The Kaiser Papers A Public Service Web Site      In Copyright Since September 11, 2000
Help for Kaiser Permanente Patients on this public service web site.
Permission is granted to mirror if credit to the source is given and the material is not offered for sale.

      Why the thistle is used as a logo on these web pages. | 
                                 

                                                                            




                                                                                                               
 

 






Kaiser Permanente Claims, complaints, grievances, and appeals, addresses -
Processes for Oregon medical plans

 
Requesting medical
services and benefits

Post-service claims for services
you have already received

If you have a medical bill from
a non-Kaiser Permanente (non-
plan) provider or facility, Claims
Administration will handle your
claim. If you have questions about
a specific claim, or if you need
help with the claim procedures,
Membership Services can help.

Sometimes your Kaiser Permanente
health care provider will refer
you to a non-Kaiser Permanente
health care provider "non-
plan provider." If so, the non-Plan
provider will send the bill directly
to us. You won't need to file a claim.

If you didn't have an authorized
referral, however, you will need
to file a claim. This claim will ask
Kaiser Permanente to cover the
services you received from the
non-Plan provider. To file a claim
you should:

* Complete a Non-Plan Care
Information form.

Membership Services can
give you the Non-Plan Care
Information form. Or you can
download a copy from our Web
site. To download a form, go to
kaiserpermanente.org and
select the appropriate link.

Fill out the form completely. Send
it, with your itemized bill, to:

Claims Administration
Kaiser Permanente
500 NE Multnomah St., Suite 100
Portland, OR 97232





Page 1
*If you have your medical records
from the non-Kaiser Permanente
provider, please send a copy with
your claim form. If you don't send
a copy and we need the records
to decide your claim, we'll let you
know. Your claim will be delayed
while we wait for it.

*Your non-Kaiser Permanente
provider may want to bill us
directly. If so, your provider can
send us the CMS 1500 claim form
for professional services and the
UB-92 form for hospital claims.
You will still need to fill out the
Non-Plan Care Information form
and send it to us even if your
provider bills us directly.

*You must submit a claim within 90

days after you've received care, or
as soon as reasonably possible.
 
*We will not review your claim
if we haven't received your
completed Non-Plan Care
Information form within 12
months from the date you saw
the non-Plan provider. The only
exception is if you don't have the
legal capacity to file the claim
within 12 months.

We will make a decision on your
claim and pay the covered charges
within 30 calendar days. However,
if we need more information to
make the decision, it may take
longer. If we have to extend the
30-day period, we'll let you know
in writing and explain why. The
written notice will tell you how long
the time period will be extended.
The length of the extension will
follow applicable state and federal
laws. These include the Employee
Retirement Income Security Act
of 1974 (ERISA). There is more
information about ERISA on the
next page.
We will tell you about our decision
on your claim in writing. In the
notice we will explain any unpaid
amounts. We will also tell you how
to appeal if you are not satisfied with
our decision.

The notice will also provide you
with other information about the
claim that is required by state and
federal laws.

Bills for services you've
already received

If you have any questions or
concerns about a bill from Kaiser
Permanente, contact Membership

Services. If you think the charges
are not appropriate, Membership
Services will tell you what you can
do next.

If you think the charges are not
appropriate because of concerns
you have about services or benefits,
you can file a written grievance. If
you think the charges are wrong,
such as a bill for services you didn't
receive, or that you already paid,
Membership Services can help you.

If our records show that the
charges are correct, we will give
you an explanation. At the same
time, we will let you know how to
file a grievance if you are still not
satisfied.

Pre-service claims, requests
for services you want

We provide treatment and services
based on medical necessity and
appropriateness. If you need care,
or if you think you need a specific
treatment or service, talk to your
Kaiser Permanente health care
provider. Your health care provider
will discuss your needs with you;
recommend a course of treatment;
and determine if a particular kind
of treatment or services is medically
appropriate.
 
