90 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) 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, then your coverage will end on the date we told you and we will not pay any share of the costs after this date. • If you continued to get 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, then you will have to pay the full cost of this care. Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals process. Legal The formal name for the independent review organization is the Independent Term Review Entity. It is sometimes called the IRE. Step-by-step: Level 2 Alternate appeal process During the Level 2 appeal, the independent review organization reviews the decision we made to your fast appeal. This organization decides whether the decision should be changed. The independent review organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the independent review organization. Medicare oversees its work. Step 1: We will automatically forward your case to the independent review organization. • We are required to send the information for your Level 2 appeal to the independent review organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. Section 9 of this chapter tells you how to make a complaint.) Step 2: The independent review organization does a fast review of your appeal. The reviewers give you an answer within 72 hours. • Reviewers at the independent review organization will take a careful look at all of the information related to your appeal. • If this organization says yes to your appeal, then we must pay you back for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services. • If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it. ♦ The notice you get from the independent review organization will tell you in writing what you can do if you wish to go on to a Level 3 appeal. kp.org