Appeals and grievances,- Capitation and/or delegation supplement - 2022 Administrative Guide

Health 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. Time frames for filing an appeal vary depending on applicable state or federal requirements.

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

This system helps us fulfill the requirements and expectations of our members and our network 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 member’s health, 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. This 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 health care provider complaints and use the information during their recredentialing. We conduct an annual analysis of the complaint data to look for opportunities for improvement. Health care provider and member complaints are important to the recredentialing process because they help us attract and retain health care providers, employer groups and members.

Member grievance and appeals

Network providers are required to:

• Immediately, within 1 hour of receipt, forward all member grievances and appeals (complaints, appeal, quality of care/service concern, whether oral or written) to us for processing to:
  UnitedHealthcare
  P.O. Box 6106
  Mail Stop CA 124-015
  Cypress, CA 90630
• Respond to our requests for information about the member’s appeal or grievance within the designated time frame. For expedited appeals, submit the requested information within 2 hours. For standard appeals, submit within 24 hours (no exceptions or delays due to weekend or holidays). Time frames 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. This means 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 your possession, requested by an external review organization. Respond to our requests for proof of claim payment or a copy of the pre-service authorization of overturned appeals: expedited appeals, within 2 hours, standard appeals, within 24 hours (no exceptions or delays due to weekend or holidays). Time frames 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 time frames on reversals of adverse determinations. Respond to requests for proof overturned appeals were resolved: expedited appeals, within 2 hours, standard appeals, within 24 hours (no exceptions or delays due to weekend or holidays). Time frames 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 file their grievance. We do not delegate authority or responsibility for processing member grievances, appeals or complaints to our network providers. However, we do require our network providers help resolve grievances, appeals or complaints.