2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 91 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 3: If the independent review organization says no to your appeal, you choose whether you want to take your appeal further. • There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision. • A Level 3 appeal is reviewed 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 8 — Taking your appeal to Level 3 and beyond Section 8.1 – Appeal Levels 3, 4, and 5 for Medical Service Requests This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your appeals have been turned down. If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. The written response you receive to your Level 2 appeal will explain how to make a Level 3 appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 appeal: An Administrative Law Judge or an attorney adjudicator who works for the federal government will review your appeal and give you an answer. • If the Administrative Law Judge or attorney adjudicator says yes to your appeal, the appeals process may or may not be over. Unlike a decision at a Level 2 appeal, we have the right to appeal a Level 3 decision that is favorable to you. If we decide to appeal, it will go to a Level 4 appeal. ♦ If we decide not to appeal, we must authorize or provide you with the medical care within 60 calendar days after receiving the Administrative Law Judge's or attorney adjudicator's decision. ♦ If we decide to appeal the decision, we will send you a copy of the Level 4 appeal request with any accompanying documents. We may wait for the Level 4 appeal decision before authorizing or providing the medical care in dispute. • If the Administrative Law Judge or attorney adjudicator says no to your appeal, 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 can continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.