Claims Questions And Appeals
The Arizona Supreme Court, in an interesting case involving a Medicare-related coverage dispute between a Medicare Advantage plan administrator, United Behavioral Health (UBH), and two inpatient psychiatric care providers, held that the Medicare administrative appeals process preempts the arbitration language contained in the UBH provider agreements. For amounts of at least $1,400, the final level of appeal is judicial review in U.S. district court. Enrollment in Independence Medicare Advantage plans depends on contract renewal. You or your representative can follow the instructions found in the Level 4 review decision to file a Level 5.
If the appeal or claim analysis requires clinical expertise, the case is sent for review by one of the clinicians on our team (physician, physician's assistant, or registered nurse). If your appeal is denied and your drug is worth at least $160 in 2018, you can choose to appeal to the Council within 60 days of the date on your OMHA level denial letter.
An appeal may be filed in writing or by contacting UnitedHealthcare® Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in the Summary of Benefits or Chapter Two of the Evidence of Coverage, 8 a.m.-8 p.m. local time, 7 days a week.
All requests for payment appeals must include a completed and signed Waiver of Liability (WOL) statement. For How to Appeal Medicare Advantage Denial help, call the Medicare Rights Center national hotline (800-333-4114) or your state's Health Insurance Assistance program , a free resource for seniors who have questions about Medicare coverage.
If you're getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicare-covered services are ending too soon, you have the right to a fast track appeal.
Similar to Medicare Advantage appeals, there is an expedited appeals process if your health or life is at risk. On September 27, the OIG published a Review regarding the rate of overturned Medicare Advantage denials upon repeal. You may file a grievance if you have a complaint other than one that involves a coverage determination (see Appeals above).