
Standard – 1-866-308-6294
Expedited – 1-866-308-6296

Or

Call:

Standard – 1-844-368-5888 TTY 711
Expedited – 1-855-409-7041

Available 8 a.m. to 8 p.m. local time, 7 days a week.

Expedited/Fast Complaint (Grievance)

You can file an expedited/fast complaint if one of the following has occurred:

• We denied your request to an expedited appeal or an expedited coverage of determination.  This type of decision is called a downgrade.  This means that we will utilize the standard process for your request. 
• We took an extension for an appeal or coverage determination.

Please include the words "fast", "expedited" or "24-hour review" on your request.  We will provide you with a written resolution to your expedited/fast complaint within 24 hours of receipt.

Appeals, Coverage Determinations and Grievances

Medicare Complaint Form

Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • Provide your health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting an appeal from your health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
    • Click here to find and download the CMS Appointment of Representation form.
  • Review your plan's Appeals and Grievances process in the Evidence of Coverage document.
  
  

  What is an Appeal?

  An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

  The standard resolution time frame for completion is 30 calendar days for a pre-service appeal. If we need more time, we may take a 14 day calendar day extension. If we take an extension, we will let you know.

  If your appeal is regarding a Part B drug which you have not yet received, the timeframe from completion is 7 calendar days. An extension for Part B drug appeals is not allowed.

   

  When can an Appeal be filed?

  You may file a Part C/Medical appeal within sixty (60) calendar days of the date of the notice of the coverage determination. For example, you may file an appeal for any of the following reasons:

  • your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
  • your Medicare Advantage health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
  • your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
  • If you think that your Medicare Advantage health plan is stopping your coverage too soon.
  
  

  Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

  Where can an Appeal be filed?

  An appeal may be filed in writing directly to us.

  UnitedHealthcare Complaint and Appeals Department

  P. O. Box 6103, MS CA124-0187
  Cypress, CA 90630-0023
  Fax: Expedited appeals only – 1-844-226-0356

  UnitedHealthcare Appeals and Grievances Department Part D

  PO Box 6103, MS CA 124-0197
  Cypress CA 90630-0023

  Fax: Expedited appeals only – 1-877-960-8235

  OR

  Call 1-800-514-4911 TTY 711
  8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

  Why file an Appeal?

  You may use the appeal procedure when you want a reconsideration of a decision (coverage determination) that was made regarding a service or the amount of payment your health plan paid for a service.

  Fast Decisions/Expedited Appeals

  You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize: 

  • your life or health, or
  • your ability to regain maximum function.
  
  

  If your health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request.

  Medicare Complaint Form

  Grievances

  Who can file a Grievance?

  A grievance may be filed by any of the following:

  • You may file a grievance.
  • Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
    • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in filing a grievance from my Medicare Advantage health plan regarding the quality of services I have received from my provider."
    • You must sign and date the statement.
    • Your representative must also sign and date this statement.
    • You must include this signed statement with your grievance.
  
  

  What is a Grievance?

  A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office. 

  When can a Grievance be filed?

  You may file a grievance within ninety (90) calendar days for Part C/Medical and sixty (60) calendar days for Part D after the problem happened.

  You may file a Part C/medical grievance at any time. Grievances regarding your drug benefit (Part D) must be filed within sixty (60) days after the problem happened.

  Expedited Grievance

  You have the right to request an expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.

  Where can a Grievance be filed?

  A grievance may be filed in writing directly to us.

  UnitedHealthcare Appeals and Grievances Department Part C/Medical

  P. O. Box 6103, MS CA124-0187
  Cypress, CA 90630-0023
  Fax: Expedited appeals only – 1-844-226-0356

  OR

  Call 1-800-514-4911 TTY 711
  8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

  A grievance may be filed in writing directly to us.

  UnitedHealthcare Appeals and Grievances Department Part D

  PO Box 6103, MS CA 124-0197
  Cypress CA 90630-0023

  Fax: Expedited appeals only – 1-877-960-8235

  OR

  Call 1-800-514-4911 TTY 711
  8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

  Why file a Grievance?

  You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

  Part D - Grievance, Coverage Determinations and Appeals

  Filing a grievance (making a complaint) about your prescription coverage

  A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

  Some types of problems that might lead to filing a grievance include:

  • Issues with the service you receive from Customer Service.
  • If you feel that you are being encouraged to leave (disenroll from) the plan.
  • If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
  • We don't give you a decision within the required time frame.
  • We don't give you required notices.
  • You believe our notices and other written materials are hard to understand.
  • Waiting too long for prescriptions to be filled.
  • Rude behavior by network pharmacists or other staff.
  • We don't forward your case to the Independent Review Entity if we do not give you a decision on time.
  
  

  If you have any of these problems and want to make a complaint, it is called "filing a grievance."

  Who may file a Grievance

  You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

  If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.

  Filing a Grievance with our plan

  The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.

  If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.

  Submit a written request for a Part C/Medical and Part D grievance to:  

  UnitedHealthcare Appeals and Grievances Department Part C/Medical
  P. O. Box 31364
  Salt Lake City, UT 84131-0364
  Fax: Fax/Expedited appeals only – 1-844-226-0356

  OR

  Call 1-800-514-4911 TTY 711
  8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

You may contact UnitedHealthcare to file an expedited Grievance. Please be sure to include the words "fast," "expedited" or "24-hour review" on your request.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

Whether you call or write, you should contact Customer Service right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

Review the Evidence of Coverage for additional details.'

Medicare Complaint Form

Coverage Determination

Asking for a coverage determination (coverage decision)

An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the coverage.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you . You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug, or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). 

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form (PDF)(54.6 KB) – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 8: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document. 

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.

Both you and the person you have named as an authorized representative must sign the representative form. This statement must be sent to

For Coverage Determinations

OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

For Appeals

Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294

If your prescribing doctor calls on your behalf, no representative form is required. Or you can call us at: 1-888-867-5511, TTY 711, Available 8 a.m. - 8 p.m. local time, 7 days a week.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email.
• Send the letter or the Redetermination Request Form to the Medicare Part C and Part D Appeals and Grievance Department PO Box 6103, MS CA124-0197, Cypress CA 90630-0023.You may also fax your letter of appeal to the Medicare Part D Appeals and Grievances Department toll-free at 1-877-960-8235. You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The Medicare Part C/Medical and Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

Submit a written request for an appeal to:  

An appeal may be filed in writing directly to us. 

