Medical Claims and Appeals
Appealing Denied Medical Claims
If a claim is denied, contact UMR to find out why. UMR will instruct you on rectifying the problem or discuss ways to appeal the decision. Contact an HR Expert if you are unable to resolve your claims problem after contacting UMR.
Formal UMR Appeals Process
Members can call the UMR Customer First Representatives (CFR) at 888-438-6105 any time to discuss claims or Explanation of Benefits (EOBs). CFR can make adjustments immediately if they determine a claim is eligible for additional benefits. If the claim is not adjusted, follow the steps below if you want to appeal.
First Level Appeal
Submit an appeal in writing within 180 days by completing the UMR Post-Service Appeal Request Form and submitting it to UMR. Appeals are reviewed internally by UMR and determinations are issued to the member.
The UMR CFR team can help you in the initial stages of filing an appeal. When you are appealing claims which have been denied, include your:
- Member name
- UMR ID number
- Patient name, if different than member
- Detailed description of the appeal
- Supporting documents from your healthcare provider(s)
- Dates of service
- Providers' names
Send your appeal to:
Claims Appeal Unit
P.O. Box 30546
Salt Lake City, UT 84130-0546
Once your appeal is filed, a UMR appeals representative will be assigned. Their contact information will be on the notice of appeal sent to you.
Second Level Appeal
A second level appeal may be filed within 60 days of the notification of first level appeal. Your appeal will be reviewed internally by UMR and the University of Arkansas System Office and the plan sponsor, and the determination will be issued to you. Send your second level appeal to the UMR Claims Appeal Unit (see UMR contact information above).
Third Level Appeal
The final appeal level is a review by an external vendor. Contact UMR for third level appeal information.
Expedited Appeal Process for Out-of-network Mental Health Provider
The University of Arkansas has implemented an expedited appeal process for participants who want to see out-of-network mental health providers.
To request authorization to see an out-of-network provider and have the services covered as in-network, follow the first level appeal steps above. Include the name and contact information of the out-of-network provider you wish to see and your reasons for requesting out-of-network care (for example, continuing care with an established provider, lack of local in-network providers, substantial wait for an appointment with in-network providers).
If your request is denied, UMR will forward your request directly to the University of Arkansas System Office without a second level appeal. If the System Office denies your request to see an out-of-network provider, you can request a third level appeal, conducted by an independent review organization physician or physician panel.
Appealing Denied Pharmacy Claims
Employees who have a denied pharmacy claim or who pay higher co-pays for medications can, under certain circumstances, appeal.
If you require a medication that is subject to Step Therapy, Quantity Limits or prior authorization requirements and you believe you have a valid reason for bypassing these criteria, contact MedImpact directly at 800-788-2949 for assistance with the appeal process.
Participants who cannot take Tier 1 or Tier 2 drugs (see below) can request an individual exception based on medical necessity when approved by a physician. If your physician believes there are no acceptable treatment alternatives, she/he can complete and sign the University of Arkansas Pharmacy Advisory Committee Formulary Request and submit it to the University of Arkansas System Office Pharmacy Advisory Committee for review. To request a physician-supported exception, follow the Processing Steps for Pharmacy Formulary Exception and Review Request.
Tier 1: Generic
- $15 for up to a 30-day supply
- $45 for a 31 to 90-day supply
Tier 2: Preferred name brand
- $40 for up to a 30-day supply
- $120 for a 31 to 90-day supply
Tier 3: Non-preferred
- $80 for up to a 30-day supply
- $120 for a 31 to 90-day supply