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Effective Date:

Approval Date: 71

Attachment 10 Plan Appeal and Grievance Procedures

UnitedHealthcare Wellmark Health Plan of Iowa Delta Dental of Iowa Definition Any questions or concerns regarding coverage decisions, preauthorization decisions, or any action concerning the provision of health care services, or other matters concerning the operations of health plan. Denial of benefits, or disagreement with decision to reduce benefits, or complaint regarding a claim, provider or service provided by Wellmark Denial or partial denial, or a complaint regarding a claim. Who can file a complaint or an appeal An Enrollee's physician, family member or other individual may act as the Enrollee's representative to assist in filing a complaint on behalf of the Enrollee. Enrollee or someone appointed by the Enrollee. The Enrollee, a representative of the Enrollee, or the dentist. Type of appeal

Informal Enrollee contacts Customer Service Department or other health plan employee with an inquiry. Enrollee calls Customer Service Department Enrollee calls Customer Service Department Decision maker Customer service department. If Enrollee is dissatisfied with the response, the enrollee must always be advised of next step in complaint process. Customer service department researches and resolve issue and notify Enrollee of right to appeal if appropriate Customer Service Department. If Enrollee disagrees with the decision, enrollee can receive a full and fair review. Standard or First Level Appeal Process Used for all cases that are not life threatening or severe enough to seriously jeopardize the member's health and/or ability to regain maximum function. Written expression of dissatisfaction with health plan requesting that a decision be overturned. If enrollee is not satisfied with resolution of a complaint, enrollee may contact customer service department by phone or submit a written appeal by completing an Enrollee Appeal Form. The enrollee may submit a written request of review and appeal. The written request should have the reason for the request, documents, records and any other information related to the claim. Time frames for filing an appeal Complaint form shall be filed within 90 days from date the problem in question occurred. The form shall be signed and the facts listed. The Enrollee Appeal Form must be filed within 120 days of the complaint decision. The written request should be submitted within 180 days from the notice of denial.