Member Grievance and Appeals


We at University Care Advantage (HMO SNP) want to provide you with the best possible health coverage and care.

You as a member have the right to file a grievance or appeal (complaint) if you have concerns or problems related to your coverage of care. The following description details out the procedure for filing a grievance, appeal and organization determinations. 


You can also file a complaint or get information directly from Medicare.

University Care Advantage

Attn: Grievance and Appeals Department
2701 E. Elvira Rd.
Tucson, AZ 85756

Toll-free: (877) 874-3930
Hours of Operation: 24 hours a day, 7 days a week
Fax: (866) 465-8340
TTY: 711

Email: UAHNGrievanceMailbox@bannerhealth.com

You have the right to get a summary of information about the appeals, grievances and exceptions that members have filed against University Advantage in the past. Call our Customer Care Center to request this information.

To obtain total number of grievances, appeals and exceptions filed with University Care Advantage, contact:

(877) 874-3930 and ask for the Grievance and Appeals Department

Medicare

You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.  TTY/TDD users should call 1-877-486-2048.  You can also visit the Medicare website at 
http://www.medicare.gov/.

Appoint a Representative
To appoint a representative, fill out the CMS Appointment of Representative Form (CMS Form-1696), then send it to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision. See below for form.




Clicking a category below will expand the selection to reveal documents, forms and links.
  • Appeals
    • Why file an appeal?
      An appeal for Part C is called a Reconsideration.  During the reconsideration process we will review our adverse (negative, whether in full or in part) organization determination.  If you have a grievance related to a decision (organization determination) we made regarding your care, you would use the reconsideration (appeal) process.

      If you need help, want to know how to appoint a representative or have questions regarding the appeals process, you can call us at 1-877-874-3930, TTY users should call 711.  There are other resources available to assist you including 1-800-MEDICARE (1-800-633-4227) if you would prefer to contact a resource outside of your plan.  You may also use the legal resource list if you prefer.

      Who can file an appeal?
      You, your representative, your provider may file on your behalf, or a non-contract physician or provider may request that a determination be reconsidered.  When a non-contract physician or provider seeks a standard reconsideration for purposes of obtaining payment only (appealing a claims decision), then the non-contract physician or provider must sign a waiver of liability to waive any right to payment from the enrollee for a service.

      Contract providers do not have appeal rights.    

      What is an appeal?
      An appeal is any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, approving the health care services, or on any amounts the enrollee must pay for services. A reconsideration is the enrollee’s first step in the appeal process after an adverse (negative) organization determination.

      When can an appeal be filed?
      Your request must be filed within 60 calendar days from the date printed or written on the written organization determination denial notice.  

      If you can show good cause for missing the filing time frame for a reconsideration, University Care Advantage will consider the circumstances that prevented the timely filing of your request.  The party requesting the extension must file a written request and include the reason for the delay.   Examples of circumstances where this might apply include (but are not limited to):

      - The party was prevented by serious illness from contacting the plan;
      - The party had a death or serious illness in their immediate family;
      - Important records were destroyed by fire or other accidental cause;
      - The enrollee, representative, or physician or other provider did not receive notice of the determination or decision.

      Where can an appeal be filed or status of an appeal be checked?
      In order to provide you with the quickest response time, please file your appeal (reconsideration) or check on the status of such directly with University Care Advantage’s Grievance & Appeals Department:

      University Care Advantage
      Attn: Grievance & Appeals Department
      2701 E. Elvira Road
      Tucson, AZ 85756
      1-877-874-3930
      TTY users call 711
      Fax: 1-866-465-8340
      Email: UAHNGrievanceMailbox@bannerhealth.com 

      There are two types of appeals:
      1) Standard Reconsiderations
       on pre-service requests require us to provide written notice of our decision regarding your request no later than 30 calendar days from the date we receive the request.  The time frame may be extended if we require additional information or if you request it by up to 14 days. If our decision is favorable to you, we will process (effectuate) the decision immediately.  If our decision is adverse to you, additional appeal rights will be provided to you. Standard Reconsiderations on payment requests require us to provide written notice of our decision regarding your request no later than 60 calendar days from the date of receipt.  If our decision is favorable to you, we will process (effectuate) the decision immediately.  If our decision is adverse to you, additional appeal rights will be provided to you.

      2) Expedited Reconsiderations require us to provide notice of our decision regarding your request no later than 72 hours after receiving the request.  The time frame may be extended by up to 14 days if you request an extension or if we need additional information and/or documents and it is in your best interest for us to do so.  If our decision is favorable to you, we will process (effectuate) the decision immediately.  If our decision is adverse to you, additional appeal rights will be provided to you.

      What should you include with an appeal?
      To expedite the intake processing of your reconsideration, please provide as much information from the list below as you are able:
      - Name
      University Care Advantage or Medicare Identification Number
      - Contact information
      - Original denial notice
      - Dates of Service
      - Authorized Representative Form (if applicable)
      - Nature of request
      - Additional Information, Doctor’s notes, results, supporting documentation, etc.

