How to Request an Appeal. If you disagree with a pre-service request for Benefits determination, post-service claim determination or a rescission of coverage determination, you can contact us in writing to request an appeal. Your request for an appeal should include: • The patient's name and the identification number from the ID card. • The date(s) of medical service(s). • The provider's name. • The reason you believe the claim should be paid. • Any documentation or other written information to support your request for claim payment. Your first appeal request must be submitted to us within 180 days after you receive the denial of a pre- service request for Benefits or the claim denial.
How to Request an Appeal. If you disagree with a pre-service request for Benefits determination, post-service claim determination or a rescission of coverage determination, you can contact us to request an appeal. Your appeal request must be submitted to us within 180 calendar days after you receive the denial of a pre-service request for Benefits or the claim denial. You only have one level of internal appeal. Your request for an appeal should include: • The patient's name and the identification number from the ID card. • The date(s) of medical service(s). • The Provider's name. • The reason you believe the claim should be paid. • Any documentation or other written information to support your request for claim payment. If someone other than yourself is submitting the complaint on your behalf, you must authorize the representative in writing. SAMPLE A qualified individual who was not involved in the decision being appealed will be chosen to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a health care professional with expertise in the field, who was not involved in the prior determination. We may consult with, or ask medical experts to take part in the appeal process. By submitting an appeal, you consent to this referral and the sharing of needed medical claim information. Upon request and free of charge, you have the right to reasonable access to copies of all documents, records and other information related to your claim for Benefits. If any new or additional evidence is relied upon or generated by us during the determination of the appeal, we will provide it to you free of charge prior to the due date of the response to the adverse benefit determination. A written appeal must be submitted to the address below. You, your designee or guardian, your Physician or your health care Provider may file the appeal. Written appeals should be addressed to: UnitedHealthcare Appeals & Grievances PO Box 6111 Mail Stop CA-0197 Cypress, CA 9063 We will acknowledge, in writing, the receipt of your appeal within three business days and request all the information required to evaluate your case. You will be notified orally of the decision and written notice will be sent following oral notification.
How to Request an Appeal. If you disagree with a pre-service request for Benefits determination, post-service claim determination or a rescission of coverage determination, you can contact us verbally or in writing to request an appeal. Your appeal request must be submitted to us within 180 calendar days after you receive the denial of a pre-service request for Benefits or the claim denial. Your request for an appeal should include: • The patient's name and the identification number from the ID card. • The date(s) of medical service(s). • The provider's name. • The reason you believe the claim should be paid. • Any documentation or other written information to support your request for claim payment. If someone other than yourself is submitting the complaint on your behalf, you must authorize the representative in writing.
