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If you do not agree with certain decisions/actions made by our plan, and you contact us within 60 calendar days to ask that we change our decision/action, this is called an appeal. We will send you something in writing if we make a decision to:
We will also send you something in writing if, by the date we should have, we did not:
If you do not agree with the decision/action listed in the letter, you can contact us to appeal. The 90 calendar day period begins on the day after the mailing date on the letter. Unless we tell you a different date, we will give you an answer to your appeal in writing within 15 calendar days from the date you contacted us. You, or your provider making the request on your behalf or supporting your request, can ask for a faster decision. This is called an expedited decision. Expedited decisions are for situations when making the decision within the standard time frame could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function. If it is decided that your health condition meets the criteria for an expedited decision, the decision will be issued as quickly as needed but no later than 72 hours after the request is received. If we deny the request to expedite the decision we will notify you in writing within two (2) calendar days.
If we made a decision to reduce, suspend or stop services before you receive all of the services that were approved, your letter will tell you how you can keep receiving the services and when you may have to pay for the services.
Mail the form or your letter to:
PO Box 31364
Salt Lake City, UT 84131
If you contact us because you are unhappy with something about our plan or one of our providers, this is called a grievance. For example, if you cannot get a timely appointment, if you think the provider office staff did not treat you fairly, or if you receive a bill you should contact us. You can file a grievance at any time. We will give you an answer to your grievance by phone (or by mail if we can't reach you by phone) within the following time frames:
You also have the right at any time to file a complaint by contacting the following:
Ohio Department of Medicaid
Bureau of Managed Care
P.O. Box 182709
Columbus, Ohio 43218-2709
Ohio Department of Insurance
50 W. Town Street
3rd Floor – Suite 300
Columbus, Ohio 43215
Healthchek is Ohio's early and periodic screening, diagnostic, and treatment (EPSDT) benefit. Healthchek covers medical exams, immunizations (shots), health education, and laboratory tests for everyone eligible for Medicaid under the age of 21 years. These exams are important to make sure that young adults are healthy and are developing physically and mentally. Members under the age of 21 years should have at least one exam per year.
Healthchek also covers complete medical, vision, dental, hearing, nutritional, developmental, and mental health exams, in addition to other care to treat physical, mental, or other problems or conditions found by an exam. Healthchek covers tests and treatment services that may not be covered for people over age 20; some of the tests and treatment services may require prior authorization.
Healthchek services are available at no cost to members and include:
Additionally, care management services are available to all members. Please see page 16 of the Member Handbook (Coming Soon) to learn more about the care management services offered by our plan.
Emergency services are services for a medical problem that you think is so serious that it must be treated right away by a doctor. We cover care for emergencies both in and out of the county where you live.
Some examples of when emergency services are needed include: miscarriage/pregnancy with vaginal bleeding, heart attacks, severe chest pain, severe bleeding that does not stop, serious breathing difficulties, and possible stroke. You do not have to contact UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) for an okay before you get emergency services. If you have an emergency, call 911 or go to the NEAREST emergency room (ER) or other appropriate setting.
If you are not sure whether you need to go to the emergency room, call your primary care provider or the NurseLine at 800-542-8630 (TTY 711). Your PCP or the NurseLine can talk to you about your medical problem and give you advice on what you should do.
Remember, if you need emergency services:
After Hours Care or Care When Traveling Outside the UnitedHealthcare Service Area
Sometimes you may need your PCP when the office is closed or when you are traveling outside the UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) service area. If you need urgent or non-emergent care, call your PCP's office. You will receive directions on how to access care. There is someone to help you 24 hours a day, seven days a week. If your PCP tells you to go to the nearest emergency room, call UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) within 24 hours or as soon as possible.
You can also call UnitedHealthcare Connected® for MyCare Ohio's (Medicare-Medicaid Plan) NurseLine services. NurseLine nurses are available to answer your health-related questions 24 hours a day and 7 days a week. Call NurseLine at 1-800-542-8630 (TTY 711).
