60 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 5: Asking us to pay our share of a bill you have received for covered medical services Chapter 5 — Asking us to pay our share of a bill you have received for covered medical services Section 1 — Situations in which you should ask us to pay our share of the cost of your covered services Sometimes when you get medical care, you may need to pay the full cost. Other times, you may find that you have paid more than you expected under the coverage rules of our plan. In these cases, you can ask us to pay you back (paying you back is often called reimbursing you). It is your right to be paid back by our plan whenever you've paid more than your share of the cost for medical services that are covered by our plan. There may be deadlines that you must meet to get paid back. Please see Section 2 of this chapter. There may also be times when you get a bill from a provider for the full cost of medical care you have received or possibly for more than your share of cost-sharing as discussed in this document. First try to resolve the bill with the provider. If that does not work, send the bill to us instead of paying it. We will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly. If we decide not to pay it, we will notify the provider. You should never pay more than plan-allowed cost-sharing. If this provider is contracted, you still have the right to treatment. Here are examples of situations in which you may need to ask us to pay you back or to pay a bill you have received: When you've received emergency or urgently needed medical care from a provider who is not in our network Outside the service area, you can receive emergency or urgently needed services from any provider, whether or not the provider is a part of our network. In these cases: • You are only responsible for paying your share of the cost for emergency or urgently needed services. Emergency providers are legally required to provide emergency care. • If you pay the entire amount yourself at the time you receive the care, ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you have made. • You may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along with documentation of any payments you have already made. ♦ If the provider is owed anything, we will pay the provider directly. ♦ If you have already paid more than your share of the cost of the service, we will determine how much you owed and pay you back for our share of the cost. When a network provider sends you a bill you think you should not pay Network providers should always bill us directly, and ask you only for your share of the cost. But sometimes they make mistakes, and ask you to pay more than your share. kp.org