You are eligible for Cardinal Care when you have full Medicaid benefits, and meet one of the following categories:

• You are age 65 and older,
• You are an adult or child with a disability,
• You reside in a nursing facility (NF),
• Individuals who receive services under the 1915(c) Cardinal Care home- and community-based care (HCBS) Waiver
• Aged, blind or disabled (ABD) individuals, including disabled children and adults.
• Managed Care eligible populations who have Medicare (dual-eligible).
• Low-Income Families and Children Covered Populations, including
  • Children under age 21
  • Foster Care and Adoption Assistance Child under age 21
  • Pregnant women including twelve months post delivery
  • Infants born to a Medicaid-eligible individual
  • FAMIS Children under age nineteen (19)
  • Adults
    • Under age twenty-six (26) who were formerly in foster care until their discharge from foster care at age eighteen (18) or older.
    • Ages nineteen (19) to sixty-four (64) who are parents or caretaker adult relatives with a child under age nineteen (19) (MAGI adults)
    • Ages nineteen (19) to sixty-four (64) who are childless (MAGI adults)

You have the right to:

• Be treated with respect and with due consideration to his or her dignity and privacy by UnitedHealthcare personnel, network doctors and other health care professionals.  
• Privacy and confidentiality for treatments, tests and procedures you receive. See Notice of Privacy Practices in your benefit plan documents for a description of how UnitedHealthcare protects your personal health information.
• Voice concerns about the service and care you receive.
• Register complaints and appeals concerning your health plan and the care provided to you.
• Get timely responses to your concerns.
• Candidly discuss with your doctor the appropriate and medically necessary treatment options for your conditions, regardless of cost or benefit coverage.
• Receive information on available treatment options and alternatives presented in a manner appropriate to the member’s condition and ability to understand.
• Access doctors, health care professionals and other health care facilities.
• Participate in decisions about your care with your doctor and other health care professionals, including the right to refuse treatment.
• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other Federal regulations on the use of restraints and seclusion.
• The right to request and receive a copy of his or her medical records, and request that they be amended or corrected.
• Free exercise of rights. All members are free to exercise his or her rights, and that the exercise of those rights does not adversely affect the way UnitedHealthcare and its network providers or the State agency treat the enrollee.
• Get and make recommendations regarding the organization’s rights and responsibilities policies.
• Get information about UnitedHealthcare, our services, network doctors and health care professionals.
• Be informed about, and refuse to participate in, any experimental treatment.
• Have coverage decisions and claims processed according to regulatory standards, when applicable.
• Choose an Advance Directive to designate the kind of care you wish to receive should you become unable to express your wishes. 

You have the responsibility to:

• Know and confirm your benefits before receiving treatment.
• Contact an appropriate health care professional when you have a medical need or concern.
• Show your ID card before receiving health care services.
• Pay any necessary copayment at the time you receive treatment.
• Use emergency room services only for injuries and illnesses that, in the judgment of a reasonable person, require immediate treatment to avoid jeopardy to life or health.
• Keep scheduled appointments.
• Provide information needed for your care.
• Follow the agreed-upon instructions and guidelines of doctors and health care professionals.
• Participate in understanding your health problems and developing mutually agreed-upon treatment goals.
• Notify your employer or state exchange of any changes in your address or family status.
• Sign in to your member website (such as myuhc.com or myuhc.com/exchange) or call us when you have a question about your eligibility, benefits, claims and more.
• Sign in to your member website (such as myuhc.com or myuhc.com/exchange) or call us before receiving services to verify that your doctor or health care professional participates in the UnitedHealthcare network.

UnitedHealthcare Community Plan will send you a letter if a covered service that you requested is not approved or if payment is denied in whole or in part. If you are not happy with our decision, call UnitedHealthcare Community Plan within 30 days from when you get our letter. 

You must appeal within 10 days of the date on the letter to make sure your services are not stopped. You can appeal by sending a letter to UnitedHealthcare Community Plan or by calling UnitedHealthcare Community Plan. You can ask for up to 14 days of extra time for your appeal. UnitedHealthcare Community Plan can take extra time on your appeal if it is better for you. If this happens, UnitedHealthcare Community Plan will tell you in writing the reason for the delay.

You can call Member Services and get help with your appeal. When you call Member Services, we will help you file an appeal. Then we will send you a letter and ask you or someone acting on your behalf to sign a form.

How will I find out if services are denied?

UnitedHealthcare Community Plan will send you a letter if a covered service requested by your PCP is denied, delayed, limited or stopped.

What are the timeframes for the appeal process?

UnitedHealthcare Community Plan has up to 30 calendar days to decide if your request for care is medically needed and covered. We will send you a letter of our decision within 30 days. In some cases you have the right to a decision within one business day. If your provider requests, we must give you a quick decision. You can get a quick decision if your health or ability to function could be seriously hurt by waiting.

When do I have the right to ask for an appeal?

You may request an appeal for denial of payment for services in whole or in part. If you ask for an appeal within 10 days from the time you get the denial notice from the health plan, you have the right to keep getting any service the health plan denied or reduced at least until the final appeal decision is made. If you do not request an appeal within 10 days from the time you get the denial notice, the service the health plan denied will be stopped.

Does my appeal request have to be in writing?

You may request an appeal by phone, but an appeal form will be sent to you, which must be signed and returned. An appeal form will be included in each letter you receive when UnitedHealthcare Community Plan denies a service to you. This form must be signed and returned.

Can someone from UnitedHealthcare Community Plan help me file an appeal?

