Any appeal to request the reversal of an adverse medical determination should be submitted in accordance with the guidelines listed in the subsection Appeals of Care Management Determinations.

Adjustments and Appeals Initial adjustment requests should be directed to UnitedHealthcare with a completed claim adjustment form, which is available on page 41 of the Provider Administrative Manual. These requests should be directed to the following address:

UnitedHealthcare Services
P.O. Box 659747
Route 2702
San Antonio, TX 78265-9747

During the adjustment review, additional information may be requested to make a determination. Delays in providing this information will result in delays of processing the request.

After the initial adjustment determination is made, if you are not in agreement, you may appeal the determination with the health plan. A written response to your appeal will be provided within 30 days of receipt of all pertinent information.

Appeal Requests

Appeals must be submitted in accordance to the time frame specified in the Participation Agreement or as required by law. The appeal should be sent to the Compliance Department at the address listed below:

IBA Health Plans
P.O. Box 51100
Kalamazoo, MI 49005-1100

Please include the following information:

Covered Person's identification number
Patient name
Claim number of the claim being appealed
Provider name and participating provider ID
Issue or reason for appeal
Any pertinent information that would be of assistance in reviewing your request

Appeals of Care Management Determinations

An appeal is a specific request to reverse an adverse determination and restriction of benefit coverage. Adverse determinations are based on:

Contract limitations
Specific benefit contract exclusions
Lack of medical information

An explanation of the appeals process is provided with the verbal and written notification of each denial determination. If you disagree with a denial decision made by the Care Management Department, there are appeal opportunities available to reverse the initial determination you may discuss the determination with the Medical Director by calling the Care Management Department at (800) 851-0404. The physician or health care provider and the patient make the final treatment decision.

Binding Arbitration

Participating Practitioners and Providers are entitled to initiate a binding arbitration process. You must exhaust the internal appeal process prior to requesting binding arbitration. The Network Services Manager or designee will send an acknowledgement of request for binding arbitration within 14 days of receipt. An arbitrator from a nationally recognized arbitration firm will be retained for the process. A court reporter will record the proceedings. The decision of the arbitrator is final. If the arbitrator does not reverse the decision, the provider is responsible for the arbitrator's charges.

Rapid Dispute Resolution

Non-contracted hospitals are entitled to request rapid dispute resolution. The Network Services Manager or designee will send an acknowledgement of request for rapid dispute resolution within 14 days of receipt. The Network Services Manager or designee will coordinate the rapid dispute resolution process with the Michigan Department of Community Health Mediator. A court reporter will record the proceedings. The decision of the mediator is final. The cost of the process will be assessed to the party determined to be at fault; if both parties, then the cost will be split between the two.