Khiếu Nại
You are our customer and are very important to us. We want to make your health care program a good one. We want to make sure you are happy with our program, so you can file a complaint at any time.
If you are not happy, please call Member Services at 1-800-641-1902, TTY 711. We want to help you solve any health care problems. We will try to help you on the phone.
We hope we can solve your problem with your first phone call. There may be times when you don’t agree. Maybe you still feel unhappy. So we made “Quality Steps” just for you. These steps give you every chance to let us learn more about your problem.
Quality steps for grievances:
- Call us and tell us your problem. We will try to solve your problem on the first call. Dịch vụ thành viên: Toll-free 1-800-641-1902, TTY 711
- If you are not happy with the answer, call or write to us and let us know at: Write to: UnitedHealthcare Community Plan Attn: Appeals and Grievances P.O. Box 31364 Salt Lake City, UT 84131 Call: Toll-free 1-800-641-1902, TTY 711
- When your call or letter is received, our Appeals and Grievance Department will promptly do a thorough review of the case and make a decision.
- Contract allows 90 calendar days to resolve a grievance, estimated timeframe is set to 60 calendar days.
- We welcome your input regarding your complaint.
- You may get help in telling us about your problem or in appealing the decision by calling our Member Services. You may ask them for help with filing a grievance or appeal or filling out forms. You may ask for an interpreter.
- If you have a complaint about Non-Emergent Medical Transportation, please call Member Services at 1-800-641-1902, TTY 711.
Kháng Cáo
Sometimes we will make decisions about the health care you need. If you or your provider asks us to pay for care that we do not think is covered by UnitedHealthcare Community Plan or if we don’t make our decision promptly, this is called an adverse benefit determination.
An adverse benefit determination is defined as: 1. The denial or limited authorization of a requested service including the type or level of service requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; 2. The reduction, suspension or termination of a previously authorized service; 3. The denial, in whole or in part, of payment for a service; 4. The failure to provide services in a timely manner as defined by the State; or 5. The failure of UnitedHealthcare Community Plan to act within the following time limits: ∙ Resolution of a grievance — 90 calendar days ∙ Resolution of a standard appeal — 30 calendar days ∙ Resolution of an expedited appeal — 72 hours. Both may be extended by 14 calendar days if justified. 6. Definition of an adverse benefit determination doesn’t include the denial to use an out-of-network doctor when only one Managed Care Organization is present. 7. The denial of a member’s request to dispute a financial liability, including cost sharing, copayments and other member financial liabilities.
We will send you a letter to tell you about our adverse benefit determination. If you don’t agree with this, you may appeal. You have certain rights during an appeal. These are the things you should know:
You have 60 calendar days from the date on the letter from us saying that we have taken an adverse benefit determination to ask for an appeal. We will make a decision on the appeal and notify you in writing of our decision within 30 calendar days of when we receive your appeal request. We may extend the time to make a decision by up to 14 calendar days if you ask for an extension or we can show we need additional information to make a decision and give reasons why the delay benefits you.
You may file an appeal either verbally or in writing and must follow a verbal filing with a written, signed appeal Write to: UnitedHealthcare Community Plan Attn: Appeals and Grievances P.O. Box 31364 Salt Lake City, UT 84131 Call: Toll-Free
1-800-641-1902, TTY 711
You can ask your provider to file an appeal on your behalf. In order to do so, you must appoint them in writing as your representative.
You have the right to present evidence for your appeal in person or in writing. You can do this at anytime during the appeal. 8:00 a.m.–5:00 p.m. CT (7:00 a.m.–4:00 p.m. MT), Monday–Friday, at: UnitedHealthcare 2717 N. 118th Street, Suite 300 Omaha, NE 68164
- You can ask for a copy of the rules we used to make our decision.
- You can have someone else, such as a family member, friend, health care provider, lawyer or the Medicaid Enrollment Center, help you with the appeal.
- You can ask to see and receive a copy of the information in our files that we used to make our decision.
- You can send written comments or documents for us to look at when we review your appeal
You or your provider can call us and ask for an expedited 72-hour appeal if your provider has said that waiting for this health service would increase the risk to your health. If you choose to do an expedited appeal, you have limited time (72 hours or less) to present documentation in person or in writing regarding your request.
The Managed Care Organization may extend the time to make a decision by up to 14 calendar days if you ask for an extension or if the health plan can show a need for additional information to make a decision and give reasons why the delay.