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Member Complaints & Grievances - UnitedheatlhOne Individual Plans Supplement, 2018 UnitedHealthcare Administrative Guide

Member disputes may arise from time to time with UnitedHealthOne or with our participating care providers. We respect the rights of our members to express dissatisfaction regarding quality of care or services and to appeal any denied claim or service. Instructions on how to file a complaint or grievance with us are in the member’s Combined Evidence of Coverage and Disclosure Form, Evidence of Coverage, or Certificate of Coverage. Please refer to Member Appeals, Grievances or Complaints section in Chapter 9: Our Claims Process for detailed information about your role in the member appeal process.

UnitedHealthcare Oxford Navigate Individual - Internal Utilization Management Appeals Process

Internal UM appeals must be initiated by the member or their designee 180 calendar days from receipt of the initial adverse UM determination. UM appeals include denials as not medically necessary, experimental or investigational, cosmetic, dental rather than medical, or excluded as a preexisting condition.

To initiate the standard internal UM appeal process, write to:

UnitedHealthcare Oxford Navigate Individual
Grievance Administrator
P.O. Box 31371
Salt Lake City, UT 84131-0371
Standard Fax: 801-478-5463

If you feel the situation is urgent, request an expedited (urgent) appeal orally, by fax or in writing to:

UnitedHealthcare Oxford Navigate Individual
Grievance Administrator
3100 AMS Blvd.
Green Bay, WI 54313
Expedited Fax: 866-654-6323
Phone: 800-291-2634

Determinations concerning services that have already been provided are not eligible to be appealed on an expedited basis. Expedited UM appeals are determined within 72 hours of receipt of the appeal. For expedited requests involving continued inpatient care in a network facility for a substance use disorder, the determination will be made within 24 hours of receipt of the request for review. Standard UM appeals are determined within 10 calendar days of receipt of the appeal.

All UM appeals are done by clinical peer reviewers other than the clinical peer reviewer who rendered the initial UM determination.

If the member or designee is not happy with the results of the appeal process, they may pursue an external appeal through an independent Utilization Review Organization (IURO) for final internal UM determinations. You must complete an internal appeal before you can request a review by an IURO, except when:

  1. We fail to meet the deadlines for completion of the internal appeals process:
    • Without demonstrating good cause, or
    • Because of matters beyond our control, and
    • While in the context of an ongoing, good faith exchange of information between parties, and
    • It is not a pattern or practice of noncompliance;
  2. We, for any reason, expressly waive our rights to an internal review of an appeal; or
  3. The treating care provider and/or member have applied for expedited external review at the same time as applying for an expedited internal review.

To initiate the external appeal, the member or designee must:

  1. File a written request with the New Jersey Department of Banking and Insurance within four months of receiving a final determination on an appeal.
  2. Sign a release that allows the IURO to review all the necessary medical records related to the appeal; and
  3. Send a check or money order in the amount of $25 made payable to: New Jersey Department of Banking and Insurance with the request. The form, release and check must be sent to:

    Department of Banking and Insurance
    Consumer Protection Services
    Office of Managed Care
    P.O. Box 329
    Trenton, NJ 08625-1062
    Phone: 888-393-1062

The IURO completes the review within 45 days of receipt.

The IURO completes its review within 48 hours if the appeal involves:

Urgent or emergency care

  • An admission
  • Availability of care
  • Continued stay
  • Health care services for which the member received emergency services and not yet discharged
  • A medical condition that would put the member’s life or health in danger when waiting for the normal appeal process

If UnitedHealthcare Oxford Navigate Individual has good cause for not meeting the deadlines of the appeals process, members or their designee and/or their care provider may request a written explanation of the delay. UnitedHealthcare Oxford Navigate Individual must provide the explanation within 10 days of the request and must include a specific description of the bases for which it was determined the delay should not cause the internal appeals process to be exhausted. If an external reviewer or court agrees with UnitedHealthcare Oxford Navigate Individual and rejects the request for immediate review, the member has the opportunity to resubmit their appeal.

Internal Administrative Appeal Process

The administrative appeal process is used to appeal an initial determination concerning a claim for benefits or an administrative issue. Issues include but are not limited to:

  • Denials based on benefit exclusions or limitations not involving UM decisions;
  • Claims payment disputes; and
  • Administrative issues concerning other requirements of the health plan. Administrative issues include but are not limited to issues involving:
    • Eligibility;
    • Enrollment issues; and
    • Rescission of coverage.

Please Note: Benefit and administrative issues do not include initial determinations that the service or supply is not medically necessary, experimental or investigational, cosmetic, dental rather than medical, or treatment of a preexisting condition. Those determinations are UM decisions.

Administrative appeals must be initiated by the member or their designee in writing unless expedited.

Determinations concerning services that have already been provided are not eligible to be appealed on an expedited basis. Expedited administrative appeals are determined within 72 hours from receipt of the appeal. All other appeals are determined within 30 calendar days of receipt of the appeal.

Notice to Texas Providers

To verify benefits for GRIC members, call 800-395-0923.

Tools have been developed by third parties, such as the MCG® Care Guidelines (formerly known as Milliman Care Guidelines®), to assist in administering health benefits making informed decisions in many health care settings, including acute and sub-acute medical, rehabilitation, skilled nursing facilities, home health care and ambulatory facilities.

As affiliates of UnitedHealthcare, GRIC and Oxford Health Insurance, Inc. may also use UnitedHealthcare’s medical policies as guidance. These policies are available on UHCprovider.com/policies.

Notification does not guarantee coverage or payment (unless mandated by law). The member’s eligibility for coverage is determined by the health benefit plan. For benefit or coverage information, please contact the insurer at the phone number on the back of the member’s health care ID card.

To obtain a verification as required by 28 TAC §19.1719, please call 800-842-1792.

Important Information Regarding Diabetes (Michigan)

Michigan requires insurers to provide coverage for certain expenses to treat diabetes. It also requires insurers to establish and provide members and participating care providers with a program to help prevent the onset of clinical diabetes. We have adopted the American Diabetes Association (ADA) Clinical Practice Guidelines.

The program for participating care providers emphasizes best practice guidelines to help prevent the onset of clinical diabetes and to treat diabetes, including diet, lifestyle, physical exercise and fitness, and early diagnosis and treatment. The Standards of Medical Care in Diabetes and Clinical Practice Recommendations are on care.diabetesjournals.org.

Subscription information for the American Diabetes Journals is available on the website. You can also call 800- 232-3472 and select option one, 8:30 a.m. to 8 p.m. ET, Monday through Friday. View journal articles without an online subscription.