UnitedHealthcare Coverage Determination Part C/Medical and Part D

P. O. Box 5250
Kingston, NY 12402-5250
Fax: Fax/Expedited appeals only – 1-501-262-7072

OR

Call 1-800-514-4911 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Morphine Milligram Equivalent (MME) limits
• Opioid day supply limits (7-day supply)
• Therapeutic dose limits
• Clinically significant drug interactions
  • Therapeutic duplication
  • Inappropriate or incorrect drug therapy
  • Patient-specific drug contraindications
  • Under-utilization
  • The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.

For information regarding your Medicaid benefit and the appeals and grievances process, please access your Medicaid Plan’s Member Handbook.

Appeals, Coverage Determinations and Grievances

Medicare Complaint Form

Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • Provide your health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting an appeal from your health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
    • Click here to find and download the CMS Appointment of Representation form.
  • Review your plan's Appeals and Grievances process in the Evidence of Coverage document.
  
  

  What is an Appeal?

  An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

  When can an Appeal be filed?

  You may file a Part C appeal within sixty (60) calendar days of the date of the notice of the coverage determination. For example, you may file an appeal for any of the following reasons:

  • your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
  • your Medicare Advantage health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
  • your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
  • If you think that your Medicare Advantage health plan is stopping your coverage too soon.
  
  

  Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

  Where can an Appeal be filed?

  An appeal may be filed in writing directly to us.

  UnitedHealthcare Appeals and Grievances Department Part C

  UnitedHealthcare Complaint and Appeals Department
  P.O. Box 6103
  MS CA124-0187
  Cypress, CA 90630-0023

  Fax: Expedited appeals only – 1-844-226-0356
  

  OR

  Call 1-877-517-7113 TTY 711

  8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

  An appeal may be filed in writing directly to us.

  UnitedHealthcare Appeals and Grievances Department Part D

  PO Box 6103, MS CA 124-0197
  Cypress CA 90630-0023

  Fax: Expedited appeals only – 1-866-308-6294

  OR

  Call 1-877-514-4912 TTY 711
  8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

  Why file an Appeal?

  You may use the appeal procedure when you want a reconsideration of a decision (coverage determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service. 

  Fast Decisions/Expedited Appeals

  You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize: 

  • your life or health, or
  • your ability to regain maximum function.
  
  

  If your health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request.

  Medicare Complaint Form

  Grievances

  Who can file a Grievance?

  A grievance may be filed by any of the following:

  • You may file a grievance.
  • Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
    • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in filing a grievance with my Medicare Advantage health plan regarding quality of services provided by my physician"
    • You must sign and date the statement.
    • Your representative must also sign and date this statement.
    • You must include this signed statement with your grievance.
  
  

  What is a Grievance?

  A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your Medicare Advantage health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

  When can a Grievance be filed?

  You may file a verbal grievance by calling customer service or a written grievance by writing to the plan within sixty (60) calendar days of the date of the circumstance giving rise to the grievance. 

  Expedited Grievance

  You have the right to request an expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.

  Where can a Grievance be filed?

  A grievance may be filed verbally or in writing. A verbal grievance may be filed by calling the Customer Service number on the back of your ID card. For complaints about Part D Drugs you may also call the phone number for Medicare Part D Grievances listed on the back of your ID Card. If we were unable to resolve your complaint over the phone you may file written complaint.

  A written Grievance may be filed by writing to the plan at the address listed in the Grievance, Coverage Determinations and Appeals section below.

  Why file a Grievance?

  You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information. 

  Prievance, Coverage Determinations and Appeals

  Filing a grievance (making a complaint) about your prescription coverage

  A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

  Some types of problems that might lead to filing a grievance include:

  • Issues with the service you receive from Customer Service.
  • If you feel that you are being encouraged to leave (disenroll from) the plan.
  • If you disagree with our decision not to give you a “fast” decision or a "fast" appeal.
  • We don't give you a decision within the required time frame.
  • We don't give you required notices.
  • You believe our notices and other written materials are hard to understand.
  • Waiting too long for prescriptions to be filled.
  • Rude behavior by network pharmacists or other staff.
  
  

  If you have any of these problems and want to make a complaint, it is called "filing a grievance."

  Who may file a grievance

  You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

  If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.

  Filing a grievance with our plan

  The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for listed on the back of your member ID card. We will try to resolve your complaint over the phone.

  If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. Submit a written request for a Part C and Part D grievance to:  

  Submit a written request for a Part C and Part D grievance to:  

  UnitedHealthcare Appeals and Grievances Department Part C

  UnitedHealthcare Complaint and Appeals Department
  P.O. Box 6103
  MS CA124-0187
  Cypress, CA 90630-0023

  OR

  Call 1-877-517-7113 TTY 711
  8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

  A grievance may be filed in writing directly to us.

  UnitedHealthcare Appeals and Grievances Department Part D

  P.O. Box 6106, MS CA124-0197
  Cypress, CA 90630-0023
  

  OR

  Call 1-877-514-4912 TTY 711
  8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

  If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.

  If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

  1. You may submit a written request for a Fast Grievance to the Medicare Part D Appeals & Grievance Dept. at PO Box 6106, M/S CA 124-0197, Cypress CA 90630-0016; or
  2. You may fax your written request toll-free to 1-866-308-6296; or
  3. You may contact UnitedHealthcare to file an expedited Grievance.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

• Or you may call 1-800-514-4912. TTY 711
• 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Whether you call or write, you should contact Customer Service right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

Review the Evidence of Coverage for additional details.

Medicare Complaint Form

Coverage Determination

Asking for a coverage determination (coverage decision)

An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the coverage.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you . You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug, or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier.
  • Tier exceptions are not available for drugs in the Preferred Generic Tier.
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that does not contain branded drugs used for your condition.
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs.
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form (PDF)(54.6 KB) – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case.  Click here to find and download the CMS Appointment of Representation form.

Both you and the person you have named as an authorized representative must sign the representative form.

For Coverage Determinations

OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

For Appeals

Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294

If your prescribing doctor calls on your behalf, no representative form is required.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at “Appeal Level 1” and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form  or by secure email.
• Send the letter or the Redetermination Request Form to the Medicare Part C and Part D Appeals and Grievance Department PO Box 6103, MS CA124-0197, Cypress CA 90630-0023.You may also fax your letter of appeal to the Medicare Part D Appeals and Grievances Department toll-free at 1-877-960-8235. You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The Medicare Part C and Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

Submit a written request for a Part C and Part D grievance to:  

UnitedHealthcare Coverage Determination Part C

UnitedHealthcare Complaint and Appeals Department
P.O. Box 6103
MS CA124-0187
Cypress, CA 90630-0023

OR

Call 1-877-514-4912 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

An appeal may be filed in writing directly to us. 

