Member Appeals, Grievances or Complaints - Chapter 9, 2018 UnitedHealthcare Administrative Guide

Members may be unhappy with our participating care providers or with us. We respect the members’ rights to express dissatisfaction regarding quality of care/services and to appeal any denied claim/service. All members receive instructions on how to file a complaint/grievance with us in their Combined Evidence of Coverage and Disclosure Form, Evidence of Coverage or Certificate of Coverage, as applicable.

When there is a member grievance or appeal, you are required to comply with the following requirements:

  1. Assist the member with locating and completing the Appeals and Grievance Form upon request from the member. This form is located by logging onto MyUHC.com > Claims and Accounts > Medical Appeals and Grievances > Member Service Request Form. Note: An appeal, grievance or complaint process may differ based on product. Please see applicable benefit plan supplement to verify the process for those plan members.

  2. Immediately forward all member grievances and appeals (complaints, appeals, quality of care/service concerns) in writing for processing to:

    Medicare Advantage (MA) and Medicare Advantage Prescription Drug (MAPD) Plans:
    UnitedHealthcare
    P.O. Box 6106
    Mail Stop CA 124-0157
    Cypress, CA 90630

    For Medicare and Retirement Prescription Drug Plans (PDP):
    UnitedHealthcare
    P.O. Box 6106
    Mail Stop CA 124-0197
    Cypress, CA 90630

    For Commercial plans:
    UnitedHealthcare
    P.O. Box 30573
    Salt Lake City, UT 84130-0573

    All Savers Supplement ASIC Members:
    Grievance Administrator
    P.O. Box 31371
    Salt Lake City, UT 84131-0371
    Standard Fax: 801-478-5463
    Expedited Fax: 866-654-6323
    Phone: 800-291-2634

    UnitedHealthOne Individual Plans Supplement (Golden Rule Insurance Company, UnitedHealthcare Oxford Navigate Individual benefit plans offered by Oxford Health Insurance, Inc.):
    Grievance Administrator
    P.O. Box 31371
    Salt Lake City, UT 84131-0370
    Standard Fax: 801-478-5463
    Expedited Fax: 866-654-6323
    Phone: 800-657-8205

  3. Respond to our requests for information within the designated timeframe. You must supply records as requested within two hours for expedited appeals and 24-hours for standard appeals. This includes, but is not limited to, weekends and holidays.

  4. For Medicare member appeal requests, CMS regulation states once an appeal is received, within 60 calendar days of the denial, it must be reviewed under the appeal process. Reopen of an organization determination can only be made due to clerical error resulting in a change to the decision outside of the appeal process. Comply with all of our final determinations.

  5. Cooperate with our external independent medical review organization and us. This includes:
    ›› Promptly forwarding all medical records and information relevant to the disputed health care service in your possession to the external review organization
    ›› Providing newly discovered relevant medical records or any information in the participating medical group/ IPA’s possession to the external review organization

  6. Provide us with proof that reversals of adverse determinations were done within the stated time frames. You must supply proof within:
    ›› Expedited appeals, within two hours of overturn notice
    ›› Standard appeals, within 24 hours of overturn notice. This applies to all calendar days (no exceptions or delays allowed for weekends or holidays).