Medical Claims and Appeals

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
Fax: 1-877-291-3248
Email: UMR-Appeals@umr.com

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.