2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 89 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) • You must continue to pay your share of the costs and there may be coverage limitations that apply. What happens if the review organization says no? • It means they agree with the decision made to your Level 1 appeal. • The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by an Administrative Law Judge or attorney adjudicator. Step 4: If the answer is no, you will need to decide 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. • The Level 3 appeal is handled 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 7.5 – What if you miss the deadline for making your Level 1 appeal? You can appeal to us instead As explained above, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-step: How to make a Level 1 Alternate appeal Legal A fast review (or fast appeal) is also called an expedited appeal. Term Step 1: Contact us and ask for a fast review. • Ask for a fast review. This means you are asking us to give you an answer using the fast deadlines rather than the standard deadlines. Chapter 2 has contact information. Step 2: We do a fast review of the decision we made about when to end coverage for your services. • During this review, we take another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending our plan's coverage for services you were receiving. Step 3: We give you our decision within 72 hours after you ask for a fast review. • If we say yes to your appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.