      What happens after an appeal is filed?
      After University Care Advantage receives your reconsideration request, the Grievance & Appeals Department will notify you of receipt.  We will begin our investigation immediately, including reviewing additional documents received and requesting additional information not recorded in the file.  A unique case number is assigned to your file and all documents are attached to your case number.  If your case involves medical necessity, a medical professional with appropriate expertise and who was not included in your original determination will review your file to make a decision regarding your case.  The medical professional’s notes and reasoning for decision is forwarded back to the Grievance & Appeals Department.  You are notified of the decision.

      If the decision is favorable, we will effectuate it immediately and the reconsideration is closed.  If the decision is adverse or partially favorable to you, we provide additional appeal rights available to you in our written notice.
    • Legal Resources List
      Updated 09/25/15...open
    • Waiver of Liability Form
      H4931_WebCert_v15 Pending (Updated 09/16/14)...open
  • Appointment of Representative Form
    • To appoint a representative, you can do one of two things. Fill out the CMS Appointment of Representative Form (CMS Form-1696) or create a document in your own words that contains all the elements of CMS Form-1696. We will accept both. Then send either option to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision.
    • Appointment of Representative Form
      Form CMS-1696 (Rev 06/12)...open
    • Nombramiento de Representante
      Formulario de CMS-1696 (Rev 06/12) Spanish...open
  • Filing A Complaint (Grievance or Appeal) with Medicare
  • Grievances
    • Why should you file a grievance?
      You should file a grievance if you were unhappy with any aspect of care that you have received from University Care Advantage, whether or not remedial action is requested.

      Who can file a grievance?
      You or your authorized representative may file a grievance. You may file in person, by phone or in writing (mail, email, or fax) using the contact information provided below.

      There are two types of grievances:

      1) Grievance. All grievances (which includes complaints, concerns or disputes) which do not meet criteria for an expedited or “fast” grievance will be processed in this category. We will respond to you within 30 calendar days regarding grievances within this classification. If we need more information or the delay will benefit you, we can take up to 14 days more to answer your complaint.

      2) Expedited or “fast” grievance. If you have asked University Care Advantage to give you a “fast” or expedited response for a coverage determination or a redetermination (appeal) and we have said no, you can make a “fast” or expedited grievance. We must also review as a “fast” or expedited grievance if we extend a review timeframe for a determination and you do not agree with this decision. “Fast” or expedited grievance means we will provide a response to you within 24 hours.

      When should a grievance be filed?
      Your grievance must be made within 60 days after you experience the problem.  For quality of care complaints, you may file your grievance or complaint with University Care Advantage at the address below and/or directly with the Quality Improvement Organization.  You are not required to file quality of care grievances within the 60-day time period. 

      Quality Improvement Organization
      There is a Quality Improvement Organization for each state. For Arizona, it's called Livanta. Livanta has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. Livanta, LLC is an independent organization. It is not connected with our plan.

      Contact information for Livanta, LLC is:
      Livanta, LLC
      9090 Junction Drive, Suite 10
      Anapolis Junction, MD 20701

      CALL           877-588-1123
      TTY              855-887-6668
      FAX             Appeals: 855-694-2929   Other reviews: 844-420-6672
      WEBSITE   www.BFCCQIOAREA5.com 

      Where should a grievance be filed or status of one be checked?
      In order to provide you with the quickest response time to your grievance, please file your grievance or check the status of such with the Grievance & Appeals department of University Care Advantage:

      University Care Advantage
      Attn: Grievance & Appeals Department
      2701 E. Elvira Road
      Tucson, AZ 85756
      1-877-874-3930
      TTY users call 711
      Fax: 1-866-465-8340
      Email: UAHNGrievanceMailbox@bannerhealth.com

      What happens after filing a grievance?
      Upon receipt of your grievance, University Care Advantage will send you an acknowledgement notice to let you know that we have received your grievance and we are beginning the investigation process into your complaint. We contact each party involved and request additional information (this may include notes, statements from others present during the event, police reports, etc.). At any time during our investigation, you may submit additional information and/or evidence regarding your grievance. We record each grievance separately and maintain all records related to each by a case number which is assigned upon receipt. If corrective action is required, we work with the appropriate areas, vendors, contractors, and/or subcontractors to remedy the actions. We will provide notification to all concerned parties at the closure of the investigation. University Care Advantage’s Grievance & Appeals Department responds to each grievance in writing regardless of how it was received.
    • Appointment of Representative Form
      To appoint a representative, you can do one of two things. Fill out the CMS Appointment of Representative Form (CMS Form-1696) or create a document in your own words that contains all the elements of CMS Form-1696. We will accept both. Then send either option to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision....open
    • Nombramiento de Representante
      To appoint a representative, you can do one of two things. Fill out the CMS Appointment of Representative Form (CMS Form-1696) or create a document in your own words that contains all the elements of CMS Form-1696. We will accept both. Then send either option to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision....open
  • Member Rights & Responsibilities
  • Notice of Privacy Practices
  • Organization Determination
    • Who can request an Organization Determination?
      You, your authorized representative, or your provider may request an Organization Determination.

