When you appeal, you may give testimony in writing or by telephone. Please send your written testimony 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 To arrange to give testimony by telephone, you should contact Member Services. We will add the information that you provide through testimony or other means to your claim file and we will review it without regard to whether this information was submitted and/or considered in our initial decision regarding your claim. Sharing Additional Information That We Collect If we believe that your appeal of our initial adverse benefit determination will be denied, then before we issue another adverse benefit determination, we will also share with you any new or additional reasons for that decision. We will send you a letter explaining the new or additional information and/or reasons and inform you how you can respond to the information in the letter if you choose to do so. If you do not respond before we must make our final decision, that decision will be based on the information already in your claim file. Internal Claims and Appeals Procedures Kaiser will review claims and appeals, and we may use medical experts to help us review them. There are several types of claims, and each has a different procedure described below for sending your claim and appeal to us as described in this “Internal Claims and Appeals Procedures” section:  Pre-Service claims (urgent and non-urgent)  Concurrent care claims (urgent and non-urgent)  Post-Service claims When you file an appeal, we will review your claim without regard to our previous adverse benefit determination. The individual who reviews your appeal will not have participated in our original decision regarding your claim nor will they be the subordinate of someone who did participate in our original decision. If you miss a deadline for making a claim or appeal, we may decline to review it. Except when simultaneous external review can occur (urgent pre-Service appeal and urgent concurrent appeal), you must exhaust the internal claims and appeals procedures described below before initiating an external review. Pre-Service Claims and Appeals Pre-Service claims are requests that we provide or pay for a Service that you have not yet received. Failure to receive authorization before receiving a Service that must be authorized in order to be a covered benefit may be the basis for our denial of your pre-Service claim or a post-Service claim for payment. If you receive any of the Services you are requesting before we make our decision, your pre-Service claim or appeal will become a post-Service claim or appeal with respect to those Services. If you have any general questions about pre-service claims or appeals, please contact Member Services. Here are the procedures for filing a non-urgent pre-service claim, an urgent pre-service claim, a non-urgent pre-Service appeal, and an urgent pre-Service appeal. EWCLGHDHP1983ACT0124 86 WAPEBB-CD-ACT