Some treatments and services need
to go through a review process.

This medical necessity review is
based on criteria set by our medical
group or another group of doctors,
and is part of our utilization
management program.

*Your health care provider may
decide that a treatment, service,
or equipment is not medically
appropriate or necessary. If you
disagree, you can ask for a second
opinion from another Kaiser
Permanente health care provider.

Just ask the manager or the staff
member making appointments
in the medical office where you
receive care.

Membership Services can help
you find the correct manager.
The manager will listen to your
issues and discuss your request
with your health care provider. If

you need a second opinion, the
manager will see that you get one.

If your health care provider
still believes that the treatment,
service, or medical item you want
is not medically necessary, we will
let you know. We will send you a

denial letter within 14 days after
you've talked to the manager.
The letter will tell you why your
health care provider made the
decision. It will also tell you how
to file a first-level appeal.
 
*The treatment, service, or item
your health care provider
wants you to have might need
the medical necessity review
described earlier. If your health
care provider believes a treatment,
service, or item is medically
necessary, he or she will ask for
the review. We will let you know
if the request is denied. We will
send you a denial letter within two
business days after your health
care provider's request. The letter
will tell you the reason we denied
the request. It will also tell you
how to file a first-level appeal.

Page 2
*Your medical plan might exclude
or limit your coverage for
treatment, service, or medical
item. If you have questions
about this, contact Membership
Services. If you are not satisfied
after you talk with Membership
Services, you can ask for a
written "pre-service benefit
determination." We will prepare
one and send it to you within 14
days of your request. If you are
still not satisfied, you may file a
written grievance.

We may need more information to
make a decision on your pre-service

request. If you are covered under
an ERISA benefit plan, we will ask
you in writing for this information.
Our request to you will say how
long you have to provide that
information. It may take us more
than two business days to make a
decision if we have to ask you for
more information.

(Please see the "Complaints,
Grievances, and Appeals" section
for important information about
ERISA.)

Expedited procedures- If you
urgently need the treatment,
service, or medical item, we can
review your request more quickly.
Your request is considered urgent if
the regular time to make a decision
could seriously risk your life, health,
or ability to regain maximum
function.

It is also considered urgent if a
health care provider who is familiar
with your medical condition
believes the delay would cause you
severe pain that can't be adequately
managed without the care or
treatment requested.

In urgent situations, we will
respond to you as fast as your
condition requires. But in no case
will our decision take more than 24
to 72 hours, depending on the state
and federal laws that apply. We will

respond within 24 hours to
certain requests to continue
previously approved treatment
that includes urgent care, such as
inpatient services or skilled nursing
facility services.

Important information for
members whose benefit plans
are subject to ERISA

The Employee Retirement Income
Security Act of 1974 (ERISA) is a
federal law that regulates employee
benefits. Among the benefits
regulated by ERISA are claim and

appeal procedures for benefit plans
offered by certain employers. If you
are not sure whether these ERISA
laws apply to your benefit plan,
please ask your employer.

If your employer's benefit plan is
subject to ERISA:

*When you ask for care or service
that must be approved before
the care or service is given, you
are filing a "pre-service claim"
for benefits.

*When you ask to pay for
services that you have already
received, you are filing a "post-
service claim."

*You must follow our procedures
for filing claims.

*We must respond to your
claim following certain rules
set by ERISA.

*If you are not satisfied with
our decision on your pre-service
claim or post-service claim, you
only have to file one appeal
before you can take legal action
to resolve your claim. This is
a right you have under ERISA's
Section 502(a).
 *Appeals are reviewed by an
appropriate, named fiduciary

 
*Additional levels of voluntary
appeal may be available within
Kaiser Permanente.

*We do not charge for any part of
the appeal process.

Complaints,
grievances, and
appeals

Member satisfaction

Everyone associated with Kaiser
Permanente wants you to have
the best care and service possible.
Please call Membership Services
at the numbers listed on page 6 of
this flyer if you need help with the
following:
 
*Questions about your coverage.
*Using our services.
*Finding the right medical care
resource.

