A qualified individual who was not involved in the decision being appealed will be appointed to decide the appeal. If your appeal is related to clinical matters, the review will be done in consultation with a healthcare professional with appropriate expertise in the field who was not involved in the prior determination. UnitedHealthcare may consult with, or seek the participation of, medical experts as part of the appeal resolution process. You consent to this referral and the sharing of pertinent medical claim information. Upon request and free of charge, you have the right to reasonable access to and copies of all documents, records and other information relevant to your claim for benefits.
For procedures associated with urgent claims, see "Urgent claim appeals that require immediate action.
The plan administrator will review and decide your appeal within a reasonable period of time but no longer than 60 days after it is submitted. The review will take into account all comments, documents, records and other information relating to the claim that you submit without regard to whether such information was submitted or considered in the initial benefit determination. The review will not give deference to the initial adverse benefit determination. In addition, the individual who decides your appeal will not be the same individual who decided your initial claim adverse benefit determination and will not be that individual's subordinate. The decision of the plan administrator is final and binding on all individuals claiming benefits under the plan.
For appeals of pre-service claims, you will be notified of the determination on first level appeal within a reasonable period of time but no longer than 15 days from receipt of a request for appeal of a denied claim. If you are not satisfied with the decision, you have the right to file a second level appeal. Your second level appeal request must be submitted within 60 days of receipt of the first level appeal decision. UnitedHealthcare will make a determination on your appeal no more than 15 days from receipt of a request for review of the first level appeal decision.
The table below describes the timeframes, which you and UnitedHealthcare are required to follow.
* UnitedHealthcare may require a one-time extension for the initial claim determination, of no more than 15 days, only if more time is needed due to circumstances beyond control of the Plan.
UnitedHealthcare will review and decide your appeal within a reasonable period of time but no longer than 30 days from receipt of a request for appeal of a denied claim. If you are not satisfied with the decision, you have the right to file a second level appeal. Your second level appeal request must be submitted within 60 days of receipt of the first level appeal decision. UnitedHealthcare will make a determination on your appeal no more than 30 days from receipt of a request for review of the first level appeal decision. For pre-service and post-service claim appeals, Stryker has delegated to UnitedHealthcare the exclusive right to interpret and administer the provisions of the plan. UnitedHealthcare's claim appeal decisions are conclusive and binding. UnitedHealthcare's decision is based only on whether or not benefits are available for the proposed treatment or procedure. The determination as to whether the pending health service is necessary or appropriate is between you and your physician.
The table below describes the timeframes, which you and UnitedHealthcare are required to follow.
Except in instances in which notice is provided under the expedited procedures for urgent care claims, you will be notified in writing of the decision at each level of appeal.
If the decision upholds the adverse benefit determination of your claim, the notification will provide:
- The specific reason or reasons for the adverse benefit determination
- Reference to specific plan provisions on which the determination was based
- A description of your right to receive (upon request and free of charge) reasonable access to, and copies of, all documents, records and other information relevant to your claim
- If the adverse benefit determination was based on a determination of experimental or investigational treatment or similar exclusion or limit, either:
- An explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to your circumstances
- A statement that such an explanation will be provided free of charge upon request
- If an internal rule, guideline, protocol or other similar criterion was relied on in denying your claim, either:
- A description of the specific rule, guideline, protocol or criterion relied on
- A statement that a copy of such a rule, guideline, protocol or criterion will be provided free of charge upon request
- A statement of your right to bring a civil action under Section 502 of ERISA
If, after exhausting your internal appeals, you are not satisfied with the final determination, you may choose to participate in the external review program. This program only applies if the adverse benefit determination is based on:
- Clinical reasons;
- The exclusions for experimental or investigational services or unproven services; or
- As otherwise required by applicable law.
This external review program offers an independent review process to review the adverse benefit determination of a requested service or procedure or the denial of payment for a service or procedure. The process is available at no charge to you after exhausting the appeals process identified above and you receive a decision that is unfavorable, or if UnitedHealthcare fails to respond to your appeal within the time lines stated below.
You may request an independent review of the adverse benefit determination. Neither you nor UnitedHealthcare will have an opportunity to meet with the reviewer or otherwise participate in the reviewer's decision.
