2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 83 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal. If the Quality Improvement Organization has said no to your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to Level 2 of the appeals process. Section 6.3 – Step-by-step: How to make a Level 2 appeal to change your hospital discharge date During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at their 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 stay after your planned discharge date. Step 1: Contact the Quality Improvement Organization again and ask for another review. You must ask for this review within 60 calendar days after the day the Quality Improvement Organization said no to your Level 1 appeal. You can ask for this review only if you stay in the hospital 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 calendar days of receipt of your request for a Level 2 appeal, the reviewers will decide on your appeal and tell you their decision. If the review organization says yes: • We must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary. • You must continue to pay your share of the costs and coverage limitations may apply. If the review organization says no: • It means they agree with the decision they made on your Level 1 appeal. This is called upholding the decision. • The notice you get will tell you in writing what you can do if you wish to continue with the review process. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3. • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you want to go 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. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.