Colorado's UHC Rocky Mountain Dual Complete CO-S003 (HMO-POS D-SNP) H2582-002-000 Appeals and Grievances Process

What is an Appeal?

An appeal is a type of complaint you make when you want a reconsideration of a decision (determination) that was made regarding a service, or the amount of payment your Medicare Advantage health plan pays or will pay for a service or the amount you must pay for a service.

Why file an Appeal?

You may use the appeal procedure when you want a reconsideration of a decision (coverage determination) that was made regarding a service or the amount of payment your health plan paid for a service.

When can an Appeal be filed?

You may file an appeal within sixty five (65) calendar days of the date of the notice of the coverage determination. For example, you may file an appeal for any of the following reasons:

• your health plan refuses to cover or pay for services you think your Medicare Advantage health plan should cover.
• your health plan or one of the Contracting Medical Providers refuses to give you a service you think should be covered.
• your Medicare Advantage health plan or one of the Contracting Medical Providers reduces or cuts back on services you have been receiving.
• If you think that your health plan is stopping your coverage too soon.

Note: The sixty five (65) day limit may be extended for good cause. Include in your written request the reason why you could not file within the sixty five (65) day timeframe.

Who can file an Appeal?

An appeal may be filed by any of the following:

• You may file an appeal.
• Someone else may file the appeal for you on your behalf. You may appoint an individual to act as your representative to file the appeal for you by following the steps below:
  • If you want a friend, relative, or another person to be your representative, call Customer Service and ask for the “Appointment of Representative” form. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. 
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your appeal. Click here to find and download the CMS Appointment of Representation form.(The form is also available on Medicare’s website at www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf.)
  • Review your plan's Appeals and Grievances process in the Evidence of Coverage document.
• Your doctor can make a request for you.
• You also have the right to hire a lawyer.

Where can an Appeal be filed?

Part C/B
P.O. Box 6103, MS CA124-0187
Cypress, CA 90630-0023

Fax -Standard: 1-844-226-0356
Fax-Expedited: 1-866-373-1081
Standard Phone: 1-800-701-9054 TTY 711
Expedited Phone number: 1-877-262-9203 TTY 711
8 a.m. - 8 p.m. 7 Days Oct-Mar; M-F Apr-Sept
Website: myuhc.com/communityplan

Part D
P.O. Box 6106, MS CA124-0197
Cypress, CA 90630-0016
Fax -Standard: 1-866-308-6294
Fax-Expedited: 1-866-308-6296
Part D Standard Phone: 1-800-701-9054 TTY 711
Part D Expedited Phone number: 1-866-308-6296 TTY 711

Fast Decisions/Expedited Appeals

You have the right to request and receive expedited decisions affecting your medical treatment in "Time-Sensitive" situations. A Time-Sensitive situation is a situation where waiting for a decision to be made within the timeframe of the standard decision-making process could seriously jeopardize:

• Your life or health, or
• Your ability to regain maximum function.

If your Medicare Advantage health plan or your Primary Care Provider decides, based on medical criteria, that your situation is Time-Sensitive or if any physician calls or writes in support of your request for an expedited review, your Medicare Advantage health plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours plus (14) calendar days, if an extension is taken, after receiving the request.

Medicare Complaint Form

Who can file a Grievance?

A grievance may be filed by any of the following:

• You may file a grievance.
• Someone else may file the grievance for you on your behalf. You may appoint an individual to act as your representative to file the grievance for you by following the steps below:
  • Provide your Medicare Advantage dual eligible health plan with your name, your Medicare number and a statement, which appoints an individual as your representative. (Note: you may appoint a physician or a Provider.) For example: "I [your name] appoint [name of representative] to act as my representative in requesting a grievance from your Medicare Advantage health plan regarding the denial or discontinuation of medical services."
  • You must sign and date the statement.
  • Your representative must also sign and date this statement.
  • You must include this signed statement with your grievance.

What is a Grievance?

A grievance is a type of complaint you make if you have a complaint or problem that does not involve payment or services by your health plan or a Contracting Medical Provider. For example, you would file a grievance: if you have a problem with things such as the quality of your care during a hospital stay; you feel you are being encouraged to leave your plan; waiting times on the phone, at a network pharmacy, in the waiting room, or in the exam room; waiting too long for prescriptions to be filled; the way your doctors, network pharmacists or others behave; not being able to reach someone by phone or obtain the information you need; or lack of cleanliness or the condition of the doctor's office.

When can a Grievance be filed?

Complaints related to Part D can be made at any time after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid Issue can be made any time after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Complaints about access to care are answered in 2 business days.

Expedited Grievance

You have the right to request an expedited grievance if you disagree with your Medicare Advantage health plan's decision to invoke an extension on your request for an organization determination or reconsideration, or your health plan's decision to process your expedited reconsideration request as a standard request. In such cases, your Medicare Advantage health plan will respond to your grievance within twenty-four (24) hours of receipt.

