Resolving disputes
Agreement concern or complaint
If you have a concern or complaint about your relationship with us, send a letter containing the details to the address listed in your agreement with us. A representative will look into your complaint and try to resolve it through an informal discussion. If you disagree with the outcome of this discussion, an arbitration proceeding may be filed as described below and in your agreement with us.
If your concern or complaint relates to a matter involving UnitedHealthcare administrative procedures, such as the credentialing, notification, or claim appeal processes described in this Guide, you and we will follow the dispute procedures set forth in those plans to resolve the concern or complaint. After following those procedures, if one of us remains dissatisfied, an arbitration proceeding may be filed as described below and in our agreement.
If we have a concern or complaint about your agreement with us, we’ll send you a letter containing the details. If we cannot resolve the complaint through informal discussions with you, an arbitration proceeding may be filed as described in your agreement with us.
Arbitration proceedings will be held at the location described in your agreement with us or if a location is not specified in your agreement, then at a location as described in the Arbitration counties by location section.
Arbitration
Both Blue Cross and the provider shall abide by the following procedures for the arbitration process:
• The party (Blue Cross or the provider) who is initiating the arbitration process shall send written notice to the other party setting forth the basis of the dispute and their desire to arbitrate. Blue Cross and the provider shall share the costs of the arbitration equally. Arbitration shall be in accordance with the rules and procedures of either the American Arbitration Association or the American Health Lawyers’ Association or another nationally recognized arbitration association acceptable to both Blue Cross and the provider.
• Arbitration shall be conducted in Baton Rouge, Louisiana, before a single arbitrator mutually agreed upon by both Blue Cross and the provider.
• The arbitrator shall be bound by the terms and conditions set forth in the provider’s agreement and the Member Contract/Certificate.
• The arbitrator may not award consequential, special, punitive or exemplary damages. The arbitrator may award costs, including reasonable attorney’s fees, against Blue Cross or the provider. If the decision of the arbitrator does not include such award, both Blue Cross and the provider shall share the costs of the arbitration equally.
• The decision of the arbitrator shall be final and in writing and shall be binding on both Blue Cross and the provider and enforceable under the laws of the state of Louisiana.
• This provision shall survive the termination of the provider’s agreement. The general dispute resolution and arbitration processes described above do not supersede or replace the member appeals and grievances process for medical necessity and appropriateness, investigational, experimental or cosmetic coverage determinations as described in the Appeals section of this manual.
Notwithstanding the foregoing, benefits and utilization management determination issues (for example, Medical Necessity or Investigational determinations) shall be handled in accordance with the Subscriber Contract/Certificate and as outlined in this manual.
Agreement concern or complaint
If you have a concern or complaint about your relationship with us, send a letter containing the details to the address listed in your agreement with us. A representative will look into your complaint and try to resolve it through an informal discussion. If you disagree with the outcome of this discussion, an arbitration proceeding may be filed as described below and in your agreement with us.
If your concern or complaint relates to a matter involving UnitedHealthcare administrative procedures, such as the credentialing, notification, or claim appeal processes described in this Guide, you and we will follow the dispute procedures set forth in those plans to resolve the concern or complaint. After following those procedures, if one of us remains dissatisfied, an arbitration proceeding may be filed as described below and in our agreement.
If we have a concern or complaint about your agreement with us, we’ll send you a letter containing the details. If we cannot resolve the complaint through informal discussions with you, an arbitration proceeding may be filed as described in your agreement with us.
Arbitration proceedings will be held at the location described in your agreement with us or if a location is not specified in your agreement, then at a location as described in the Arbitration counties by location section.
Arbitration
Both Blue Cross and the provider shall abide by the following procedures for the arbitration process:
• The party (Blue Cross or the provider) who is initiating the arbitration process shall send written notice to the other party setting forth the basis of the dispute and their desire to arbitrate. Blue Cross and the provider shall share the costs of the arbitration equally. Arbitration shall be in accordance with the rules and procedures of either the American Arbitration Association or the American Health Lawyers’ Association or another nationally recognized arbitration association acceptable to both Blue Cross and the provider.
• Arbitration shall be conducted in Baton Rouge, Louisiana, before a single arbitrator mutually agreed upon by both Blue Cross and the provider.
• The arbitrator shall be bound by the terms and conditions set forth in the provider’s agreement and the Member Contract/Certificate.
• The arbitrator may not award consequential, special, punitive or exemplary damages. The arbitrator may award costs, including reasonable attorney’s fees, against Blue Cross or the provider. If the decision of the arbitrator does not include such award, both Blue Cross and the provider shall share the costs of the arbitration equally.
• The decision of the arbitrator shall be final and in writing and shall be binding on both Blue Cross and the provider and enforceable under the laws of the state of Louisiana.
• This provision shall survive the termination of the provider’s agreement. The general dispute resolution and arbitration processes described above do not supersede or replace the member appeals and grievances process for medical necessity and appropriateness, investigational, experimental or cosmetic coverage determinations as described in the Appeals section of this manual.
Notwithstanding the foregoing, benefits and utilization management determination issues (for example, Medical Necessity or Investigational determinations) shall be handled in accordance with the Subscriber Contract/Certificate and as outlined in this manual.
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