Prior authorization is an okay for services that must be approved by UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan). Your doctor must call Utilization Management (UM) at 1-800-366-7304 before you obtain a service or procedure that is listed as requiring an okay on pages 19-22. Our UM team is available Monday through Friday, 8 a.m. to 5 p.m. On-call staff is available 24 hours a day, 7 days a week for emergency okays.
UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) also reviews some of your services and care as they are happening. This is called concurrent review. Examples are when you are:
UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) reviews your progress with your doctor to be sure you still need those services or if other services would be better for you.
UnitedHealthcare Connected® for MyCare Ohio (Medicare-Medicaid Plan) has policies and procedures to follow when the UM team makes decisions regarding medical services. The UM doctors and nurses make their decision based on your coverage and what you need for your medical condition. The goal is to make sure that services are medically necessary, that they are provided in an appropriate setting, and that quality care is provided.
We want to help you stay well. If you are sick we want you to get better.
If you have questions about UM decisions or processes, call Member Services at 1-877-542-9236 (TTY 711).
A Preferred Drug List (PDL) helps your doctor choose drugs to prescribe for you. If a drug has a generic form, this is what UnitedHealthcare Community Plan will cover. In some cases, you may be able to get drugs that are not on our list if your doctor asks for prior authorization.
In some cases, you may be able to get drugs that are not on our list if you are already taking the medication or if your doctor asks for prior authorization. Call our Member services or look at the Find A drug section of this website to see if your drugs need approval. In some cases, you may be able to get drugs that are not on our list if your doctor asks for prior authorization.
UnitedHealthcare Connected® covers some OTC drugs with a prescription. The updated OTC list can be found within our Preferred drug List (PDL) under Find A Drug on this website. You can also call Member services with questions. These are limited to generic drugs when available..
There are a few reasons this could happen.
If you need other drugs, your doctor must get Prior Authorization from UnitedHealthcare Connected®. Your doctor has to state how long you have been taking the drug and what other drugs you have tried.
Medicaid is a program for people with low income who meet certain eligibility requirements and programs can vary from state-to-state.
You can use any pharmacy that is listed in the Provider Directory on this website.
Except in limited cases such as emergency care, urgently needed care when our network is not available, or out of service area dialysis, you must obtain covered services from network providers for the services to be covered. If you get non-emergency care from non-network providers without prior authorization, you must pay the entire cost yourself.
If you believe that you meet any of the above criteria and should not be enrolled, please contact Member Services at 1-877-542-9236 (TTY 711), or you can also contact the Medicaid Hotline at 1-800-324-8680, TTY users should call Ohio Relay at 7-1-1, or on the managed care enrollment center (MCEC) website at www.ohiomh.com.
Member Services will help make sure that the PCP you want to switch to is a participating provider with UnitedHealthcare Connected®. They will also check to be sure the PCP you want to switch to is accepting new patients. Members can change their PCP monthly. If you change during your first month of membership, you PCP change will be effective immediately. After your first month of membership, your PCP change will take effect the first day of the next month. We will send you a new ID card with your new PCP listed. We will also let you know when you can start seeing your new PCP.
Sometimes a PCP, specialist, clinic, hospital or other plan provider you are using might leave the Plan. If this happens, you will have to switch to another provider who is part of our Plan. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services.
This will allow your doctor to schedule other patients.
We can help you if you do not speak or understand English. We have representatives that speak different languages. If you we don't have a representative who speaks your language, we will arrange for a translator or interpreter to help us with your call. Please call Member Services at 1-800-493-4647, TTY 711 and notify our representatives what languages you speak. If you need an interpreter when you visit your doctor, ask the doctors office to arrange for a translator.
If you have a medical emergency:
If you need urgent care, you can visit an urgent care center. You do not need to get an OK before you do. If you need help locating an urgent care center near you, Member Services can help. If you do not know if you need to visit an urgent care center, you can call your PCP or our 24/7 NurseLine services.
UnitedHealthcare Connected® for MyCare Ohio H2531-001-000
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