92 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Level 4 appeal: The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the federal government. • If the answer is yes, or if the Council denies our request to review a favorable Level 3 appeal decision, the appeals process may or may not be over. Unlike a decision at Level 2, we have the right to appeal a Level 4 decision that is favorable to you. We will decide whether to appeal this decision to Level 5. ♦ If we decide not to appeal the decision, we must authorize or provide you with the medical care within 60 calendar days after receiving the Council's decision. ♦ If we decide to appeal the decision, we will let you know in writing. • If the answer is no or if the Council denies the review request, the appeals process may or may not be over. ♦ If you decide to accept this decision that turns down your appeal, the appeals process is over. ♦ If you do not want to accept the decision, you may be able to continue to the next level of the review process. If the Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 appeal and how to continue with a Level 5 appeal. Level 5 appeal: A judge at the Federal District Court will review your appeal. • A judge will review all of the information and decide yes or no to your request. This is a final answer. There are no more appeal levels after the Federal District Court. MAKING COMPLAINTS Section 9 — How to make a complaint about quality of care, waiting times, customer service, or other concerns Section 9.1 – What kinds of problems are handled by the complaint process? The complaint process is only used for certain types of problems. This includes problems related to quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by the complaint process. Complaint Example Quality of your medical • Are you unhappy with the quality of the care you have care received (including care in the hospital)? Respecting your privacy • Did someone not respect your right to privacy or share confidential information? Disrespect, poor customer • Has someone been rude or disrespectful to you? service, or other negative • Are you unhappy with our Member Services? behaviors • Do you feel you are being encouraged to leave the plan? kp.org