2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 77 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Deadlines for a standard appeal • For standard appeals, we must give you our answer within 30 calendar days after we receive your appeal. If your request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if your health condition requires us to. ♦ However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we will tell you in writing. We can't take extra time to make a decision if your request is for a Medicare Part B prescription drug. ♦ If you believe we should not take extra days, you can file a fast complaint. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (See Section 9 of this chapter for information on complaints.) ♦ If we do not give you an answer by the deadline (or by the end of the extended time period), we will send your request to a Level 2 appeal, where an independent review organization will review the appeal. Section 5.4 explains the Level 2 appeal process. • If our answer is yes to part or all of what you requested, we must authorize or provide the coverage within 30 calendar days if your request is for a medical item or service, or within 7 calendar days if your request is for a Medicare Part B prescription drug. • If our plan says no to part or all of your appeal, we will automatically send your appeal to the independent review organization for a Level 2 appeal. Section 5.4 – Step-by-step: How a Level 2 appeal is done Legal The formal name for the independent review organization is the Independent Term Review Entity. It is sometimes called the IRE. The independent review organization is an independent organization hired by Medicare. It is not connected with us and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: The independent review organization reviews your appeal. • We will send the information about your appeal to this organization. This information is called your case file. You have the right to ask us for a copy of your case file. We are allowed to charge you a fee for copying and sending this information to you. • You have a right to give the independent review organization additional information to support your appeal. • Reviewers at the independent review organization will take a careful look at all of the information related to your appeal. If you had a fast appeal at Level 1, you will also have a fast appeal at Level 2 • For the fast appeal, the review organization must give you an answer to your Level 2 appeal within 72 hours of when it receives your appeal. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.