2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 73 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the independent review organization to review our decision to dismiss your appeal. • You also have the right to hire a lawyer. You may contact your own lawyer or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. Section 4.3 – Which section of this chapter gives the details for your situation? There are three different situations that involve coverage decisions and appeals. Since each situation has different rules and deadlines, we give the details for each one in a separate section: • Section 5 in this chapter: "Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision." • Section 6 in this chapter: "How to ask us to cover a longer inpatient hospital stay if you think the doctor is discharging you too soon." • Section 7 in this chapter: "How to ask us to keep covering certain medical services if you think your coverage is ending too soon" (applies only to these services: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services). If you're not sure which section you should be using, please call Member Services. You can also get help or information from government organizations such as your SHIP. Section 5 — Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision Section 5.1 – This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care This section is about your benefits for medical care. These benefits are described in the Medical Benefits Chart found at the front of this EOC. In some cases, different rules apply to a request for a Medicare Part B prescription drug. In those cases, we will explain how the rules for Medicare Part B prescription drugs are different from the rules for medical items and services. This section tells you what you can do if you are in any of the five following situations: • You are not getting certain medical care you want, and you believe that this is covered by our plan. Ask for a coverage decision. Section 5.2. • We will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by our plan. Ask for a coverage decision. Section 5.2. • You have received medical care that you believe should be covered by our plan, but we have said we will not pay for this care. Make an appeal. Section 5.3. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.