If you have a compliment or
suggestion, please call or send a
letter to the administrator of the
facility where you received care.
The administrator will share your
comments with the medical care
team members who helped you
and with their supervisors.

If you have any issues about your
care, please talk with your health
care provider or another member
of your health care team. If you are
not satisfied with your health care
provider, you can ask for another.
Membership Services can help. You
always have the right to a second
opinion within Kaiser Permanente.

Most issues can be resolved within
your health care team. If you feel
that you need extra help with
an issue, we have complaint and
grievances procedures for you.
We will handle all complaints and
grievances in confidence.

Page 3
Members who are covered
by a Washington plan, the
federal Employee Health
Benefits Program, Medicare,
or the Oregon Health Plan
have different grievance and
appeal procedures. Please ask
Membership Services for a copy
of the procedures that apply to
your plan.

Oral complaints
You can file an oral complaint if you
are not satisfied with the availability,
delivery, or quality of our services;
benefits; or other administrative
issues. Here are a few examples of
things that a member might file a
complaint about:

*Delays in getting an appointment.

*How our staff communicates
with you.

*Policies and procedures you
don't like.


(If you have a concern about care
we've denied, you need to file
an appeal instead of a complaint.
Follow the procedures in the
section titled "Appeals." You would
file a grievance if we have denied
your claim for medical services you
have already received. Follow the
procedure described in the section
titled "Grievances.")

To file a complaint, contact the
administrative office in the facility
where you had the problem. You
can also ask Membership Services
for help. Discuss your complaint
fully with the staff. Be specific
about how you want the matter
resolved.



Written complaints
You may file a written complaint
if you are not satisfied with how
we responded to your oral

complaint about:

*The availability of our services.

*The delivery of our services.

*The quality of our services.

* Other administrative matters.

For example, you might have a
complaint about delays in getting
care, or about not hearing back
from your health care provider's
office. Send your written complaint
to Member Relations at the address
listed on page 6.

Grievances
A grievance is a written complaint
requesting a specific action. Usually
the action would involve the way
we billed you for services you
received, eligibility problems, or
benefit interpretations. You can
submit a grievance, or someone else
can submit a grievance for you.


You can file a written grievance:

*If you disagree with charges on
a bill from Kaiser Permanente.
(This is considered an initial claim
for benefits under ERISA.)

*If you disagree with a decision
we made to deny your claim for
services you received from a
non-Kaiser Permanente provider
or facility. You must file the
grievance within 185 days of
the date on the denial notice
from the Claims Administration
Department. (This is a post-
service appeal under ERISA.)


*If you received a written denial
of coverage for benefits or
services because of the reasons
listed below:

  *You are not eligible for benefits.

   *Your plan excludes certain
procedures.

   *Your plan does not include
special benefits such as
prescription drugs or vision
hardware.

You have reached the maximum
amount of a particular benefit.
You must file the grievance within
185 days of the denial notice.
(These are pre-service appeals
under ERISA.)

You should follow the directions
under "Appeals" if we denied
coverage in writing for services
or items you or your health care
provider requested, and we denied
coverage because of one or both of
these reasons:

*The services or item were not
medically necessary.

*The services or item did not meet
medical criteria for coverage.

Grievance procedures. To file a
written grievance, write down your
concerns. Be specific about what
you want us to do. You may submit
any written comments, documents,
records, and other information
related to your grievance. If you
need help filing a written grievance,
contact Membership Services, (see
page 6).

Send your grievance to Member
Relations at the address listed
on page 6. We will let you know
that we received your grievance
within seven working days. We
will forward your grievance to the
correct manager or department for
a resolution. We will conduct an
independent review, and will let
you know of our decision
in writing.