UnitedHealthcare Coverage Determination Part D

P. O. Box 29675
Hot Springs, AZ 71903-9675
Fax: Fax/Expedited appeals only – 1-501-262-7072

OR

Call 1-877-514-4912 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:
We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Morphine Milligram Equivalent (MME) limits
• Opioid day supply limits (7-day supply)
• Therapeutic dose limits
• Clinically significant drug interactions
  • Therapeutic duplication
  • Inappropriate or incorrect drug therapy
  • Patient-specific drug contraindications
  • Under-utilization
  • The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Medicare Complaint Form

Your health plan must follow strict rules for how it identifies, tracks, resolves and reports all appeals and grievances.

Medicare Part D Prior Authorization, Formulary Exception or Coverage Determination Request(s)

Prior Authorizations /Formulary Exceptions

Medicare Part D prior authorization forms list

Prescription Drugs - Not Covered by Medicare Part D

While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare® Connected™ for MyCare Ohio. You can view our plan's List of Covered Drugs on our website at www.myuhc.com/communityplan. Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare® Connected™ for MyCare Ohio (Medicare-Medicaid Plan). You do not have any co-pays for non-Part D drugs covered by our plan.

Please note that our list of medications that require prior authorization, formulary exceptions or coverage determinations can change.

Submit a Pharmacy Prior Authorization. Formulary Exception or Coverage Determination Request to OptumRx.

Submit a Pharmacy Prior Authorization Request, Formulary Exception or Coverage Determination electronically to OptumRx.

Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • Provide your health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting an appeal from your health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
    • Click here to find and download the CMS Appointment of Representation form.
  • Please refer to your plan's Appeals and Grievance process of the  Coverage Document or your plan's member handbook.

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your health plan pays or will pay for a service or the amount you must pay for a service.

When can an Appeal be filed?

You may file an appeal within ninety (90) calendar days of the date of the notice of the initial coverage decision. For example, you may file an appeal for any of the following reasons:

• your health plan refuses to cover or pay for services you think your health plan should cover.
• your health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• your health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your health plan is stopping your coverage too soon.

Note: The ninety (90) day limit may be extended for good cause. Include in your written request the reason why you could not file within the ninety (90) day timeframe.

If you are appealing because you were told that a service you are getting will be reduced or stopped, you have a shorter timeframe to appeal if you want us to continue covering that service while the appeal is processing.   For more information, please see your Member Handbook

In most cases, you must file your appeal with the Health Plan.  However, if your problem is about a service or item covered primarily by Medicaid or both Medicare and Medicaid, you can request a State Hearing which is filed with the Bureau of State Hearings.    

To file a State Hearing, your request must be made within 90 calendar days of receiving the notice of your State Hearing rights. The 90 calendar days begins on the day after the mailing date on the notice.  If you have a good reason for being late the Bureau of State Hearings may extend this deadline for you.

For more information regarding State Hearings, please see your Member Handbook 

Where can an Appeal be filed?

An appeal may be filed by calling us at 1-877-542-9236 (TTY 711) 8 a.m. to 8p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week) writing directly to us, calling us or submitting a form electronically via fax.

How do I Start an Appeal?

To start your appeal, you, your doctor or other provider, or your representative must contact us. You can call us at 1-877-542-9236 (TTY 7-1-1), 8 a.m. – 8 p.m. local time, Monday – Friday.

You can submit a request to the following address:

Part D Appeals:

UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6103
Cypress, CA 90630-9948
Standard Fax: 1-877-960-8235

Part C Appeals:

Write of us at the following address:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your health plan paid for a service.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• your life or health, or
• your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request.

Coverage Determination

Asking for a coverage determination (coverage decision)

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.

An initial coverage decision about your Part D drugs is called a "coverage determination.", or simply put, a "coverage decision." A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. And some drugs may require a coverage determination to verify whether they are covered by the Medicare Part D plan. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to the 'Find a Drug' Look Up Page and download your plan's formulary.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier.
  • Tier exceptions are not available for drugs in the Preferred Generic Tier.
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that does not contain branded drugs used for your condition.
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs.
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form (PDF)(54.6 KB) – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.

Both you and the person you have named as an authorized representative must sign the representative form.

For Coverage Determinations

OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

For Appeals

Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294

If your prescribing doctor calls on your behalf, no representative form is required.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage
Appeal Level 1 - You may ask us to review an adverse coverage decision we've issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

To file an appeal:

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form (PDF)(66.8 KB) or by secure email.

Send the letter or the Redetermination Request Form to the

Part D Appeals:
UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6103
Cypress, CA 90630-9948
Standard Fax: 877-960-8235

Part C Appeals:
Grievances and Medical (Non-Drug) Appeals:

Write of us at the following address:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082

• You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The Medicare Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

Who may file your appeal of the coverage determination?
If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:

We will give you our decision within 7 calendar days of receiving the appeal request. If we do not give you our decision within 7 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Clinically significant drug interactions
• Therapeutic duplication
• Inappropriate or incorrect drug therapy
• Patient-specific drug contraindications
• Over-utilization and under-utilization
• Abuse or misuse

The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
  
• Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
  
• Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting a grievance from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
• You must sign and date the statement.
• Your representative must also sign and date this statement.

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When can a Grievance be filed?

Complaints related to Part D must be made within 90 calendar days after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid Issue must be made within 90 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Complaints about access to care are answered in 2 business days.

Expedited Grievance

You have the right to request an expedited grievance if you disagree with your health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your health plan's decision to process your expedited reconsideration request as a standard request. In such cases, health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where can a Grievance be filed?

Call Member Services at 1-877-542-9236 (TTY 711) 8 a.m. – 8 p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week). Or you can write us at:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 31364
Salt Lake City, UT 84131 0364

Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Grievance, Coverage Determinations and Appeals

Filing a grievance (making a complaint) about your prescription coverage

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

Some types of problems that might lead to filing a grievance include:

• Issues with the service you receive from Customer Service.
• If you feel that you are being encouraged to leave (disenroll from) the plan.
• If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
• We don't give you a decision within the required time frame.
• We don't give you required notices.
• You believe our notices and other written materials are hard to understand.
• Waiting too long for prescriptions to be filled.
• Rude behavior by network pharmacists or other staff.
• We don't forward your case to the Independent Review Entity if we do not give you a decision on time.

If you have any of these problems and want to make a complaint, it is called "filing a grievance."

