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.

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.

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.

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.