Page 4
We will give you a decision within
30 days, except:

*If your grievance is an initial
pre-service claim under ERISA
and we need more information
to make a decision, we will ask
you in writing for it. You will
then have 50 days to give us
the information. We will make
a decision within 15 days after
you've given us the information

we need. If you don't give us
the information, we will make a
decision within 15 days after the
end of the 50-day period.

*We will respond to all grievances
according to how urgent the
situation is. But if your grievance
is about care you need urgently
that we have denied, we will
respond to the grievance within
72 hours (see "Expedited
Procedures" described earlier.)

If we deny a specific request you've
made in a grievance, we will let
you know in writing. Our notice
to you will include the reasons for
the decision. We'll tell you how to
appeal the decision. We also will tell
you how you can file a complaint
with the Oregon Department of
Consumer and Business Services.

(For members who have a plan
that is covered by ERISA, additional
appeals are considered voluntary
unless your grievance was classified
as an initial claim.)

Appeals
If you disagree with the decision
made on your grievance, follow
these appeal steps. Or follow
these steps if we have denied care
that you want or your health care
provider wants you to have.

We've developed these procedures
according to state and federal laws.
We will let you know we have
received your appeal within
seven days.


If your plan is covered
under ERISA
, you only have to
file one appeal before you can take
legal action.

If your plan is not covered
under ERISA
, you have two
levels of appeal if:

*We have denied your grievance.
 
*We have denied you care or
service because it was not
considered medically necessary,
or did not meet medical criteria.

These appeals are called "first-level"
and "second-level" appeals.


First-level appeals

If you are covered under an
ERISA plan, this level of appeal is
voluntary if you filed a grievance
that was denied. You can voluntarily
follow the procedure outlined
below. Exception: If your grievance
was about a bill from Kaiser
Permanente, this is the one required
level of appeal under ERISA.

For other members not covered
under an ERISA plan, you must
follo
w this appeal procedure if you
want to have a denial reviewed.
 
*You have 185 days from the time
of the denial notice to submit a
first-level appeal if you disagree
with our decision:
 
  *to deny your grievance, or
 
  *to deny care that you or your
health care provider requested,
as explained in the denial letter
you received.

 You may ask for an expedited
appeal if it is about urgently
needed care (see "Expedited
Procedures" explained earlier).
You may ask orally or in writing.


 To submit an appeal, follow the
instructions that we will include
in the denial notice we send you.
Send your appeal to Member
Relations at the address listed on
page 6. You may include any other
information you have about your
claim. This could include written
comments, documents, records,
or other information.

*We will decide your first-level
appeal within 30 days after we
receive it.

*If you've asked for an expedited
appeal, how quickly we respond
depends on how urgent the
situation is. But it will not take
more than 72 hours if we agree it
is urgent.

*Member Relations will
independently review your
appeal and include other staff
or physicians in the review as
needed. They will tell you in
writing of their decision. If your
appeal is denied, the written
notice will explain the reasons for
the decision. It will also tell you
how to file a complaint with the
Oregon Department of Consumer
and Business Services, and give
you other information that state
and federal laws require.

Second-level appeals

If you don't agree with the decision
about your first-level appeal, you
may submit a second-level appeal.
 
*You must file your second-level
appeal in writing to Member
Relations.
 
*You must file your second-level
appeal within 60 days after the
date on the letter denying your
first-level appeal.
 
*You may include any other
information relating to your
claim that may be helpful. This
could include written comments,
documents, records, or more.

Page 5
You have the right to speak directly
to the review panel.
 
*You may speak to the review
panel in person or by telephone.

 
*You must tell us in your
written second-level appeal if
you plan to speak directly to the
review panel.
 
*You also must tell us in your
written second-level appeal
the name of anyone who will
attend with you, and his or her
relationship to you.

We will decide your second-level
appeal within 30 days after we
receive it.
 
*We will expedite a decision if
your appeal is about care you
urgently need that we have denied
(see "Expedited Procedures"
described earlier).
 