Member services is available to help you file a complaint or an appeal. You can ask them to help you when you call 1-844-752-9434. They will send you an appeal request form and ask that you return it before your appeal request is taken.

There are different types of complaints

You can make an internal complaint and/or an external complaint. An internal complaint is filed with and reviewed by UnitedHealthcare Community Plan. An external complaint is filed with and reviewed by an organization that is not affiliated with UnitedHealthcare Community Plan.

Internal complaints

To make an internal complaint, call Member Services at the number below. You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. You can file a complaint in writing, by mailing or faxing it to us at:

Grievance and Appeals 
P.O. Box 31364 
Salt Lake City, UT 84131-0364

So that we can best help you, include details on who or what the complaint is about and any information about your complaint. UnitedHealthcare Community Plan will review your complaint and request any additional information. You can call Member Services at the number below if you need help filing a complaint or if you need assistance in another language or format. We will notify you of the outcome of your complaint within a reasonable time, but no later than 30 calendar days after we receive your complaint. If your complaint is related to your request for an expedited appeal, we will respond within 24 hours after the receipt of the complaint.

External complaints

You can file a complaint with the Cardinal Care helpline

You can make a complaint about UnitedHealthcare Community Plan to the Cardinal Care helpline.

Contact the Cardinal Care helpline at 1-844-374-9159 or TDD 1-800-817-6608.

You can file a complaint with the Office for Civil Rights

You can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. You can also visit http://www.hhs.gov/ocr for more information.

You may contact the local Office for Civil Rights office at:

Office of Civil Rights- Region III 
Department of Health and Human Services 
150 S Independence Mall West Suite 372 
Public Ledger Building 
Philadelphia, PA 19106 
1-800-368-1019 
Fax: 215-861-4431 
TDD: 1-800-537-7697

You can file a complaint with the Office of the State Long-Term Care Ombudsman

The State Long-Term Care Ombudsman serves as an advocate for older persons receiving long-term care services. Local Ombudsmen provide older Virginians and their families with information, advocacy, complaint counseling, and assistance in resolving care problems. The State’s Long-Term Care Ombudsman program offers assistance to persons receiving long term care services, whether the care is provided in a nursing facility or assisted living facility, or through community-based services to assist persons still living at home. A Long-Term Care Ombudsman does not work for the facility, the State, or UnitedHealthcare Community Plan. This helps them to be fair and objective in resolving problems and concerns. The program also represents the interests of long-term care consumers before state and federal government agencies and the General  Assembly.

The State Long-Term Care Ombudsman can help you if you are having a problem with UnitedHealthcare Community Plan or a nursing facility. The State Long-Term Care Ombudsman is not connected with us or with any insurance company or health plan.

The services are free.

Office of the State Long-Term Care Ombudsman

1-800-552-5019 This call is free.

1-800-464-9950 This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it.

Virginia Office of the State Long-Term Care Ombudsman 
Virginia Department for Aging and Rehabilitative Services 
8004 Franklin Farms Drive 
Henrico, Virginia 23229 
804-662-9140 
http://www.ElderRightsVA.org

If you disagree with our decision on your appeal request, you can appeal directly to DMAS. This process is known as a State Fair Hearing. You may also submit a request for a State Fair Hearing if we deny payment for covered services or if we do not respond to an appeal request for services within the times described in this handbook. The State requires that you firstexhaust (complete) UnitedHealthcare Community Plan appeals process before you can file an appeal request through the State Fair Hearing process. If we do not respond to your appeal request timely DMAS will count this as an exhausted appeal.

Standard or expedited review requests

For standard requests, appeals will be heard and DMAS will give you an answer generally within 90 days from the date you filed your appeal. If you want your State Fair Hearing to be handled quickly, you must write “EXPEDITED REQUEST” on your appeal request. You must also ask your doctor to send a letter to DMAS that explains why you need an expedited appeal. DMAS will tell you if you qualify for an expedited appeal within 72 hours of receiving the letter from your doctor.

Authorized representative

You can give someone like your PCP, provider, or friend or family Member written permission to help you with your State Fair Hearing request. This person is known as your authorized representative.

Where to send the State Fair Hearing request

You or your representative must send your standard or expedited appeal request to DMAS by internet, mail, fax, email, telephone, in person, or through other commonly available electronic means. Send State Fair Hearing requests to DMAS within no more than 120 calendar days from the date of our final decision. You may be able to appeal after the 120 day deadline in special circumstances with permission from DMAS.

You may write a letter or complete a Virginia Medicaid Appeal Request Form. The form is available at your local Department of Social Services or on the internet at http://www.dmas.virginia.gov/Content_atchs/forms/dmas-200.pdf. You should also send DMAS a copy of the letter we sent to you in response to your Appeal.

You must sign the appeal request and send it to:

Appeals Division 
Department of Medical Assistance Services 
600 E. Broad Street 
Richmond, Virginia 23219 
Fax: 804-452-5454

Standard and Expedited Appeals may also be made by calling 804-371-8488.

If you lose your/your child’s ID card, call Member Services right away at 1-844-752-9434. Member Services will send you a new one. Call TTY 711 for hearing impaired.

UnitedHealthcare invites all members to join their Member Advisory Committee. As a member of the committee, you can participate in quarterly educational meetings where you can share you experiences, opinions and hear about how UnitedHealthcare is working to improve the member experience. These meetings can be attend in-person or virtually. Attending committee meetings will give you and your caregiver or family member the chance to provide input on Cardinal Care and meet other members. If you would like more information or want to attend, contact our Member Services department.