While we encourage you to use our grievance procedure, you have the right to contact Washington’s designated ombudsman’s office, the Washington State Office of the Insurance Commissioner, for assistance with questions and complaints. Contact them by mail, telephone or online at: Office of the Insurance Commissioner, Consumer Protection Division P.O. Box 40256 Olympia, WA 98504 1-800-562-6900 www.insurance.wa.gov Language and Translation Assistance If we send you grievance or adverse benefit determination correspondence, we will include a notice of language assistance (oral translation). You may request language assistance with your claim and/or appeal by calling 1-324-8010. The notice of language assistance “Help in Your Language” is also included in this EOC. Appointing a Representative If you would like someone to act on your behalf regarding your claim, you may appoint an authorized representative, an individual who by law or by your consent may act on your behalf. You must make this appointment in writing. Contact Member Services for information about how to appoint a representative. You must pay the cost of anyone you hire to represent or help you. Help with Your Claim and/or Appeal While you are encouraged to use our appeal procedures, you have the right to seek assistance from the Office of the Insurance Commissioner. Contact them by mail, telephone, or online at: Office of the Insurance Commissioner, Consumer Protection Division P.O. Box 40256 Olympia, WA 98504 1-800-562-6900 www.insurance.wa.gov Reviewing Information Regarding Your Claim If you want to review the information that we have collected regarding your claim, you may request, and we will provide without charge, copies of all relevant documents, records, and other information (including complete medical necessity criteria, benefit provisions, guidelines, or protocols) used to make a denial determination. You also have the right to request any diagnosis and treatment codes and their meanings that are the subject of your claim. To make a request, you should contact Member Services. Providing Additional Information Regarding Your Claim When you appeal, you may send us additional information including comments, documents, and additional medical records that you believe support your claim. If we asked for additional information and you did not provide it before we made our initial decision about your claim, then you may still send us the additional information so that we may include it as part of our review of your appeal. Please mail or fax all additional information to: Kaiser Foundation Health Plan of the Northwest Member Relations Department 500 NE Multnomah St., Suite 100 Portland, OR 97232-2099 Fax: 1-855-347-7239 EWCLGHDHP1983ACT0124 85 WAPEBB-CD-ACT