62 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 5: Asking us to pay our share of a bill you have received for covered medical services o The date you received the services. o Where you received the services. o Who provided the services. o Why you think we should pay for the services. o Your signature and date signed. (If you want someone other than yourself to make the request, we will also need a completed "Appointment of Representative" form, which is available at kp.org.) ♦ A copy of the bill, your medical record(s) for these services, and your receipt if you paid for the services. Mail your request for payment together with any bills or paid receipts to us at this address: Kaiser Permanente Claims Department Northwest Region P.O. Box 370050 Denver, CO 80237-9998 Section 3 — We will consider your request for payment and say yes or no Section 3.1 – We check to see whether we should cover the service and how much we owe When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision. • If we decide that the medical care is covered and you followed all the rules, we will pay for our share of the cost. If you have already paid for the service, we will mail your reimbursement of our share of the cost to you. If you have not paid for the service yet, we will mail the payment directly to the provider. • If we decide that the medical care is not covered, or you did not follow all the rules, we will not pay for our share of the cost. We will send you a letter explaining the reasons why we are not sending the payment and your right to appeal that decision. Section 3.2 – If we tell you that we will not pay for all or part of the medical care, you can make an appeal If you think we have made a mistake in turning down your request for payment or the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment. The appeals process is a formal process with detailed procedures and important deadlines. For the details on how to make this appeal, go to Chapter 7 of this document. kp.org