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Claims, complaints, grievances, and appeals - Washington plans in easy printable form
Requesting medical services
and benefits

Post-service claims -
Services you already received
If you have a medical bill from
a non-Kaiser Permanente (non-
Plan) provider or facility, Claims
Administration will handle the
claim. Membership Services can
assist you with questions about a
specific claim or about the claim
procedures in general.

If you receive non-Plan services
following an authorized referral
from Kaiser Permanente, the non-
plan provider will send the bill to
Claims Administration directly.
You are not required to file the
claim.

If you receive services from a non-
Plan provider or facility without an
authorized referral, and you believe
Kaiser Permanente should cover
the services:

*Send a completed
Non-Plan Care
Information form (claim form)
and the itemized bill to:

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

*You can request a claim form
from Membership Services or
download it from our Web site.
To download a claim form, go
to kaiserpermanente.org and
select the appropriate link.

*When you submit the claim,
include a copy of your medical
records from the non-Kaiser
Permanente facility if you have
them. If you don't submit the
medical records and we determine
they are necessary to decide your
claim, we will notify you.

*The non-Kaiser Permanente
provider may bill us directly. We
accept the CMS 1500 claim form

Page 1
for professional services and UB-
92 form for hospital claims. You
still need to send the Non-Plan
Care Information form even if
the provider bills us directly.

*You must submit a claim within
90 days after receiving care, or as
soon as reasonably possible.

*We will not review a claim if
we do not receive a complete
application within 12 months
from the time the completed
claim form is due, unless you
lack legal capacity to file the
claim within 12 months.

We will reach a decision on your
claim and pay the covered charges
within 30 calendar days unless
additional information is required
to make a decision. If the 30-day
period must be extended, you
will be notified in writing with an
explanation about why. The written
notice will tell you how long the
time period may be extended
depending on the requirements
of applicable state and federal
laws, including the Employee
Retirement Income Security Act
of 1974 (ERISA). Refer to the next
page for important information
and explanations about ERISA.

You will receive written notification
regarding the claim determination.
This notification will provide an
explanation for any unpaid amounts.
It will also tell you how to appeal
the determination if you are not
satisfied with the outcome, along
with other important disclosures
required by state and federal laws.

If you. have questions or concerns
about a bill from Kaiser Permanente,
contact Membership Services for
an explanation. If you believe
the charges are not appropriate,
Membership Services will advise
you how to proceed.

If you believe charges are not
appropriate due to concerns
involving our services or your
benefits, you may file a grievance.
If you think the charges are in
error (such as a bill for services
you did not receive or that you
paid at the time of service),
Membership Services can assist
you. If it is determined the charges
are accurate, you will be given an
explanation along with information
about how to file a grievance. Refer
to "Complaints, Grievances, and
Appeals" for more information on
filing a grievance.

Pre-service claims-Requesting

future care or service
When you need care, talk with your
health care provider about your
medical needs or request for medical
services. We provide treatment
and services based on medical
necessity and appropriateness. Your
health care provider will use his
or her judgment to determine if a
treatment or service is medically
appropriate. Some treatments and
services are subject to approval
through utilization review, based
on criteria developed by the Kaiser
Permanente medical group or
another organization. If you think
you need a specific treatment
or service, talk with your Kaiser
Permanente health care provider.
Your health care provider will
discuss your needs with you and
recommend the most appropriate
course of treatment. If your request
for treatment, service, or equipment
is urgent, we will respond to the
request on the same day the request
is received.

*If you request treatment,
service, or equipment that your
health care provider believes
is not medically appropriate
or necessary and you disagree,
you may ask for a second opinion
from another health care provider.
For primary care services, you
can request a different health
care provider at any time. You
also have the right to request
a pre-service determination in
writing. Contact the manager in
the area where your health care
provider is located. Membership
Services can connect you with
the correct manager, who will
listen to your issues and discuss
your request with your health
care provider. If your health care
provider continues to believe the
treatment, service, or equipment
you requested is not medically
necessary, we will send you a
denial letter within two business
days of your contact with the
manager. The letter will explain
the reason for the determination
along with instructions for filing
a first-level appeal.