Who may file a grievance

You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.

Filing a grievance with our plan
The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Medicare Part D Grievances (for complaints about Medicare Part D drugs) listed on the back of your member ID card. We will try to resolve your complaint over the phone.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.

Submit a written request for a grievance to Part C & D Grievances:

Write of us at the following address:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 31364
Salt Lake City, UT 84131 0364
Expedited Fax: 801-994-1349
Standard Fax: 801-994-1082

If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

1. You may submit a written request for a Fast Grievance to the

   Write of us at the following address:
   UnitedHealthcare Community Plan
   Attn: Complaint and Appeals Department:
   P.O. Box 31364
   Salt Lake City, UT 84131 0364

2. You may fax your expedited written request toll-free to 1-801-994-1349; or
3. You may contact UnitedHealthcare to file an expedited Grievance.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

Whether you call or write, you should contact Customer Service right away. Complaints related to Part D must be made within 90 calendar days after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid issue must be made within 90 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

Please refer to your plan's Appeals and Grievance process: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan's member handbook.

Medicare Complaint Form

Medicare Complaint Form

Your Medicare Advantage health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.

Appeals

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting an appeal from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
    • Click here to find and download the CMS Appointment of Representation form.
  • Review your plan's Appeals and Grievances process in the Evidence of Coverage document.

What is an Appeal?
An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

When can an Appeal be filed?

You may file an appeal within sixty (60) calendar days of the date of the notice of the coverage determination. For example, you may file an appeal for any of the following reasons:

• your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
• your Medicare Advantage health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your Medicare Advantage health plan is stopping your coverage too soon.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Where can an Appeal be filed?

An appeal may be filed in writing directly to us.

UnitedHealthcare Appeals and Grievances Department Part C

UnitedHealthcare Complaint and Appeals Department
P.O. Box 6103
MS CA124-0187
Cypress, CA 90630-0023

Fax: Expedited appeals only – 1-866-373-1081

OR

Call 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

An appeal may be filed in writing directly to us. 

UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197
Cypress CA 90630-0023

Fax: Expedited appeals only – 1-866-308-6294

OR

Call 1-800-290-4909 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• your life or health, or
• your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus fourteen (14) calendar days, if an extention is taken, after receiving the request.

Medicare Complaint Form

Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I your name appoint name of representative to act as my representative in requesting a grievance from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your grievance.

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your Medicare Advantage health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When can a Grievance be filed?

You may file a verbal by calling customer service or a written grievance by writing to the plan within sixty (60) of the date the circumstance giving rise to the grievance. Note: The sixty (60) day limit may be extended for good cause. Include your written request the reason why you could not file within sixty (60) day timeframe.

Expedited Grievance

You have the right to request an expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where can a Grievance be filed?

A grievance may be filed verbally or in writing.

A verbal grievance may be filled by calling the Customer Service number on the back of your ID card. For complaints about Part D Drugs you may also call the phone number for Medicare Part D Grievances listed on the back of your ID Card. If we were unable to resolve your complaint over the phone you may file written complaint.

A written Grievance may be filed by writing to

UnitedHealthcare Appeals and Grievances Department Part C

UnitedHealthcare Complaint and Appeals Department
P.O. Box 6103
MS CA124-0187
Cypress, CA 90630-0023

Fax: Expedited appeals only – 1-866-373-1081

OR

Call 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

An appeal may be filed in writing directly to us. 

UnitedHealthcare Appeals and Grievances Department Part D
PO Box 6103, MS CA 124-0197
Cypress CA 90630-0023

Fax/Expedited appeals only – 1-866-308-6294

OR

Call 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Grievance, Coverage Determinations and Appeals

Filing a grievance (making a complaint) about your prescription coverage

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

Some types of problems that might lead to filing a grievance include:

• Issues with the service you receive from Customer Service.
• If you feel that you are being encouraged to leave (disenroll from) the plan.
• If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
• We don't give you a decision within the required time frame.
• We don't give you required notices.
• You believe our notices and other written materials are hard to understand.
• Waiting too long for prescriptions to be filled.
• Rude behavior by network pharmacists or other staff.
• We don't forward your case to the Independent Review Entity if we do not give you a decision on time.

If you have any of these problems and want to make a complaint, it is called "filing a grievance."

Who may file a grievance

You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.

Filing a grievance with our plan

The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number  listed on the back of your member ID card. We will try to resolve your complaint over the phone.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.

Submit a written request for a Part D related grievance to:

UnitedHealthcare Community Plan
Appeals & Grievance Dept.
PO Box 6106, M/S CA 124-0197
Cypress,CA 90630-0016

• You may fax your written request toll-free to 1-866-308-6294.
• Or call 1-800-290-4009 TTY 711

8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

If you ask for a written response, file a written grievance, or if your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

1. 1. You may submit a written request for a Fast Grievance to the Medicare Part D Appeals & Grievance Dept. at PO Box 6103, MS CA124-0197 Cypress CA 90630-0023; or
2. You may fax your written request toll-free to 1-866-308-6296; or
3. You may contact UnitedHealthcare to file an expedited Grievance.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

• Or Call 1-800-290-4009 TTY 711 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.

Review the Evidence of Coverage for additional details.

Medicare Complaint Form

Coverage Determinations

Asking for a coverage determination (coverage decision)

An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the coverage.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug , or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier.
  • Tier exceptions are not available for drugs in the Preferred Generic Tier.
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that does not contain branded drugs used for your condition.
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs.
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form (PDF)(54.6 KB) – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.

Both you and the person you have named as an authorized representative must sign the representative form.

For Coverage Determinations

OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

For Appeals

Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948
Fax: 1-866-308-6294

If your prescribing doctor calls on your behalf, no representative form is required.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we’ve issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

To file an appeal:

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form (PDF)(66.8 KB) or by secure email.
  • Send the letter or the Redetermination Request Form(PDF)(66.8 KB) to the Medicare Part D Appeals and Grievance Department P.O. Box 6103 Cypress, CA 90630-0233 8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept
• You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
• The Medicare Part D Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.

The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

Submit a written request for a Part C and Part D grievance to:  

UnitedHealthcare Coverage Determination Part C

UnitedHealthcare Complaint and Appeals Department
P.O. Box 6103
MS CA124-0187
Cypress, CA 90630-0023

OR

Call: 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

An appeal may be filed in writing directly to us.

