Should you be denied coverage for a health claim or service, 您将收到书面通知，并获得有关皇冠搏彩中心网站上诉程序的信息. The following letter explains the Funds’ appeal process.
医疗保险中心 & 医疗补助服务(CMS)有规定管理你提交医疗保险上诉的权利. 作为UMWA健康和退休皇冠搏彩中心网站("皇冠搏彩中心网站")管理的健康计划的医疗保险合格受益人, you have a right to a 医疗保险 Appeal. Your appeal rights include a standard 30 calendar day appeal for a service, a standard 60 calendar day appeal for payment and a 72 hour expedited appeal. This notice informs you of the current 医疗保险 Appeal process. 此外，当您提出标准或快速上诉时，我们会为您提供有用的信息.
你有权上诉
如果你不同意皇冠搏彩中心网站对你的医疗费用或保健的决定，你可以上诉. You have a right to appeal if you think:
皇冠搏彩中心网站通常有30个日历日来处理您的服务申诉，60个日历日来处理您的付款申诉. In some cases, you have a right to a faster 72-hour appeal. 如果您的健康或功能可能因等待30个日历天而受到严重损害，您可以快速上诉. If you ask for a fast appeal, the Funds will decide if you get a 72-hour fast appeal. If not, your appeal will be processed in 30 calendar days. 如果任何医生要求皇冠搏彩中心网站给你快速上诉或支持你的快速上诉请求, 皇冠搏彩中心网站一定会给你的.
There are two kinds of standard appeals
1. Standard (30 calendar days) appeal for a service:
皇冠搏彩中心网站负责在收到您的请求之日起30个日历日内或不迟于延期的最后一天(最多14个日历日)处理您的上诉服务请求。. Even though you may file your request with the Social Security Administration, that office will transfer your request to the Funds for processing.
14天延长
An extension up to 14 calendar days is permitted for a 30 calendar day appeal if the extension of time benefits you; for example, 如果您需要时间向皇冠搏彩中心网站提供额外的信息，或者如果我们需要额外的信息. 如果皇冠搏彩中心网站需要额外的时间(最多14个日历日)来处理您的请求，您将收到书面通知. 如果您不同意皇冠搏彩中心网站给予自身延期的决定，您有权提出加急申诉.
2. Standard (60 calendar days) appeal for a payment
皇冠搏彩中心网站负责在收到您的请求之日起60个日历日内处理您的付款请求.
1. 以书面形式提出请求, 亲自或邮寄, or by telephone with the Funds or with an office of the Social Security Administration.
2. Written requests to the Funds should be mailed to:
UMWA Health and Retirement Funds
邮政信箱292167
纳什维尔，田纳西州37229
3. Written requests may be faxed to the Funds at 1-800-382-7792.
4. Telephone requests can be made by calling 1-800-292-2288.
5. File your request within 60 calendar days of the date of the notice.
30个日历日的上诉:
If the Funds does not rule in your favor, the Funds will forward your appeal request to the 医疗保险中心 & 医疗补助独立审查实体在皇冠搏彩中心网站收到您的请求之日起30个日历日内作出决定.
对于60个日历日的上诉:
If the Funds does not rule in your favor, the Funds will forward your appeal request to the 医疗保险中心 & 医疗补助服务独立审查实体在皇冠搏彩中心网站收到您的请求之日起60个日历日内作出决定.
加急上诉在72小时内处理，不适用于拒绝付款.
14天延长
An extension up to 14 calendar days is permitted for a 72-hour appeal if the Funds determines that an extension of time benefits you or if you request an extension; for example, if you need time to provide the Funds with additional information. 如果皇冠搏彩中心网站需要额外的时间(最多14个日历日)来处理您的请求，您将收到书面通知. 如果您不同意皇冠搏彩中心网站给予自身延期的决定，您有权提出加急申诉.
1. File an oral or written request for a 72-hour appeal. Specifically state that “I want an expedited appeal, 快速上诉或72小时上诉”或“我认为等待30个日历天进行正常上诉可能会严重损害我的健康.”
2. To file a request orally, call 1-800-292-2288. 的资金 will document the oral request in writing.
3. To hand-deliver your request, the Funds’ address is:
UMWA Health and Retirement Funds
皇家公园道801号三楼
纳什维尔，田纳西州37214
4. To FAX your request, the Funds’ FAX number is 1-800-382-7792. If you are in a hospital or a nursing facility, 你方可要求协助将你的书面申诉通过传真机传送给皇冠搏彩中心网站.
5. To mail a written request, our address is:
UMWA Health and Retirement Funds
邮政信箱292167
纳什维尔，田纳西州37229
6. The 72-hour review time will not begin until your request for appeal is received.
7. You must file your request within 60 calendar days of the date of the notice.
如果皇冠搏彩中心网站拒绝您的快速上诉请求:该请求将在皇冠搏彩中心网站收到您的快速上诉请求之日起30个日历日内或不迟于延期的最后一天(最多14个额外日历日)内处理. You have the right to file an expedited grievance with the Funds at 1-800-291-1425, if the Funds denies your request for an expedited appeal.
如果皇冠搏彩中心网站批准您的加急上诉请求:皇冠搏彩中心网站将对您的上诉作出决定，并在收到您的请求后72小时内通知您. If our decision is not fully in your favor, we will automatically forward your appeal request to the 医疗保险中心 & 医疗补助服务独立审查实体在收到您的请求后24小时内进行独立审查. 医疗保险中心 & 医疗补助服务独立审查实体将在收到皇冠搏彩中心网站的申请后72小时内向您发送信函，告知他们的决定.
支持你的上诉, 谁可以提出上诉, 帮助你的诉求, and Peer Review Organization Complaint Process
The following information applies to Standard and Expedited Appeals
您不需要提交额外的信息来支持您的服务请求或支付已收到的服务. 的资金 is responsible for gathering all necessary medical information, 然而, 包括相关的医疗记录或医生的意见来支持你的上诉可能会对你有帮助. To obtain medical records, send a written request to your primary care physician. 如果您的专科医生的医疗记录不包括在您的初级保健医生的医疗记录中, 您可能需要向为您提供医疗服务的专科医生单独提出书面请求.
If you decide to appeal and want help with your appeal, 你可以去看医生, 我的一个朋友, 律师, 或者别人帮你. There are several groups that can help you. You may want to contact the Area Agency on Aging, 保险, Counseling and Assistance Program, the 医疗保险 Rights Center at Toll-Free 1-800-466-9050. Your Funds’ Health Call Center (1-800-291-1425)也可以帮助你.
的资金’ Health Call Center provides prompt responses to your questions and concerns. 当您对您的计划或医生有疑问或担忧时，我们鼓励您与我们联系. We will work with you to get your questions answered and your issues resolved quickly.
Feel free to contact the Health Call Center toll-free at 1-800-291-1425, 如果你有任何问题.
我们是来帮忙的!
