2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 93 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Complaint Example Waiting times • Are you having trouble getting an appointment, or waiting too long to get it? • Have you been kept waiting too long by doctors or other health professionals? Or by our Member Services or other staff at the plan? ♦ Examples include waiting too long on the phone or in the waiting or exam room. Cleanliness • Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor's office? Information you get from • Did we fail to give you a required notice? us • Is our written information hard to understand? Timeliness • If you have asked for a coverage decision or made an (These types of complaints appeal, and you think that we are not responding quickly are all related to the timeli- enough, you can make a complaint about our slowness. Here ness of our actions related are examples: to coverage decisions and ♦ You asked us for a fast coverage decision or a fast appeal, appeals) and we have said no; you can make a complaint. ♦ You believe we are not meeting the deadlines for coverage decisions or appeals; you can make a complaint. ♦ You believe we are not meeting deadlines for covering or reimbursing you for certain medical items or services that were approved; you can make a complaint. ♦ You believe we failed to meet required deadlines for forwarding your case to the independent review organization; you can make a complaint. Section 9.2 – How to make a complaint • A complaint is also called a grievance. Legal • Making a complaint is also called filing a grievance. Terms • Using the process for complaints is also called using the process for filing a grievance. • A fast complaint is also called an expedited grievance. Section 9.3 – Step-by-step: Making a complaint Step 1: Contact us promptly—either by phone or in writing. • Usually calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.