*How quickly we expedite your
appeal depends on the medical
urgency of your situation. It will
never be more than 72 hours.


If we deny your second-level appeal,
we will notify you in writing.
 
*The notice we send you will
explain the reasons for the
decisions.

*The notice will tell you how to
ask for an additional external
review by an independent review
organization (IRO) and whether
your appeal meets criteria for an
IRO review.
 
*It will also tell you how to file
a complaint with the Oregon
Department of Consumer and
Business Services.

External review by an IRO
For certain kinds of requests,
Oregon law gives you rights to
an external review by an IRO. You
can have such a review for these
requests if we have denied both
your first-level and second-level
appeals.

If your plan is covered under ERISA,
an external review is considered
another voluntary level of appeal. It
is only available after you have used
all your other voluntary appeals.

You have the right to a review by
an IRO if:

*Your second-level appeal is
denied, and
 
*Our reason involved one or more
of these decisions:
 
  *Whether the course or plan
of treatment is experimental,
investigational, or medically
necessary.
 
  *Whether the course or plan
of treatment is necessary to

continue care when a health
care provider's contract with
us has been terminated.

You must ask for an external review
by an IRO in writing.
 
*Send your request within 185 days
after the date on our final letter
telling you of our denial.
 
*Send your letter to Member
Relations at the address listed on
page 6. Within two days after
Member Relations receives
your letter, they will forward it
to the director of the Oregon
Department of Consumer and
Business Services (DCBS).

The Oregon DCBS will assign an
IRO the next business day after
the director receives your request
from us.

*The DCBS will give the IRO any
authorization it needs to complete
your review.
 
*The DCBS will let you know
in writing about the IRO it has
assigned. It will also tell you
more information about the
review process.

* The DCBS will let us know about
the IRO.

We will forward to the IRO any
documents and other information
we used to make the decision
you've challenged. If we don't
have an appropriate authorization
to disclose your protected health
information, we must get written
authorization (or permission) from
you. This information could include
medical records that are needed for
the review.

You can have an expedited review if
the regular time to make a decision
would cause a delay that could
seriously risk your life, health, or
ability to regain maximum function.
Your request also will be considered
urgent if a health care provider
who is familiar with your medical
condition believes the delay would
cause you severe pain that can't be
adequately managed without the
care or treatment requested.

You don't have to pay for the
external review.


Page 6
You can ask someone else to request
the IRO review. If you do, you must
give your permission in writing.
You must include your signed
permission when you send us the
written request for external review.

You must sign the written request
for external review even if someone
else prepares it for you.

We will implement the decision of
the IRO.

Help from the Oregon
Insurance Division

You have the right to ask for help
from the Consumer Protection Unit
of the Oregon Insurance Division.
You may also file a complaint with
them. To contact them, use the
information below.

Mailing address:

DCBS Insurance Division
Consumer Protection Unit
Room 440-2
350 Winter St. NE
Salem, OR 97301-3883

503-947-7984 or 1-800-877-4894

www.cbs.state.or.us/external/ins/
E-mail: DCBS.INSMAIL@state.or.us

Added Choice® members
In-network questions--If you
have questions about in-network
care from Kaiser Permanente, in-
network benefits, or emergency
claims, follow the procedures in
this flyer.

Out-of-network questions--If you
have questions about out-of-network
care or benefits, or nonemergency
claims, contact Membership
Services. They can tell you whom
you should contact.

Membership Services
If you have questions or need
help, call Membership Services.
We're available by telephone
8 a.m. to 6 p.m., Monday
through Friday.

Portland area.......... 503-813-2000
All other areas ..... 1-800-813-2000

Member Relations
Send written complaints,
grievances, and appeals to:

Member Relations
Kaiser Permanente
500 NE Multnomah St., Suite 100
Portland, OR 97232

Hours: Monday through Friday,
8 a.m. to 5 p.m.

