2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 61 Chapter 5: Asking us to pay our share of a bill you have received for covered medical services • You only have to pay your cost-sharing amount when you get covered services. We do not allow providers to add additional separate charges, called balance billing. This protection (that you never pay more than your cost-sharing amount) applies even if we pay the provider less than the provider charges for a service, and even if there is a dispute and we don't pay certain provider charges. • Whenever you get a bill from a network provider that you think is more than you should pay, send us the bill. We will contact the provider directly and resolve the billing problem. • If you have already paid a bill to a network provider, but you feel that you paid too much, send us the bill along with documentation of any payment you have made and ask us to pay you back the difference between the amount you paid and the amount you owed under our plan. If you are retroactively enrolled in our plan Sometimes a person's enrollment in our plan is retroactive. (This means that the first day of their enrollment has already passed. The enrollment date may even have occurred last year.) If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered services after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork such as receipts and bills for us to handle the reimbursement. All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 7 of this document has information about how to make an appeal. Section 2 — How to ask us to pay you back or to pay a bill you have received You may request us to pay you back by sending us a request in writing. If you send a request in writing, send your bill and documentation of any payment you have made. It's a good idea to make a copy of your bill and receipts for your records. You must submit your claim to us within 12 months (for Part C medical claims) of the date you received the service or item. To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment. You don't have to use the form, but it will help us process the information faster. You can file a claim to request payment by: • Completing and submitting our electronic form at kp.org and upload supporting documentation. • Either download a copy of the form from our website (kp.org) or call Member Services and ask them to send you the form. Mail the completed form to our Claims Department address listed below. • If you are unable to get the form, you can file your request for payment by sending us the following information to our Claims Department address listed below: ♦ A statement with the following information: o Your name (member/patient name) and medical/health record number. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.