*If you request treatment,
service, or equipment that
must be approved through
utilization review as described
above and your health care
provider believes it is medically
necessary, your health care
provider will submit the request
for review on your behalf. If the
request is denied, we will send
you a letter within two business
days of the doctor's request for
approval. The letter will explain
the reason for the determination
along with instructions for filing
a first-level appeal.

*If you request treatment, service,
or equipment but you learn there
may be coverage limitations
or exclusions, and you have
questions or disagree, contact
Membership Services. If you are
not satisfied after talking with
Membership Services, you may
request a pre-service benefit
determination in writing. We will
generate a benefit determination
within two business days. If you
are not satisfied after receiving
the benefit determination, you
may file a grievance.


Page 2
If you are covered under an
ERISA benefit plan and additional
information is required to make a
determination on your pre-service
request, you will be notified and
given a specified period of time to
provide the information. This may
extend the decision period past two
business days. Refer to "Complaints,
Grievances, and Appeals" for
important explanations about ERISA.

Expedited procedures are available
if your request for service is
considered urgent. A request is
urgent if the normal decision time
frames would cause a delay that
would seriously jeopardize your
life, health, or ability to regain
maximum function. It also applies
if a health care provider who is
familiar with your medical condition
believes the delay would subject
you to severe pain that cannot
be adequately managed without
the care or treatment at issue. In
urgent situations, we will respond
to you as quickly as your condition
requires, not to exceed two business
days or 72 hours whichever is
shorter. Certain requests to extend
previously approved treatment
that involves urgent care (such
as continuing inpatient or skilled
nursing facility services) are
responded to within 24 hours
of receipt.

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, including the claim and
appeal procedures for benefit plans
offered by certain employers. If
your employer's benefit plan is
subject to ERISA, each time you
request care or services that must
be approved before the care or
service is provided, you are filing
a "pre-service claim" for benefits.
You are filing a "post-service claim"
when you ask us to pay for or cover
services that you have already
received. You must follow our
procedures for filing claims,
and we must follow certain rules
established by ERISA for responding
to your claim.

If you are not satisfied with the
decision made on your pre-service
or post-service claim, you are only
required to file one appeal before
you have the right to take legal
action under Section 502 (a) of
ERISA. Your appeal will be reviewed
by an appropriate named fiduciary.
Additional levels of voluntary
appeal are available within Kaiser
Permanente. We do not impose fees
as part of any appeal process. If you
are not sure whether these ERISA
laws apply to your benefit plan,
please contact your employer for
more information.

Complaints, grievances,
and appeals

Member satisfaction
Everyone associated with Kaiser
Permanente wants you to receive the
best care and service possible. If you
have questions about your coverage
or how to use our services, or if you
need help finding the right health
care resource, call Membership
Services. If you have a compliment
or suggestion, please call or send
a letter to the administrator of the
facility where you received care.
We'll share your comments with the
employees who assisted you and
their supervisors.

Discuss any issues about your
care with your health care
provider or another member of
your health care team. If you are
not satisfied with your health care
provider, you may request another.
Contact Membership Services for
assistance. You always have the
right to a second opinion within
Kaiser Permanente.

Most issues can be resolved with
your health care team. If you feel
that additional assistance is needed,
complaint and grievance procedures
are available to help. All complaints
and grievances are handled in a
confidential manner

Members who are covered
by an Oregon plan, the
Federal Employee Health
Benefits Program, Medicare,
or Oregon Health Plan have
different grievance and appeal
procedures. Please contact
Membership Services for a copy
of the procedures that apply to
your plan.
************************
Oral complaints
If you want to talk with someone
because you are dissatisfied with
the availability, delivery, or quality
of our services, benefits, or other
administrative matters, you can
file an oral complaint. Examples
include, but are not limited to,
things like appointment delays,
the manner of communication by
our staff, or concerns about our
policies and procedures. If you
have a concern involving a denial
of future care, refer to "Appeals." If
your concern involves a denial for
services you already received, refer
to "Grievances."

To file a complaint, contact the
administrative office in the facility
where you are having the problem
or contact Membership Services for
assistance. Discuss your complaint
fully with the staff and be specific
about how you want the matter to
be resolved.