UnitedHealthcare Coverage Determination Part D

P. O. Box 5250
Kingston, NY 12402-5250
Fax: Fax/Expedited Fax – 1-501-262-7072 OR
Call: 1-800-290-4009 TTY 711
8am-8pm: 7 Days Oct-Mar; M-F Apr-Sept

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:

We will give you our decision within 7 calendar days of receiving the pre-service appeal request and 14 days for a reimbursement request. If we do not give you our decision within 7/14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Morphine Milligram Equivalent (MME) limits
• Opioid day supply limits (7-day supply)
• Therapeutic dose limits
• Clinically significant drug interactions
  • Therapeutic duplication
  • Inappropriate or incorrect drug therapy
  • Patient-specific drug contraindications
  • Under-utilization

The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Your health plan must follow strict rules for how we identify, track, resolve and report all appeals and grievances. The following information applies to benefits provided by your Medicare benefit.

Appeals, Coverage Determinations and Grievances

Medicare Complaint Form

Your health plan must follow strict rules for how they identify, track, resolve and report all appeals and grievances.

Medicare Part D Prior Authorization, Formulary Exception or Coverage Determination Request(s)

Prior Authorizations /Formulary Exceptions

Medicare Part D prior authorization forms list

Prescription Drugs - Not Covered by Medicare Part D

While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare® Connected™. You can view our plan's List of Covered Drugs on our website at www.myuhc.com/communityplan. Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare® Connected™ (Medicare-Medicaid Plan). You do not have any co-pays for non-Part D drugs covered by our plan.

Please note that our list of medications that require prior authorization, formulary exceptions or coverage determinations can change

Submit a Pharmacy Prior Authorization. Formulary Exception or Coverage Determination Request to OptumRx.

Submit a Pharmacy Prior Authorization Request, Formulary Exception or Coverage Determination electronically to OptumRx.

Coverage Determinations, Coverage Decisions and Appeals

Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
• Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan’s member handbook.

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your health plan pays or will pay for a service or the amount you must pay for a service.

You may file a Part C/Medicaid appeal within sixty (60) calendar days of the date of the notice of coverage determination. For example, you may file an appeal for any of the following reasons:

• your health plan refuses to cover or pay for services you think your health plan should cover.
• your health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• your health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your health plan is stopping your coverage too soon.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

If you are appealing because you were told that a service you are getting will be reduced or stopped, you have a shorter timeframe to appeal if you want us to continue covering that service while the appeal is processing. For more information, please see your Member Handbook.

The standard resolution timeframe for a Part C/Medicaid appeal is 30 calendar days for a pre-service appeal. If we need more time, we may take a 14 calendar day extension. If we take an extension we will let you know.

If your appeal is regarding a Part B drug which you have not yet received, the timeframe for completion is 7 calendar days. An extension for Part B drug appeals is not allowed.

You have the right to request and received expedited decisions affecting your medical treatment. A situation is considered “time-sensitive”. A time sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision making process could seriously jeopardize:

• Your life or health, or
• Your ability to regain maximum function.

If your health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus 14 calendar days, if an extension is taken, after receiving the request.

You may file an appeal within ninety (90) calendar days of the date of the notice of the initial coverage decision. For example, you may file an appeal for any of the following reasons:

• your health plan refuses to cover or pay for services you think your health plan should cover.
• your health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• your health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your health plan is stopping your coverage too soon.

Note: The ninety (90) day limit may be extended for good cause. Include in your written request the reason why you could not file within the ninety (90) day timeframe.

If you are appealing because you were told that a service you are getting will be reduced or stopped, you have a shorter timeframe to appeal if you want us to continue covering that service while the appeal is processing. For more information, please see your Member Handbook.

In most cases, you must file your appeal with the Health Plan. However, if your problem is about a service or item covered primarily by Medicaid or both Medicare and Medicaid, you can request a State Hearing which is filed with the Bureau of State Hearings.

To file a State Hearing, your request must be made within 90 calendar days of receiving the notice of your State Hearing rights. The 90 calendar days begins on the day after the mailing date on the notice. If you have a good reason for being late the Bureau of State Hearings may extend this deadline for you.

For more information regarding State Hearings, please see your Member Handbook.

Where can an Appeal be filed?

An appeal may be filed by calling us at 1-800-256-6533 (TTY 711) 8 a.m. to 8 p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week) writing directly to us, calling us or submitting a form electronically.

How do I Start an Appeal?

For a Part C/Medical appeal

You, your doctor or other provider, or your representative must contact us. You can call us at 1-866-633-4454 (TTY 711), 8 a.m. – 8 p.m. local time, Monday – Friday

Or, you can submit a request to the following address:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 6103
MS CA124-0187
Cypress, CA 90630-0023

Fax: Expedited appeals only 1-844-226-0356

For a Part D appeal, you, your provider, or your representative an write us at:

Part D Appeals:
UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6106
MS CA124-0197
Cypress, CA 90630-0023

Standard Fax: 1-866-308-6296

To start your appeal, you, your doctor or other provider, or your representative must contact us. You can call us at 1-800-256-6533 (TTY 711), 8 a.m. – 8 p.m. local time, Monday – Friday. You can submit a request to the following address:

Part D Appeals:

UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
P.O. Box 6103
MS CA124-0197
Cypress, CA 90630-9948

Standard Fax: 1-877-960-8235

Part C Appeals:

Write of us at the following address:
UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department:
P.O. Box 6103
MS CA124-0197
Cypress, CA 90630-9948
P.O. Box 31364
Salt Lake City, UT 84131 0364

Expedited Fax: 1-801-994-1349 / 1-800-256-6533 Standard Fax: 1-844-226-0356 / 1-801-994-1082

An appeal may be filed by calling us at 1-800-256-6533 (TTY 711) 8 a.m. to 8p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week) writing directly to us, calling us or submitting a form electronically.

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (coverage determination) that was made regarding a service or the amount of payment your health plan paid for a service.

The standard resolution timeframe for a Part C/Medicaid appeal is 30 calendar days for a pre-service appeal. If we need more time, we may take a 14 calendar day extension. If we take an extension we will let you know.

If your appeal is regarding a Part B drug which you have not yet received, the timeframe for completion is 7 calendar days. An extension for Part B drug appeals is not allowed.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• your life or health, or
• your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus fourteen (14) calendar days, if an extension is taken, after receiving the request.

Overview of coverage decisions and appeals 

The process for asking for coverage decisions and making appeals deals with problems related to your benefits and coverage. It also includes problems with payment.

What is a coverage decision?
A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay. If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Texas Medicaid, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.

What is an appeal?
An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Texas Medicaid. If you or your doctor disagree with our decision, you can appeal.

