United Health Care

Compliance

100

Grievances for Medicaid covered benefits are filed here

Macess

200

A request when the member or member's physician/prescriber believes that waiting the standard timeframe may jeopardize the member's life, health, or ability to regain maximum function.

Expedited 

300

A request for an independent appeal of the plan's decision to terminate SNF, HHA or CORF services.  

Fast Track Appeal

400

A decision about a Part C payment or benefits, or the discontinuation of health services, to which the member believes they are entitled

OD {Organization Determination} 

500

Complaints about services received by a member from a medical provider, facility, or pharmacy, which were inadequate or substandard.

QOC {Quality of Care}

Pharmacy Calls

100

The plan will cover only a certain amount of this drug for one copay or over a certain number of days. May be in place to ensure safe and effective use of a drug

Quantity Limits

200

A decision about Part D payments or benefits to which a member believes they are entitled.

CD {Coverage Determination} 

300

This is a request from the plan to a provider for more information to be sure the drug is being used correctly for a medical condition covered by Medicare

Prior Authorization

400

What are the steps if a member wants to check if a medication requires authorization.

1. Obtain medication information from the member.
2. Access the member's formulary.
3. Determine if the formulary indicates that the medication requires prior authorization and/or step therapy.
   • Prior authorization required
     1. Advise that prior authorization is required for this medication.
     2. Go to the next step.
   • Step therapy required
     Go to the Step Therapy section.
   • Does not require prior authorization and/or step therapy
     1. Advise that the medication does not require prior authorization and/or step therapy.
     2. Follow call closing guidelines.

500

There may be effective, lower-cost drugs that treat the same medical condition, the member may be required to try one or more of these other drugs before the plan will cover the drug.

Step Therapy

Grievances

100

Definition: A general expression of dissatisfaction about UnitedHealthcare, practitioner or any matter (other than an action). This includes, but is not limited to, quality of care or services, aspects of interpersonal relationships (e.g., rudeness of a provider or employer) or a failure to respect the member's rights.

 Grievance

200

What are the 5 W's that are important for documenting a grievance?

Who, What, Where, When & Why.

300

Where should I look if I need help finding the correct reason and sub-reason dropdowns to categorize a Quality of Service grievance?

Grievance Categorization SOP

400

What system/site are you able to view A&G {Appeal and Grievance} letters that have been sent to members.

Doc360

500

What steps do you utilize for a Quality of Care Withdrawal Request

Apologize

Determine why

Ensure they received care or scheduled to receive care

Locate the Grievance Intent in Maestro

1. give this email information to members.)
2. Include the following information in the email.
   Note: Advocates may copy and paste the below template into their email if desired.
   • Member's name:
   • Member's ID:
   • Intent Number (S-Case):
   • Member is requesting withdrawal of their Quality of Care investigation
   • Details of withdrawal reason, if available.
     Example: Member called in after receiving the letter advising that the plan would investigate her Quality of Care event with Dr. John Smith. The member does not want this complaint investigated because she does not want this to affect her relationship with the doctor.
3. Educate the member:
   • We will contact the investigation team and request withdrawal of their investigation.
   • The investigation may have already begun, but the current actions will end once the withdrawal request is received.
   • They will receive a letter from the plan advising them of the withdrawal.
     • Confirm/verify the member's address.

Attach a note to the Quality of Care intent indicating the member contacted the plan requesting a withdrawal of the plan's investigation.

Document and close the call.

Coverage Determinations

100

Should you direct a member to their provider or call the provider to have them submit a coverage determination on the members behalf? 

NO

200

Coverage Determination (CD) in Advance is only used when?

October 15 – December 31 for requests prior to the 1/1 effective date.

300

What system or site do you submit the coverage determination request

PA Initiation form or Prior Authorization System (PAS}

400

What is the turn-around time for PA for B vs D?

Expedited 24 hours from time of call

Standard: within 72 hours of the time of the call

500

When a coverage determination requires a supporting statement from the member's prescriber the member may choose to have their prescriber call OptumRx to provide this supporting information instead of waiting for the fax from OptumRx. 

What is the phone # and Hours?

If the member elects this option please provide the following phone number and hours of operation: Phone number: 800-711-4555 CR
Hours of Operation:

M - F: 5a.m. - 7 p.m. PT
Sat: 6 a.m. - 3 p.m. PT
Sun: Close

SOP/Job Aid

100

What SOP would you use to assist handling a caller who is threatening media or legal complaint regarding a Commercial, Medicare Advantage Part D, Stand Alone Part D, Medicare Advantage Special Needs, or a Medicaid plan (Medicare & Retirement or Community & State). Also, guidance is provided on how to handle conversations with an attorney. 

Legal Risk Management

KM1258804

200

What SOP would you use when a member 

• Has a privacy concern
• Would like to file a complaint regarding privacy policies and procedures
• Has received a letter from the Privacy Office

Hipaa - Privacy Complaint

KM1005783

300

What SOP would you use to locate information about benefit coverage for continuous glucose monitors {CGM}

Benefit Coverage - CGMs 

KM1004326

400

What SOP would you use to submit a request for the Navigator to call the member back

Situational Guidelines - Navigator Hand-off Process

KM1260277

 

500

What SOP would you use if a member wants to provide a compliment or Kudos

Situational Guidelines - Kudos Calls 

KM1006644