All requests for an independent review must be made within four months of the date you receive the adverse benefit determination. You, your treating physician or an authorized designated representative may request an independent review by calling 800 387 7508 (the toll-free number on your ID card) or by sending a written request to the address on your ID card.
The independent review will be performed by an independent physician, or by a physician who is qualified to decide whether the requested service or procedure is a covered health service under the plan. The independent review organization (IRO) has been contracted by UnitedHealthcare and has no material affiliation or interest with UnitedHealthcare or Stryker. UnitedHealthcare will choose the IRO based on a rotating list of approved IROs.
In certain cases, the independent review may be performed by a panel of physicians, as deemed appropriate by the IRO.
Within applicable timeframes of UnitedHealthcare's receipt of a request for independent review, the request will be forwarded to the IRO, together with:
- All relevant medical records;
- All other documents relied upon by UnitedHealthcare in making a decision on the case; and
- All other information or evidence that you or your physician has already submitted to UnitedHealthcare.
If there is any information or evidence you or your physician wish to submit in support of the request that was not previously provided, you may include this information with the request for an independent review, and UnitedHealthcare will include it with the documents forwarded to the IRO. A decision will be made within applicable timeframes. If the reviewer needs additional information to make a decision, this time period may be extended. The independent review process will be expedited if you meet the criteria for an expedited external review as defined by applicable law.
The reviewer's decision will be in writing and will include the clinical basis for the determination. The IRO will provide you and UnitedHealthcare with the reviewer's decision, a description of the qualifications of the reviewer and any other information deemed appropriate by the organization and/or as required by applicable law.
If the final independent decision is to approve payment or referral, the plan will accept the decision and provide benefits for such service or procedure in accordance with the terms and conditions of the plan. If the final independent review decision is that payment or referral will not be made, the plan will not be obligated to provide benefits for the service or procedure.
You may contact UnitedHealthcare at 800 387 7508 for more information regarding your external appeal rights and the independent review process.
Under provisions of the plan, plan benefits are not subject to assignment by a participant, beneficiary or any other person except the Plan fiduciaries, and any attempt to do so shall be void. However, ERISA provides that in the case of persons with coverage under a state Medicaid program, automatic assignment of benefits to state Medicaid agencies is enforceable against the plan. Where benefits are paid directly to a doctor, hospital or other provider of care (other than to a state Medicaid agency), such direct payments are provided at the discretion of the Plan fiduciaries as a convenience to plan participants and do not imply an enforceable assignment of plan benefits or the right to receive such benefits.
An assignment to a healthcare provider for purposes of payment does not constitute appointment of an authorized representative under these claim procedures.
You may authorize someone else to file and pursue a claim or file an appeal on your behalf. Generally, this authorization must be in writing and signed by you; however, in the case of an urgent care claim, a physician or other healthcare professional who is licensed, accredited or certified to perform specified health services consistent with state law and who has knowledge of your medical condition will be acknowledged as your authorized representative even if no written designation is submitted. Any reference in these claim procedures to "you" is intended to include your authorized representative. An assignment to a healthcare provider for purposes of payment does not constitute appointment of an authorized representative under these claim procedures. Notwithstanding this provision, plan benefits are not subject to assignment by participant, beneficiary or any other person except the Plan fiduciaries.
Because of the large volume of activity in hospitals' and doctors' billing offices, oversights and duplicate charges do occur. As an incentive to carefully review your bills, Stryker will pay you 50% of any overcharges that are recovered from a hospital or doctor up to a maximum of $2,000. Bills eligible for this program must be for you or your dependents for which Stryker's plan is primary.
- Before you leave the hospital or doctor's office, make sure you receive or will be sent an itemized bill, including the date and type of service performed and the corresponding charges.
- Check that each listed service was performed, and contact the doctor's or hospital's billing office if you have any questions.
- Ask for an explanation of any charges you don't understand.
- If you find any errors, it is your responsibility to contact the hospital's or doctor's billing department to report the error and obtain a corrected bill within 90 days of discharge or the date of service. Have the hospital or doctor send the corrected bill, with the corrected items circled, to UnitedHealthcare. Upon review of the corrected bill, UnitedHealthcare will issue a corrected Explanation of Benefits (EOB) form.
- Present the original bills and the original and corrected EOBs to your Benefits Representative for review. You and the payroll department will then be notified of the incentive amount for which you are eligible. Please note that reimbursements under this program are considered income for tax purposes.