Getting help with coverage decisions and appeals

Who can I call for help asking for coverage decisions or making an appeal?

You can ask any of these people for help:

• Call Member Services at 1-800-256-6533 (TTY 711), 8 a.m. - 8 p.m. local time, Monday – Friday.
• Call the HHSC Ombudsman’s Office for free help. The HHSC Ombudsman’s Office helps people enrolled in Medicaid with service or billing problems. The phone number is 1-866-566-8989.
• Call the State Health Insurance Assistance Program (SHIP) for free help. The SHIP is an independent organization. It is not connected with this plan. In Texas, the SHIP is called the
  Health Information Counseling & Advocacy Program (HICAP). The phone number is 1-800-252-3439.
• Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or appeal on your behalf.
• Talk to a friend or family member and ask them to act for you. You can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)
  • If you want a friend, relative, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form.
  • You can also get the form by visiting www.cms.gov/Medicare/CMS-Forms/CMS-Forms. The form gives the person permission to act for you. You must give us a copy of the signed form.
• You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form.
  • However, you do not have to have a lawyer to ask for any kind of coverage decision or to make an appeal.

Asking for a coverage decision

How to ask for a coverage decision to get a medical, behavioral health or long-term care service

To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for a decision.

• You can call us at: 1-800-256-6533 (TTY 711), 8 a.m. - 8 p.m. local time, Monday – Friday.
• You can fax us at: 1-877-940-1972.
• You can write to us at: UnitedHealthcare Community Plan of Texas, 14141 Southwest Freeway, Suite 500, Sugar Land, TX 77478

How long does it take to get a coverage decision?

It usually takes up to 3 business days after you asked unless your request is for a Medicare Part B prescription drug. If your request is for a Medicare Part B prescription drug, we will give you a decision no more than 72 hours after we receive your request. If we don’t give you our decision within 3 business days (or 72 hours for a Medicare Part B prescription drug), you can appeal.

Can I get a coverage decision faster?

Yes. If you need a response faster because of your health, ask us to make a “fast coverage decision.” If we approve the request, we will notify you of our decision within 1 business day (or within 24 hours for a Medicare Part B prescription drug). The legal term for “fast coverage decision” is “expedited determination.”

Asking for a fast coverage decision:

• If you request a fast coverage decision, start by calling or faxing our plan to ask us to cover the care you want.
• You can call us at 1-800-256-6533 (TTY 711), 8 a.m. - 8 p.m. local time, Monday – Friday or fax us at 1-877-940-1972. For details on how to contact us, go to Chapter 2 in the EOC/Member Handbook.
• You can also have your doctor or your representative call us. Here are the rules for asking for a fast coverage decision: You must meet the following two requirements to get a fast coverage decision:

1. You can get a fast coverage decision only if you are asking for coverage for medical care or an item you have not yet received. (You cannot ask for a fast coverage decision if your request is about payment for medical care or an item you already got.)
2. You can get a fast coverage decision only if the standard 3 business day deadline (or the 72 hour deadline for Medicare Part B prescription drugs) could cause serious harm to your health or hurt your ability to function.

• If your doctor says that you need a fast coverage decision, we will automatically give you one.
• If you ask for a fast coverage decision without your doctor’s support, we will decide if you get a fast coverage decision.
  • If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 3 business day deadline (or the 72 hour deadline for Medicare Part B prescription drugs) instead.
  • This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision.
  • The letter will also tell how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of a fast coverage decision. For more information about the process for making complaints, including fast complaints, refer to Section J on page 208 in the EOC/Member Handbook.

If the coverage decision is No, how will I find out?
If the answer is No, we will send you a letter telling you our reasons for saying No.

• If we say No, you have the right to ask us to change this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage.
• If you decide to make an appeal, it means you are going on to Level 1 of the appeals process.
  

Coverage Determination

Asking for a coverage determination (coverage decision)

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.

An initial coverage decision about your Part D drugs is called a "coverage determination.", or simply put, a "coverage decision." A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. And some drugs may require a coverage determination to verify whether they are covered by the Medicare Part D plan. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to the ‘Find a Drug' Look Up Page and download your plan's formulary.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier.
  • Tier exceptions are not available for drugs in the Preferred Generic Tier.
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that does not contain branded drugs used for your condition.
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs.
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

If you have questions, please call UnitedHealthcare Connected® at 1-800-256-6533 (TTY 711),
8 a.m. – 8 p.m. local time, Monday – Friday

For Part C coverage decision:

Write: UnitedHealthcare Community Plan of Texas,
14141 Southwest Freeway, Suite 800, Sugar Land, TX 77478

Fax: 1-877-950-6885.

Write: OptumRx
Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799

Fax: 1-844-403-1028

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download these forms to request an exception:

• Medicare Part D Coverage Determination Request Form – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below. The Prior Authorization Department will accept both request forms.
• Specialty Pharmacy Prior Authorization Request Forms 
• Note: PDF (Portable Document Format) files can be viewed with Adobe® Reader®. If you don't already have this viewer on your computer, download it free from the Adobe website.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.

Both you and the person you have named as an authorized representative must sign the representative form.

For OptumRx (Part D) Coverage Determinations

OptumRX (Part D) Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799

1-800-256-6533 (TTY 7-1-1)
Fax: 1-844-403-1028

If your prescribing doctor calls on your behalf, no representative form is required.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we've issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

To file an appeal:

Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email.

Part D Appeals:

UnitedHealthcare Community Plan
Attn: Part D Standard Appeals
PO Box 6103
MS CA124-0197
Cypress, CA 90630-0023

Fax: 1-866-308-6296

• You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline. 
• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter. To inquire about the status of an appeal, contact UnitedHealthcare.
• You must mail your letter within 60 days of the date the adverse determination was issues, or within 60 days from the date of the denial of reimbursement request. If you missed the 60 day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard appeal review for a Medicare Part D drug you have not yet received, we will give you our decision within 7 calendars days of receiving the appeal request.

For a standard appeal review regarding reimbursement for a Medicare Part D drug you have paid for and received, we will give you your decision within 14 calendar days.

If we do not give you our decision within 7 or 14 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Clinically significant drug interactions
• Therapeutic duplication
• Inappropriate or incorrect drug therapy
• Patient-specific drug contraindications
• Over-utilization and under-utilization
• Abuse or misuse

The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting a grievance from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When can a Grievance be filed?

Complaints related to Part D can be made at any time after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid Issue can be made any time after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Complaints about access to care are answered in 2 business days.

