2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 69 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Chapter 7 — What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 1 — Introduction Section 1.1 – What to do if you have a problem or concern This chapter explains two types of processes for handling problems and concerns: • For some problems, you need to use the process for coverage decisions and appeals. • For other problems, you need to use the process for making complaints, also called grievances. Both of these processes have been approved by Medicare. Each process has a set of rules, procedures, and deadlines that must be followed by you and us. The guide in Section 3 of this chapter will help you identify the right process to use and what you should do. Other dispute resolution options Your group may have chosen to cover benefits that are not covered by Medicare. For any such benefits, Medicare rules do not apply (including the Medicare appeal process). If you have an issue relating to a benefit covered by your group plan that is not covered by Medicare, please contact Member Services for information about our non-Medicare appeal process for non- Medicare coverage issues. Section 1.2 – What about the legal terms? There are legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To make things easier, this chapter: • Uses simpler words in place of certain legal terms. For example, this chapter generally says, making a complaint rather than filing a grievance, coverage decision rather than organization determination and independent review organization instead of Independent Review Entity. • It also uses abbreviations as little as possible. However, it can be helpful, and sometimes quite important, for you to know the correct legal terms. Knowing which terms to use will help you communicate more accurately to get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.