88 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) Step 3: Within one full day after they have all the information they need, the reviewers will tell you their decision. What happens if the reviewers say yes? • If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as it is medically necessary. • You will have to keep paying your share of the costs (such as deductibles or copayments if these apply). There may be limitations on your covered services. What happens if the reviewers say no? • If the reviewers say no, then your coverage will end on the date we have told you. • If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself. Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal. • If reviewers say no to your Level 1 appeal, and you choose to continue getting care after your coverage for the care has ended, then you can make a Level 2 appeal. Section 7.4 – Step-by-step: How to make a Level 2 appeal to have our plan cover your care for a longer time During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at the decision on your first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay the full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end. Step 1: Contact the Quality Improvement Organization again and ask for another review. You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation. Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 days of receipt of your appeal request, reviewers will decide on your appeal and tell you their decision. What happens if the review organization says yes? • We must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary. kp.org