Grievances
An expression of dissatisfaction with the manner in which the plan provides health care services regardless of whether any remedial action can be taken.
What is a Standard Grievance?
Coverage Determination (CD) in advance is only used on these dates for requests prior to the 1/1 effective date.
What dates are October 15 – December 31?
a formal process where UnitedHealthcare gives a contracting Medical Group the responsibility and authority to perform specific functions on its behalf such as medical authorizations.
What is Value Based Care Agreement?
These dates are the only dates you can assist members with coverage determinations for the new plan year.
what is AEP from September 1- December 31?
Member complaining about the excessive transfers and the time they have spent on the phone with the advocate
What is Call Center- Complaint about call time/hold/transfers?
Complaints about services received by a member from a medical provider, medical facility, or pharmacy, which were inadequate or substandard in quality. These complaints include an indication that the member's care, or ability to receive care, has been or could be affected.
What is a Quality of Care Grievance?
You must contact this department if the member is requesting reprint of the decision letter for a CD.
What is the OptumRx Prior Authorization Department?
A member or physician may request this type of appeal if the member/physician believes that waiting for a decision under the standard time frame may jeopardize the member's life, health, or ability to regain maximum function.
What is an Expedited Appeal?
A decision about Part C payment or benefits, or the discontinuation of health services that the member believes they are entitled to. It also applies to the failure of the health plan to arrange or pay for services, or to provide the member with a notice of denial in a timely manner, when the delay could adversely affect the member's health.
What is an Organization Determination?
Member is complaining about their copays that they have to pay to see a specialist.
What is Plan- Plan Benefits?
A complaint where the member complains that the plan refused to expedite an organization determination or an appeal or took an extension to respond to an organization determination or appeal.
What is an Expedited Grievance?
If the member chooses to change from an MAPD to a PDP, the authorization will not transfer.
Will the members CD transfer from one plan to another?
Appeals for ancillary benefits (i.e., dental, vision, and hearing) are handled by this group
Who is the Health Plan?
If a member is currently receiving treatment from a provider who is Out of Network (OON), they can request this to act as a bridge for coverage so a member can transition from their old provider to a new, In Network (INN) provider.
What is Continuity of Care?
Member complaining about their requested transportation provider was late / no-show for non-appointment destination (grocery store, gym, etc.)
What is Transportation Services- Complaint regarding Transportation without missing appointment?
An expression of dissatisfaction about a sales agent, regardless of whether the person is a broker, field agent (including representatives at benefit meetings), or Telesales agent.
What is a Sales Grievance?
A coverage determination can be processed if the member is indicating the medication should be covered under this Part and is not excluded.
What is Part B?
A request for an independent appeal of the plan's decision to terminate Skilled Nursing Facility (SNF), Home Health Agency (HHA) or Comprehensive Outpatient Rehabilitation Facility (CORF) services.
What is a Fast Track Appeal?
Any excessive wait times the member feels has caused harm to their health in a provider's office, for appointments for medical services or at a pharmacy, or on the phone should be referred to this team by email.
What is QIS Quality Intervention Services team/department?
The Broker enrolled the member without their knowledge / consent
What is Sales Agent Broker- Sales Agent/Broker Fraud, Misrepresentation or Behavior?
The four Grievance handling tips
What is Identify, Resolve, Document and Categorize?
These are the only prescriptions that a member can request through Medicaid that a dual SNP or Medicare Advantage plan will not cover.
What is Medicare Excluded Drugs?
If it is beyond 60 days of the adverse decision, a standard appeal can still occur if the member can show good cause that something prohibited them from being able to request an appeal in the allotted timeframe.
What is Good Cause Appeals?
If a Network provider capable of providing the same service is not available in the member's area This type of exception may be granted.
What is a Network Gap Exception?
The member is frustrated because his PCP is no longer contracted with UHC
What is Provider Network- Provider Not in-network / Distance to Provider