Portland area.......... 503-813-4480
All other areas ..... 1-800-813-2000
FAX......................... 503-813-3985

TTY

All areas............... 1-800-735-2900


Language interpretation services
All areas             1-800-324-8010


Contact your medical
facility administrator

To contact the administrator of a
specific facility, call the number
listed for that medical facility. Press
"0" when you are given the list of
options and ask to speak to the
administrator about your concerns.
You may also call Membership
Services (see page 6) or Member
Relations (see this page).
Medical office administration

Beaverton Medical Office
503-643-7565

Cascade Park Medical Office
360-418-6001

Clackamas Eye Care
503-653-1442

Division Medical Office
503-777-3311

Eastman Parkway Office
503-571-0725

Fisher's Landing Medical Office
360-418-6001

Interstate Medical Office Central
503-285-9321

Interstate Medical Office East
503-285-9321

Interstate Medical Office South
503-285-9321
Interstate Medical Office West
503-285-9321

Lake Road Nephrology Center
503-786-1167

Longview-Kelso Medical Office
360-636-2400

Mill Plain One Medical Office
360-418-6001

Mother Joseph Plaza
503-203-2040


Page 7
Mt. Scott Medical Office
503-652-2880

Mt. Talbert Medical Office
503-652-2880

North Lancaster Medical Office
503-361-5400

One Town Center
503-513-4400

Rockwood Medical Office
503-669-3900

Salmon Creek Medical Office
360-418-6001

Skyline Medical Office
503-361-5400

Sunnyside Medical Office

503-652-2880

Sunset Medical Office
503-645-2762

Tualatin Medical Office
503-885-7300

Vancouver Medical Office
360-418-6001

Hospital administration

Kaiser Sunnyside Medical Center
503-652-2880

OHSU's Doernbecher

Children's Hospital
503-494-8311

Providence St. Vincent
Medical Center
503-216-1234

St. John Medical Center
360-636-4894

Salem Hospital
503-561-5765

Southwest Washington
Medical Center
360-514-2286
Portland area 503-972-3000
ext. 2286


Dental facility administration
Aloha Dental Office
503-259-3160

Beaverton Dental Office
503-626-4148

Cascade Park Dental Office
360-896-4484

Clackamas Dental Office
503-353-3900

Eastmoreland Dental Office

503-238-4418

Glisan Dental Office
503-257-5959

Grand Avenue Dental Office
503-280-2877

Longview-Kelso Dental Office
360-575-4801

North Interstate Dental Office
urgent care, prosthetics,
and TMD treatment
503-286-6860

North Lancaster Dental Office
503-370-4843

Rockwood Dental Office
503-661-5210

Salmon Creek Dental Office
360-571-3139

Skyline Dental Office
503-588-6560

Sunset Dental Office
503-690-5009

Tigard Dental Office
503-684-9274

Dental administration
Kaiser Permanente Building
503-813-4900

Member Relations
503-813-4480
1-800-813-2000 and ask for
Member Relations

KAISER SUGGESTED FORMAT FOR SUBMITTING GRIEVANCE OR APPEALS


Kaiser Permanente Northwest
Member Relations Grievance & Appeal Form

Please print.
Subscriber's name___________________________________________________

Patient's name______________________________Health Record No.__________

Is this a medical issue _            Dental issue _         Oilier issue _    ( please check)

What is your specific request?___________________________________________
__________________________________________________________________

Has this been reviewed by another Kaiser Permanente department?       No _  Yes _

If you answered yes, who reviewed it?____________________________________

If you are requesting payment/reimbursement, what is the approximate amount?  $___________

Please describe your concern
: (Include names of persons you have talked with. names of providers.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Signature__________________________________Today's date:______________________


Return completed form to:

Member Relations
500 NE Multnomah. Suite 100
Portland, OR 97232


Please use reverse if you need additional space.

KPB Word Processing MS-05-2A (1/26/98)

KAISERPAPERS.ORG

howto.kaiserpapers.org