Appeals and Grievances - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

Care Provider, Member Appeals and Grievance Complaints

Members have the right to appeal the determination of any denied services or claim by filing an appeal with us. Timeframes for filing an appeal may vary, depending on the applicable state or federal requirements.

We maintain a system of logging, tracking and analyzing issues received from members and care providers and use the information to measure and improve member and care provider satisfaction.

This system helps us fulfill the requirements and expectations of our members and our network care providers. In addition, it supports compliance with CMS, the NCQA, The Joint Commission, and other accrediting and/or regulatory requirements.

We acknowledge and enter all written complaints into the complaint database. If we identify a potential quality of care issue within the complaint (using pre-established triggers) we forward the case to the Quality of Care Department to investigate. If the complaint involves an imminent and serious threat to the health of the member, the case is referred on to the Quality Intervention Services for immediate action.

We identify and request relevant medical records and information needed to resolve quality of care investigations. We use the results to assign severity levels and data collection codes which in turn helps us objectively and systemically monitor, evaluate and improve the quality and safety of clinical care and quality of service provided to our members.

We track and trend complaints by care provider and use the information during their recredentialing. We conduct an annual analysis of the complaint data to look for opportunities for improvement. Care provider and member complaints are important to the recredentialing process because they help us attract and retain care providers, employer groups and members.

Member Grievance and Appeals

Network care providers are required to:

  • Immediately, within one hour of receipt, forward all member grievances and appeals (complaints, appeal, quality of care/service concern, whether oral or written) to us for processing using the contact information in the applicable How to Contact Us reference table under the Expedited Appeals and Standard Member Appeals sections.
  • Respond to our requests for information about the member’s appeal or grievance within the designated timeframe. For expedited appeals, care providers must submit the requested within two hours. For standard appeals, within 24 hours (no exceptions or delays due to weekend or holidays). Timeframes apply to every calendar day of the year.
  • Comply with our final determinations regarding member appeals and grievances.
  • Cooperate with us and the external independent medical review organization including promptly forwarding copies of all medical records, and information relevant to the disputed health care service in your possession to the external review organization, and/or any newly discovered relevant medical records or any information in the your possession, requested by an external review organization. Care providers must respond to our requests for proof of claim payment or a copy of the pre-service authorization of overturned appeals: expedited appeals, within two hours, standard appeals, within 24 hours (no exceptions or delays due to weekend or holidays). Timeframes apply to every calendar day of the year.
  • Provide us with proof of claim payment or a copy of the pre-service authorization within the stipulated timeframes on reversals of adverse determinations. Care providers must respond to requests for proof overturned appeals were resolved: expedited appeals, within two hours, standard appeals, within 24 hours (no exceptions or delays due to weekend or holidays). Timeframes apply to every calendar day of the year.

UnitedHealthcare West Member Grievances

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Members may use a UnitedHealthcare West Grievance Form to help state and explain their grievance.

We do not delegate authority or responsibility for processing member grievances, appeals or complaints to our network care providers; however, we do require our network care providers to help resolve grievances, appeals or complaints.

UnitedHealthcare West Disputes & Grievance Processes

For more information regarding disputes and grievance processes for UnitedHealthcare West members (AZ, CA, CO, NV, OK, OR, TX, WA), please refer to the UnitedHealthcare West Supplement.