Where can a Grievance be filed?

Call Member Services at 1-800-701-9054 TTY 711 8 a.m. – 8 p.m. local time, Monday through Friday (voicemail available 24 hours a day/7 days a week).

Why file a Grievance?

You are encouraged to use the grievance procedure when you have any type of complaint (other than an appeal) with your health plan or a Contracting Medical Provider, especially if such complaints result from misinformation, misunderstanding or lack of information.

Grievance, Coverage Determinations and Appeals

Filing a grievance (making a complaint) about your prescription coverage

A grievance is a complaint other than one that involves a request for a coverage determination. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.

Some types of problems that might lead to filing a grievance include:

• Issues with the service you receive from Customer Service.
• If you feel that you are being encouraged to leave (disenroll from) the plan.
• If you disagree with our decision not to give you a “fast” decision or a “fast” appeal.
• We don't give you a decision within the required time frame.
• We don't give you required notices.
• You believe our notices and other written materials are hard to understand.
• Waiting too long for prescriptions to be filled.
• Rude behavior by network pharmacists or other staff.
• We don't forward your case to the Independent Review Entity if we do not give you a decision on time.

If you have any of these problems and want to make a complaint, it is called "filing a grievance."

Who may file a grievance

You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, call UnitedHealthcare® Customer Service. 

Filing a grievance with our plan

The process for making a complaint is different from the process for coverage decisions and appeals. If you have a complaint, you or your representative may call the phone number listed on the back of your member ID card. We will try to resolve your complaint over the phone.

If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. Members are able to file via the member’s portal: myuhc.com/communityplan

A&G Part C/B:
P.O. Box 6103, MS CA124-0187,
Cypress, CA 90630-0023
A&G Expedited Fax / Part C: 1-844-226-0356
Standard Phone: 1-800-701-9054 TTY 711
Expedited Phone number: 1-877-262-9203 TTY 711

Part D:
P.O. Box 6106, MS CA124-0197
Cypress, CA 90630-0016
Fax -Standard: 1-866-308-6294
Fax-Expedited: 1-866-308-6296
Part D Standard Phone: 1-800-701-9054 TTY 711
Part D Expedited Phone number: 1-866-308-6296 TTY 711

If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond in writing.

If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours.

• You may fax your expedited written request toll-free to 1-877-262-9203; or
• You may contact UnitedHealthcare to file an expedited Grievance.

Please be sure to include the words "fast", "expedited" or "24-hour review" on your request.

Whether you call or write, you should contact Customer Service right away. Complaints related to Part D can be made any time after you had the problem you want to complain about. Complaints regarding any other Medicare or Medicaid issue can be made any time after you had the problem you want to complain about. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days.

• Please refer to your plan's Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage Document or your plan's member handbook.

Medicare Complaint Form

Asking for a coverage determination (coverage decision)

An initial coverage decision about your Part D drugs is called a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide a drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.

In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to us to ask for a formal decision about the coverage.

Drug requirements and limitations

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. Some covered drugs may have additional requirements or limits that help ensure safe, effective and affordable drug use. If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you.

You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names in the plan's drug list. To find the plan's drug list go to View plans and pricing and enter your ZIP code. Choose one of the available plans in your area and view the plan details. You’ll find the form you need in the Helpful Resources section.

Some drugs covered by the Medicare Part D plan have "limited access" at network pharmacies because:

• The FDA says the drug can be given out only by certain facilities or doctors
• These drugs may require extra handling, provider coordination or patient education that can't be done at a network pharmacy

Requirements and limits apply to retail and mail service. These may include:

Prior Authorization (PA)

The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.

Quantity Limits (QL)

The plan will cover only a certain amount of this drug , or a cumulative amount across a category of drugs (such as opioids), for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.

Step Therapy (ST)

There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.

Medicare Part B or Medicare Part D Coverage Determination (B/D)

Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.

NOTE: If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug.

IN ADDITION TO THE ABOVE, YOU CAN ASK THE PLAN TO MAKE THE FOLLOWING EXCEPTIONS TO THE PLAN'S COVERAGE RULES

You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

Formulary Exceptions

• You can ask the plan to cover your drug even if it is not on the plan's drug list (formulary). If a formulary exception is approved, the non-preferred brand co-pay will apply. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.

Cost Sharing Exceptions

• If your drug is in a cost-sharing tier you think is too high, you and your doctor can ask the plan to make an exception in the cost-sharing tier so that you pay less for it.
• Drugs in some of our cost-sharing tiers are not eligible for this type of exception. For example, if we grant your request to cover a drug that is not in the plan's Drug List, we cannot lower the cost-sharing amount for that drug. In addition:
  • Tier exceptions are not available for drugs in the Specialty Tier.
  • Tier exceptions are not available for drugs in the Preferred Generic Tier.
  • Tier exceptions are not available for branded drugs in the higher tiers if you ask for an exception for reduction to a tier level that does not contain branded drugs used for your condition.
  • Tier exceptions are not available for biological (injectable) drugs if you ask for an exception for reduction to a tier that does not contain other biological (injectable) drugs.
  • Tier exceptions may be granted only if there are alternatives in the lower tiers used to treat the same condition as your drug.

Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

How to request a coverage determination (including benefit exceptions)

Call the UnitedHealthcare Customer Service number to request a coverage determination (coverage decision). When requesting a formulary or tiering exception or asking for the plan to cover an additional amount of a drug with a quantity limit or asking for the plan to waive a step therapy requirement, a statement from your doctor supporting your request is required. Usually, the coverage decision will be made within 72 hours after we receive the request or your doctor's supporting statement (if required).

You can request an expedited (fast) coverage decision if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we receive your request or prescribing doctor's supporting statement.

If you are a continuing member in the plan, you may notice that a formulary medication which you are currently taking is either not on the formulary or its cost-sharing or coverage is limited in the upcoming year.

If you are affected by a change in drug coverage you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. If we approve your request, you’ll be able to get your drug at the start of the new plan year.
• Find a different drug that we cover. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. You should discuss that list with your doctor, who can tell you which drugs may work for you.

In some situations, we will cover a one-time, temporary supply. During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. To initiate a coverage determination request, please contact UnitedHealthcare.

Have the following information ready when you call:

• Member name
• Member date of birth
• Medicare Part D Member ID number
• Name of the medication
• Physician's phone number
• Physician fax number (if available)

You may also request a coverage decision/exception by logging on to www.optumrx.com and submitting a request. If you are a new user with www.optumrx.com, you will need to register before you can access the Prior Authorization request tool. Once you have registered, you will find the Prior Authorization tool under the Health Tools Menu. Once your request has been submitted, we will attempt to contact your prescriber to get a supporting statement and/or additional clinical information needed to make a decision.

Download this form to request an exception:

• Medicare Part D Coverage Determination Request Form – for use by members and providers
• This is a CMS-model exception and prior authorization request form developed specifically for use by all Medicare Part D prescribing physicians or members. You may use this form or the Prior Authorization Request Forms listed below.

To have your doctor make a request

Your doctor or provider can contact UnitedHealthcare at  1-800-701-9054 TTY 711 for the Prior Authorization department to submit a request, or fax toll-free to 1-844-403-1028. The plan's decision on your exception request will be provided to you by telephone or mail. In addition, the initiator of the request will be notified by telephone or fax.

Your doctor can also request a coverage decision by going to www.professionals.optumrx.com.

To inquire about the status of a coverage decision, contact UnitedHealthcare.

Please refer to your plan’s Appeals and Grievance process located in Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) of the Evidence of Coverage document or your plan’s member handbook.

Note: Existing plan members who have already completed the coverage determination process for their medications may not be required to complete this process again.

What happens if we deny your request?

If we deny your request, we will send you a written reply explaining the reasons for denial. If an initial decision does not give you all that you requested, you have the right to appeal the decision. See How to appeal a decision about your prescription coverage.

How to appoint a representative to help you with a coverage determination or an appeal.

The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Click here to find and download the CMS Appointment of Representation form.

Both you and the person you have named as an authorized representative must sign the representative form.

For Coverage Determinations

Part C/B/D

OptumRX Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799
Fax: 1-844-403-1028

For Appeals

Part C/B
P.O. Box 6103, MS CA124-0187
Cypress, CA 90630-0023

Fax -Standard: 1-844-226-0356
Fax-Expedited: 1-866-373-1081
Standard Phone: 1-800-701-9054 TTY 711
Expedited Phone number: 1-877-262-9203 TTY 711
8 a.m. - 8 p.m. 7 Days Oct-Mar; M-F Apr-Sept
Website: myuhc.com/communityplan

Part D:
P.O. Box 6106, MS CA124-0197,
Cypress, CA 90630-0016

Fax -Standard: 1-866-308-6294
Fax-Expedited: 1-866-308-6296
Part D Standard Phone: 1-800-701-9054 TTY 711
Part D Expedited Phone number: 1-800-308-6296 TTY 711

Website: myuhc.com/communityplan

If your prescribing doctor calls on your behalf, no representative form is required.

Second Level Appeals

If we say no to all or part of your Level 1 appeal, your appeal will automatically go on to Level 2. The Level 2 appeal is conducted by an Independent Review Organization that is not connected to us.

• You do not need to do anything to start a Level 2 appeal. Medicare rules require we automatically send your appeal to Level 2 if we do not fully agree with your Level 1 appeal.
• If you are not satisfied with the decision at the Level 2 appeal, you may be able to continue through additional levels of appeal.