How to Appeal a Claim Decision
If you still disagree with a claim determination after contacting customer service, you can contact UnitedHealthcare in writing to formally request an appeal. If the appeal relates to a claim for payment, your request 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 disagree with the adverse benefit determination (that is, why you believe the claim should be paid)
  • Any documentation or other written information to support your request for claim payment
You have 180 calendar days after receiving notice that your claim has been denied in whole or in part in which to appeal the determination. If you do not file an appeal within this 180-day period, you will lose the right to appeal the determination.
Submit your appeal to UnitedHealthcare at the following address:
UnitedHealthcare
P.O. Box 740800
Atlanta, GA 30374-0800
Except in the case of urgent care claims, your claim appeal must be made in writing.
Urgent Claim Appeals that Require Immediate Action
Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health or the ability to regain maximum function or cause severe pain. In these urgent situations, the appeal does not need to be submitted in writing. You or your physician should call UnitedHealthcare as soon as possible. UnitedHealthcare will provide you with a written or electronic determination within 72 hours following receipt of your request for review of the determination, taking into account the seriousness of your condition.
For urgent claim appeals, Stryker has delegated to UnitedHealthcare the exclusive right to interpret and administer the provisions of the plan. UnitedHealthcare's decisions regarding these matters are conclusive and binding.
The table below describes the timeframes, which you and UnitedHealthcare are required to follow.
Urgent Request for Benefits*
Type of Request for Benefits or Appeal
Timing
If your request for benefits is incomplete, UnitedHealthcare must notify you within:
24 hours
You must then provide your completed request for benefits to UnitedHealthcare within:
48 hours after receiving notice of additional information required
UnitedHealthcare must notify you of the benefit determination within:
72 hours
If UnitedHealthcare denies your request for benefits, you must appeal the adverse benefit determination no later than:
180 days after receiving the adverse benefit determination
UnitedHealthcare must notify you of the appeal decision within:
72 hours after receiving the appeal
* You do not need to submit urgent care appeals in writing. You should call UnitedHealthcare as soon as possible to appeal an urgent care request for benefits.
Adverse Benefit Determination of Claims Based on Ineligibility to Participate
If you receive an adverse benefit determination based on a determination that an individual is not eligible for benefits, you have 180 calendar days after receiving the adverse benefit determination notice in which to appeal the determination to the plan administrator. Your appeal must be in writing. If you do not file an appeal within this 180-day period, you will lose the right to appeal the determination. Submit your appeal to the following address:
Health Plan Administrator
Stryker
2825 Airview Boulevard
Kalamazoo, MI 49002
Your appeal should set out the reasons you believe that the claim should not have been denied and should also include any additional supporting information, documents or comments that you consider appropriate. At your request, you will be provided, free of charge, with reasonable access to, and copies of, all documents, records, and other information relevant to the claim.