2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 75 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) This means we will give you an answer within 14 calendar days after we receive your request for a medical item or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request. • However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more 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. We will give you an answer to your complaint as soon as we make the decision. (The process for making a complaint is different from the process for coverage decisions and appeals. See Section 9 of this chapter for information on complaints.) For fast coverage decisions we use an expedited time frame. A fast coverage decision means we will answer within 72 hours if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours. • However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more days. 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. (See Section 9 of this chapter for information on complaints.) We will call you as soon as we make the decision. • If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Step 4: If we say no to your request for coverage for medical care, you can appeal. • If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking again to get the medical care coverage you want. If you make an appeal, it means you are going on to Level 1 of the appeals process. Section 5.3 – Step-by-step: How to make a Level 1 appeal Legal An appeal to our plan about a medical care coverage decision is called a plan Terms reconsideration. A fast appeal is also called an expedited reconsideration. Step 1: Decide if you need a standard appeal or a fast appeal. A standard appeal is usually made within 30 days or 7 days for Part B drugs. A fast appeal is generally made within 72 hours. • If you are appealing a decision we made about coverage for care that you have not yet received, you and/or your doctor will need to decide if you need a fast appeal. If your doctor tells us that your health requires a fast appeal, we will give you a fast appeal. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.