Expedited Grievance

You have the right to request an expedited grievance if you disagree with your health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your health plan's decision to process your expedited reconsideration request as a standard request. In such cases, health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where can a Grievance be filed?

Call Member Services at 1-800-256-6533 (TTY 711) 8 a.m. – 8 p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week).  

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information

Grievance, Coverage Determinations and Appeals

Filing a grievance (making a complaint) about your prescription coverage

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

Some types of problems that might lead to filing a grievance include:

• Issues with the service you receive from Customer Service.
• If you feel that you are being encouraged to leave (disenroll from) the plan.
• If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
• We don't give you a decision within the required time frame.
• We don't give you required notices.
• You believe our notices and other written materials are hard to understand.
• Waiting too long for prescriptions to be filled.
• Rude behavior by network pharmacists or other staff.
• We don't forward your case to the Independent Review Entity if we do not give you a decision on time.

If you have any of these problems and want to make a complaint, it is called "filing a grievance."

Who may file a grievance

You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service.

Filing a grievance with our plan

The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number listed on the back of your member ID card. We will try to resolve your complaint over the phone.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.

Part C Grievances:

UnitedHealthcare Complaint and Appeals Department
P.O. Box 6103
MS CA124-0187
Cypress, CA 90630-0023

Or you can call us at: 1-888-867-5511 (TTY 711)
Available 8 a.m. - 8 p.m. local time, 7 days a week

Part D Grievances UnitedHealthcare Part D Standard Appeals

Attn: Complaint and Appeals Department
P.O. Box 6103
MS CA 124-0197
Cypress, CA 90630-0023

Or

Expedited Fax: 1-877-960-8235

Or you can call us at: 1-888-867-5511TTY 711.
Available 8 a.m. - 8 p.m.; local time, 7 days a week

If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

• You may fax your expedited written request toll-free to 1-866-373-1081; or
• You may contact UnitedHealthcare to file an expedited Grievance.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

Whether you call or write, you should contact Customer Service right away. Complaints related to Part D can be made any time after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid issue can be made any time after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

• Please refer to your plan's Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan's member handbook.

Medicare Complaint Form

Your Medicare Advantage health plan must follow strict rules for how they identify, track,

Prior Authorizations /Formulary Exceptions

Medicare Part D Prior Authorization Forms List

Prescription Drugs - Not Covered by Medicare Part D

While most of your prescription drugs will be covered by Medicare Part D, there are a few drugs that are not covered by Medicare Part D but are covered by UnitedHealthcare Community Plans. You can view our plan's List of Covered Drugs on our website. Drugs with an asterisk are not covered by Medicare Part D but are covered by UnitedHealthcare Community Plans. You do not have any co-pays for non-Part D drugs covered by our plan.

Please note that our list of medications that require prior authorization, formulary exceptions or coverage determinations can change so it is important for you and/or your provider to check this information when you need to fill/refill a medication.

Submit a Pharmacy Prior Authorization. Formulary Exception or Coverage Determination Request to OptumRx
Submit a Pharmacy Prior Authorization Request, Formulary Exception or Coverage Determination electronically to OptumRx.

Appeals, Coverage Determinations and Grievances

Medicare Complaint Form

Appeals

Who can file an Appeal?

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting an appeal from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal.
  • Click hereto find and download the CMS Appointment of Representation form.
  • Please refer to your plan's Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan's member handbook.

Medicare Complaint Form

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

When can an Appeal be filed?
You may file an appeal within sixty (60) calendar days of the date of the notice of the initial coverage decision. For example, you may file an appeal for any of the following reasons:

• your Medicare Advantage health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
• your Medicare Advantage health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• if you think that your Medicare Advantage health plan is stopping your coverage too soon.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Where can an Appeal be filed?

An appeal may be filed in writing directly to us, calling us or submitting a form electronically.

How do I start an Appeal?

To start your appeal, you, your doctor or other provider, or your representative must contact us.

You can call us at 1-866-842-4968 (TTY 7-1-1), 8 a.m. – 8 p.m. local time, 7 days a week.

Customer Service also has free language interpreter services available for non-English speakers.

You can submit a Part C request to the following address:

UnitedHealthcare Community Plan
Attn: Part D Standard Complaint and Appeals Department
P.O. Box 6106 MS CA 124-0157
Cypress, CA 90630-0016
Fax: 1-888-517-7113 Expedited Fax: 1-866-373-1081
8 a.m. – 8 p.m. local time, 7 days a week.

For an Expedited Part C Appeal: You, your prescriber, or your representative should contact us by telephone 1-877-262-9203 TTY 711, or expedited fax at Expedited Fax: 1-866-373-1081, TTY 711, 8 a.m. – 8 p.m. local time, 7 days a week. Monday through Friday.

You can submit a Part D request to the following address:

UnitedHealthcare Community Plan
Attn: Part D Standard Complaint and Appeals Department
P.O. Box 6106 Cypress, CA 90630-9948
Fax: 1-866-308-6294 Expedited Fax: 1-866-308-6296
Or you can call us at: 1-888-867-5511TTY 711.
Available 8 a.m. - 8 p.m. local time, 7 days a week

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (organization determination) that was made regarding a service or the amount of payment your Medicare Advantage health plan paid for a service.

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• your life or health, or
• your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus (14) calendar days, if an extension is taken, after receiving the request.

Medicare Complaint Form

Coverage Determination

Asking for a coverage determination (coverage decision)

The process for coverage decisions and making appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered.

An initial coverage decision about your Part D drugs is called a "coverage determination.", or simply put, a "coverage decision." A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. And some drugs may require a coverage determination to verify whether they are covered by the Medicare Part D plan. The coverage determination process allows you or your prescriber to request coverage of drugs with additional requirements or ask for exceptions to your benefits.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to "Find a Drug" and download your plan's Formulary.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

Note: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier.
  • Tier exceptions are not available for drugs in the Preferred Generic Tier.
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier that does not contain branded drugs used for your condition.
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs.
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination
(including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the 2020 formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

Coverage Decisions for Medical Care Part C – Contact Information:

Write: UnitedHealthcare Customer Service Department (Organization Determinations)
P.O. Box 29675
Hot Springs, AR 71903-9675

Call: 1-866-842-4968 TTY: 711
Calls to this number are free.
Hours of Operation: 8 a.m. - 8 p.m. local time, 7 days a week

Fax: 1-501-262-7072

Coverage Decisions for Part D Prescription Drugs – Contact Information:

Write: UnitedHealthcare Part D Coverage Determinations Department
P.O. Box 31350
Salt Lake City, UT 84131-0365

Call: 1-866-842-4968 TTY: 711
Calls to this number are free.
Hours of Operation: 8 a.m. - 8 p.m. local time, 7 days a week

Fax: 1-800-527-0531
 

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form (PDF)(54.6 KB) – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at 1-800-711-4555 for the Prior Authorization department to submit a request, or fax toll-free to1-844-403-1028 call at 1-866-842-4968 (TTY 711), 8 a.m. –8 p.m. local time, 7 days a week. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications in 2020 may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.