If you remain dissatisfied, you can
file an oral or written grievance.
If you decide to file a grievance,
follow the procedures described
under "Grievances."

Grievances
A grievance is an oral or written
complaint requesting a specific
action, submitted by or on behalf
of a member.

You can file a grievance:
*If you are not satisfied with our
response to your complaint
regarding the availability, delivery,
or quality of our services, benefits,
or other administrative matters.




Page 3
Examples include complaints that
you want reported and resolved,
such as, a delay in hearing back
from your doctor's office or about
receiving an appointment in a
timely manner.

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

*If we denied your claim for
services that you received from a
non-Kaiser Permanente provider
or facility and you disagree with
the claim determination. You
must file the grievance within
185 days of the denial notice.
(These grievances are post-service
appeals under ERISA.)

*If we issued a benefit denial in
writing after you requested a pre-
service benefit determination. This
includes things like a pre-service
adverse benefit determination
based on a decision that you
are not eligible for benefits. Or,
it could be a pre-service denial
based on any number of specific
coverage exclusions such as,
certain excluded infertility
procedures, lack of special
benefits like prescription drugs,
vision hardware coverage, or
due to benefit limitations like a
maximum number of covered
mental health visits in a benefit
period. You must file the grievance
within 185 days of the denial
notice. (These grievances are pre-
service appeals under ERISA.)

Grievance procedures.
To file a grievance, outline your
concerns in writing and be specific
about your request. You may
submit any written comments,
documents, records, and
other information related to your
grievance. Send your grievance to:

Member Relations

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

Or to file an oral grievance, call
Member Relations at 503-813-4480
or toll free at 1-800-813-2000. and
ask for Member Relations.

If you need assistance filing a
written grievance, or if your
grievance is urgent, contact Member
Relations. We will acknowledge
receipt of your grievance within five
working days. Member Relations
will forward your grievance to the
correct manager or department for
resolution. An independent review
will be conducted, and we will
provide you with a written response.
If your grievance is classified as an
initial claim under ERISA, a decision
will be provided within 30 days
except as follows. If you fail to
provide necessary information to
make a determination on a grievance
that is an initial claim under ERISA,
we will allow you 50 days from the
date on our written notification to
submit the information. A decision
will be reached within 15 days
after receiving the information or
within 15 days after the end of the
50 day period if we don't receive
the information. If your grievance
is classified as an appeal under
ERISA, a decision will be provided
within 14 days after we receive your
grievance unless you are notified
that additional time is needed to
complete the review. In this case,
the extension will not delay the
decision beyond 30 days.

We will expedite a response on
all grievances according to the
clinical urgency of the situation,
not to exceed 72 hours, if your
grievance involves a denial of
urgently needed care.

If your grievance included a
specific request and that request
is denied, the decision letter
you receive will include detailed
information about the basis for the
decision and how to appeal the
decision. (For members covered
under an ERISA benefit plan,
additional appeals are considered
voluntary unless your grievance was
classified as an initial claim under
ERISA as described previously.)

Appeals
The process for requesting
reconsideration of a denied
grievance or a denial of care or
service following a utilization
review determination requested
by your health care provider is
outlined in the following appeal
procedures. These procedures
reflect the requirements of state and
federal laws. Members who are not
covered under an ERISA benefit plan
have two levels of appeal following
any denied grievance or following
a denial of care or service because
it was not considered medically
necessary or it did not meet
medical criteria (utilization review
determinations). These appeals
are referred to as "first-level" and
"second level" appeals. Members
covered under an ERISA benefit
plan are only required to file one
appeal before having a right to take
legal action under ERISA. Receipt
of appeals will be acknowledged
within five working days.

First-level appeals.

* If you disagree with the decision
rendered following a written
grievance, you have 185 days
from the date of the denial notice
to submit a first-level appeal
either orally or in writing.
(For members covered under an
ERISA benefit plan, this level of
appeal is considered voluntary.
Exception: If the grievance was
a dispute regarding a bill from
Kaiser Permanente, this appeal is
the one required level of appeal
under ERISA.)

*If you disagree with a denial for
future care or service following a
utilization review determination
requested by your health care
provider, you have 185 days from
the date of the denial notice to
submit a first-level appeal.

