Member appeals, grievances or complaints - Chapter 10, 2021 UnitedHealthcare Administrative Guide

Members may be unhappy with our 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 > Medicare and Retirement Member Appeals and Grievance Form
    Note: An appeal, grievance or complaint process may differ based on product. See the 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: 1-801-478-5463

Expedited Fax: 1-866-654-6323

Phone: 1-800-291-2634

UnitedHealthcare Level Funded and UnitedHealthcare Oxford Level Funded Appeals Review

P.O. Box 31393

Salt Lake City, UT 84131

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: 1-801-478-5463

Expedited Fax: 1-866-654-6323

Phone: 1-800-657-8205

UMR and UnitedHealthcare Shared Services

Appeals (Pre-Service)

UMR

Fax: 1-888-615-6584

Phone: 1-800-808-4424 x 15227

(Note: This is a voicemail line. We return back of the member’s ID card. calls within one business day).

Mail: UHC Appeals - CARE

P.O. Box 400046 

San Antonio, TX 78229 

UHSS

Mail: P.O. Box 80783 

Salt Lake City, UT 84130-0783

 

Reconsiderations and Appeals  (Post-Service)

UMR

Fax: 1-877-291-3248

Phone: Call the number listed on the member's ID card

Mail: UMR - Claim Appeals

P.O. Box 30546

Salt Lake City, UT 84130-0546

 (or send to the address listed on the provider ERA)

UHSS

Mail: P.O. Box 30783

Salt Lake City, UT 84130-0783

  1. Respond to our requests for information within the designated time frame. You must supply records as requested within 2 hours for expedited appeals and 24 hours for standard appeals. This includes, but is not limited to, weekends and holidays.
  2. 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. A request to review a post-service determination will not be reopened for any reason (i.e., New and Material Evidence, Fraud or Similar Fault, Other) other than for a clerical error, unless the 60-calendar-day time frame to file a reconsideration has expired.
  3. Cooperate with our external independent medical review organization and us. This includes:
    • Promptly forwarding all medical records and information relevant to the applicable health care service 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
  4. Provide us with proof that reversals of adverse determinations were done within the stated time frames. You must supply proof within:
    • Expedited appeals — 2 hours of overturn notice.
    • Standard appeals — 24 hours of overturn notice. This applies to all calendar days (no exceptions or delays allowed for weekends or holidays).