Both you and the person you have named as an authorized representative must sign the representative form.

For Coverage Determinations

Mail: OptumRx Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799

Fax: 1-844-403-1028

For Appeals

Mail: Medicare Part D Appeals and Grievance Department
PO Box 6103, M/S CA 124-0197
Cypress, CA 90630-9948 

Fax: 1-866-308-6294

If your prescribing doctor calls on your behalf, no representative form is required. Or you can call us at: 1-888-867-5511 TTY 711. Available 8 a.m. - 8 p.m. local time, 7 days a week.

Making an Appeal

If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

How to appeal a decision about your prescription coverage

Appeal Level 1 - You may ask us to review an adverse coverage decision we've issued to you, even if only part of our decision is not what you requested. An appeal to the plan about a Medicare Part D drug is also called a plan "redetermination."

Appeal Level 2 – If we reviewed your appeal at "Appeal Level 1" and did not decide in your favor, you have the right to appeal to the Independent Review Entity (IRE).

When we receive your request to review the adverse coverage determination, we give the request to people at our organization not involved in making the initial determination. This helps ensure that we give your request a fresh look.

To file an appeal:

• Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form or by secure email.
• Send the letter or the Redetermination Request Form to the Medicare Part D Appeals and Grievance Department at:

P.O. Box 6106
M/S CA 124-0197
Cypress CA 90630-9948

• Or you can fax it to the UnitedHealthcare Medicare Plans - AOR toll-free at 1-866-308-6294. Or you can call 1-800-595-9532 TTY 711 8 a.m. - 5 p.m. local time, Monday – Friday.
  
• You must mail your letter within 60 days of the date of adverse determination was issued, or within 60 days from the date the denial of reimbursement request. If you missed the 60 day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
• Note: if you are requesting an expedited (fast) appeal, you may also call UnitedHealthcare.
• The Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You'll receive a letter with detailed information about the coverage denial.
• The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.

To inquire about the status of an appeal, contact UnitedHealthcare.

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:

We will give you our decision within 7 calendar days of receiving the appeal request. If we do not give you our decision within 7 calendar days, your request will automatically go to Appeal Level 2 (Independent Review Entity).

For a fast decision about a Medicare Part D drug that you have not yet received.

We will give you our decision within 72 hours after receiving the appeal request. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2.

Next steps if the plan says "no"

If you asked for Medicare Part D drugs or payment for Medicare Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the Independent Review Entity (Appeal Level 2).

If you choose to appeal, you must send the appeal request to the Independent Review Entity (IRE). The decision you receive from the plan (Appeal Level 1) will tell you how to file the appeal, including who can file the appeal and how soon it must be filed. You must file your appeal within 60 days from the date on the letter you receive.

To obtain an aggregate number of the plan's grievances, appeals and exceptions please contact UnitedHealthcare.

The following information about your Medicare Part D Drug Benefit is available upon request:

• Information on the procedures used to control utilization of services and expenditures.
• Information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
• A summary of the compensation method used for physicians and other health care providers.
• A description of our financial condition, including a summary of the most recently audited statement.

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program is designed to help ensure safe and appropriate use of prescription drugs covered under Medicare Part D. This program focuses on reducing adverse drug events and drug interactions, optimizing medication utilization, and providing incentives to reduce costs when medically appropriate. UnitedHealthcare offers the UM/QA program at no additional cost to its members and their providers.

Utilization management

The UM/QA program incorporates utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits and step therapy.

Quality assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems developed to detect and address the following clinical issues:

• Clinically significant drug interactions
• Therapeutic duplication
• Inappropriate or incorrect drug therapy
• Patient-specific drug contraindications
• Over-utilization and under-utilization
• Abuse or misuse
• The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.

Medicare Complaint Form

Grievances

Who can file a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
  • Provide your Medicare Advantage health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting a grievance from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your grievance.

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your Medicare Advantage health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When can a Grievance be filed?

You may file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance.

Note: The sixty (60) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty (60) day timeframe.

Expedited Grievance

You have the right to request an expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your Medicare Advantage health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where can a Grievance be filed?

A grievance may be filed in writing directly to us.

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your Medicare Advantage health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Grievance, Coverage Determinations and Appeals

Filing a grievance (making a complaint) about your prescription coverage

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

Some types of problems that might lead to filing a grievance include:

• Issues with the service you receive from Customer Service.
• If you feel that you are being encouraged to leave (disenroll from) the plan.
• If you disagree with our decision not to give you a "fast" decision or a "fast" appeal.
• We don't give you a decision within the required time frame.
• We don't give you required notices.
• You believe our notices and other written materials are hard to understand.
• Waiting too long for prescriptions to be filled.
• Rude behavior by network pharmacists or other staff.
• We don't forward your case to the Independent Review Entity if we do not give you a decision on time.

Who may file a grievance

You or someone you name may file a grievance. The person you name would be your "representative." You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare^® Customer Service.

Filing a grievance with our plan

The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number for Grievances listed on the back of your member ID card. We will try to resolve your complaint over the phone.

You can call us at 1-866-842-4968 (TTY 7-1-1), 8 a.m. – 8 p.m. local time, 7 days a week.

Customer Service also has free language interpreter services available for non-English speakers.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us.

Submit a written request for a grievance to Part C & D Grievances:

UnitedHealthcare Community Plan
Attn: Complaint and Appeals Department
P.O. Box 6106,
Cypress CA 90630-9948

Or

Expedited Fax: 1-866-308-6296
Standard Fax: 1-866-308-6294

If you ask for a written response, file a written grievance, or if your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

1. You may submit a written request for a Fast Grievance to the Medicare Part D Appeals & Grievance Dept. at:

P.O. Box 6106
Cypress, CA 90630-9948

2. You may fax your written request toll-free to 1-866-308-6296; or

3. You may contact UnitedHealthcare to file an expedited Grievance. Please be sure to include the words "fast," "expedited" or "24-hour review" on your request.

Whether you call or write, you should contact Customer Service right away. The complaint must be made within 60 calendar days, after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.

• Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Medicare Complaint Form