84 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) • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 8 in this chapter tells you more about Levels 3, 4, and 5 of the appeals process. Section 6.4 – What if you miss the deadline for making your Level 1 appeal to change your hospital discharge date? Legal A fast review (or fast appeal) is also called an expedited appeal. Term You can appeal to us instead As explained above, you must act quickly to start your Level 1 appeal of your hospital discharge date. If you miss the deadline for contacting the Quality Improvement Organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-step: How to make a Level 1 alternate appeal Step 1: Contact us and ask for a fast review. • Ask for a fast review. This means you are asking us to give you an answer using the fast deadlines rather than the standard deadlines. Chapter 2 has contact information. Step 2: We do a fast review of your planned discharge date, checking to see if it was medically appropriate. • During this review, we take a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We will see if the decision about when you should leave the hospital was fair and followed all the rules. Step 3: We give you our decision within 72 hours after you ask for a fast review. • If we say yes to your appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date. We will keep providing your covered inpatient hospital services for as long as they are medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.) • If we say no to your appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends as of the day we said coverage would end. • If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. kp.org