*If your appeal involves urgently
needed care, a request for
an expedited appeal may be
submitted orally or in writing.

Page 4
To submit an appeal, follow the
instructions in the denial letter you
receive, or call or send your appeal
to Member Relations. They will
direct it to the appropriate location
for handling. You have the right to
include with your first-level appeal
any written comments, documents,
records, and other information
relating to the claim.

First-level appeals will be decided
within 14 days after we receive
your appeal unless you are
notified that additional time is
needed to complete the review.
T
he extension will not delay
the decision beyond 30 days. A
decision will be expedited to
meet the clinical urgency of the
situation, not to exceed 72 hours
if it involves a denial of urgently
needed care. Member Relations or
the area manager will conduct an
independent review of your first-
level appeal and provide a written
response. If your first-level appeal
is denied, the written notice you
receive will explain the basis for the
decision, along with information

about further appeal rights and
other important disclosures.

Second-level appeals. If you
disagree with the decision rendered
on your first-level appeal, you have
the right to submit a second-level
oral or written appeal. If you decide
to submit a second-level appeal, call
or send your appeal in writing to
Member Relations within 60 days
of the date of the decision letter.

You have the right to include with
your appeal any written comments,
documents, records, and other
information relating to the claim.
You have the right to appear in
person or by telephone before
the review panel. If you wish
to participate in person or by
telephone, you must indicate
this in your written second-
level appeal. You must also list
anyone who will attend with you,
including your relationship to them.
Member Relations will conduct an
independent review and provide a
written response.


Second-level appeals will be
decided within 14 days after we
receive your appeal unless you
are notified that additional time
is needed to complete the review.
The extension will not delay the
decision beyond 30 days. A decision
will be expedited to meet the
clinical urgency of the situation,
not to exceed 72 hours if it involves
a
denial of any urgently needed
care. If your second-level appeal
is denied, written notification will
explain the basis for the denial
and will advise you how to request
additional independent external
review by an independent review
organization (IRO).

External review by an IRO
under Washington law

Certain adverse determinations
made by Kaiser Permanente
may be eligible for review by a

certified IRO after all appeals have
been exhausted within Kaiser
Permanente, or after the timeline
for responding to a grievance has
been exhausted without good
cause and without a decision. For
members covered under an ERISA
benefit plan, external review is
considered another "voluntary"
level of appeal and is only available
once all voluntary appeals have
been exhausted.

The adverse determinations
eligible for review by an IRO are
decisions by Kaiser Permanente to
deny, modify, reduce, or terminate
payment, coverage, authorization, or
provision of health care services or
benefits including the admission to
or continued stay in a facility.

If you are dissatisfied with an
adverse determination and have
exhausted your appeal rights within
Kaiser Permanente, you may ask
for an external review within 185
days of the date on the final denial
letter. To determine if your appeal
is eligible for external review or
to file your request for external
review, contact Member Relations.
Member Relations will forward
your request to the IRO. They will


include written information received
in support of the appeal along
with medical records and other
documents relevant in making the
determination.

Your request for external review
will be expedited if the ordinary
time period for external review
would seriously jeopardize your
life, health, or your ability to regain
maximum function.

You are not responsible for the costs
of the external review, and you may
name someone else to file the appeal
for you if you give permission in
writing and include that with your
request for external review. While
you are encouraged to use our
complaints, grievances, and appeals
procedure, you have the right to


Page 5
contact the Washington Office of the
Insurance Commissioner. Contact
them by mail, telephone, or over
the Internet:

P.O. Box 40255
Olympia, WA 98504
1-800-562-6900


Added Choice® members
For questions regarding in-network
care, in-network benefits, or
emergency claims, follow the
procedures described in this flyer.
For questions regarding out-of-
network care, benefits, or non-
emergency claims, contact Kaiser
Permanente Membership Services
(phone numbers listed at right) and
ask who 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

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
l
isted 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 (previous page) or Member
Relations (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
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 6
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
503-494-9000

Providence St. Vincent
Medical Center
503-216-1234

St. John Medical Center
360-414-7578

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

 KAISER PERMANENTE

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