      What is an Organization Determination?
      Organization Determinations are determinations (decisions) made by University Care Advantage with respect to any of the following:
      • Payment for temporarily out of the area renal dialysis services, emergency services, post-stabilization care, or urgently needed services.
      • Payment for any other health services furnished by a provider other than University  Care Advantage that the enrollee believes are covered under Medicare, or if not covered under Medicare, should have been furnished, arranged for, or reimbursed by University Care Advantage.
      • Reduction, or premature discontinuation of a previously authorized ongoing course of treatment.
      • Failure of University Care Advantage to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.
      • Determination made by the plan about whether we will cover prior authorization (pre-service) requests. If you or your provider have questions regarding authorization requirements, please contact our Customer Care line below.
      • Determination made by the plan about whether we will cover something post service. In these instances you will often have a paper claim or electronic claim you want the plan to reimburse you for.

      When can an Organization Determination be requested?
      An organization determination may be requested at any time.

      Where can you file or Check the Status of an Organization Determination?
      To submit or check on a Prior Authorization (pre-service organization determination) request, you may fax it to our Prior Authorization department at 1-866-210-0512, or mail it to 2701 E. Elvira Rd., Tucson, AZ 85756, or for oral requests call 1-877-874-3930. If you or your provider have questions regarding authorization requirements, please contact Customer Care at 1-877-874-3930.

      To submit or check on a post-service claim for a reimbursement decision
         For electronic claims submission, contact your trading partner or one of ours: Emdeon, SSI and Office Ally
         For paper claims submission, mail them to ATTN: University Care Advantage, P.O. Box 35699; Phoenix, AZ 85069

      To submit or check on an organization determination that you think doesn’t fall into the above categories you can either:
         Call our Customer Care line at 1-877-874-3930
         Mail them to 2701 E. Elvira Rd., Tucson, AZ 85756

      What happens after an Organization Determination is filed?
      Phone inquiries or requests for organization determinations received by Customer Care will receive a determination at the first point of contact when possible.  If Customer Care is unable to make a determination, the request is forwarded to the appropriate area for a decision.  A written notification is sent to the enrollee informing of the determination.  If the determination is favorable, University  Care Advantage will effectuate the decision immediately.  If the determination is not favorable to the enrollee, appeal rights and where and how to file an appeal are provided.

      Pre-service requests are received via fax or through the Customer Care phone line.  Enrollees and providers may check whether authorization is required for a particular service or procedure by entering the code into the PA Grid found on our website under Providers -> Provider Resources -> PA Grid.  If an authorization is not required for the service, the Prior Authorization department notifies the requestor and the enrollee (if they are not the same) that authorization is not required for the service.  If authorization is required the request is entered into the tracking system and assigned an authorization number.  The case is then forwarded to the nurse for review.  If favorable, the enrollee and the provider are notified verbally, if possible, and a written approval is sent to both.  If the nurse is unable to approve the request, the case is forwarded to a Medical Director for review and decision.  If favorable, the case is forwarded back to the nurse for notification to the provider and enrollee.  If the decision is not favorable, the case is forwarded to the denial team for notification to the provider and the enrollee.  Appeal rights, how to file an appeal and where to file an appeal are provided in every case that does not have a favorable (whether in whole or in part) decision for the enrollee.

      For expedited pre-service requests please fax or call in the request to University Care Advantage. You or your provider may submit a request for an expedited pre-service determination.  Your provider may also support your request in an expedited pre-service determination.  If your provider indicates that by applying the standard determination time frames could jeopardize your life or health or ability to regain maximum function, University Care Advantage will automatically accept the request as expedited.  If you submit your request for an expedited determination without the support of your physician, we will determine whether your request meets the criteria for an expedited determination.  If it does not, we will notify you of our decision, the fact that we are transferring your case to our standard timelines and all applicable grievance rights.  If we accept your request as expedited, we will issue a decision to you no later than 72 hours after receipt.  All cases received as expedited are reviewed by a medical director upon receipt and being entered into our system. If favorable, the case is forwarded back to the nurse for notification to the provider and enrollee.  If the decision is not favorable, the case is forwarded to the denial team for notification to the provider and the enrollee.  Appeal rights, how to file an appeal and where to file an appeal are provided in every case that does not have a favorable  (whether in whole or in part) decision for the enrollee. For post service requests, your provider submits a claim to University Care Advantage.  We will adjudicate the claim and make payment.  We issue a provider remittance advice to the provider which details payment.  We will notify you whenever we issue a decision which is not favorable to you (in whole or in part). 
    • Appointment of Representative Form
      Organization Determination...open
  • Request for Medicare Prescription Drug Coverage Determination
    • An enrollee, an enrollee's prescriber, or an enrollee's representative may request a standard or expedited coverage determination by calling us at (877) 874-3930 or by filling a Medicare Prescription Drug Determination Form below and submitting it to University Care Advantage by mail, email, or fax at:

      Mailing Address: 2701 E. Elvira Rd., Tucson, AZ 85756
      Fax: (866) 349-0338
      Email: UAHPPharmacy@bannerhealth.com
  • Request for Reconsideration of Medicare Prescription Drug Denial