82 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) • If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to appeal, you must make an appeal directly to our plan instead. For details about this other way to make your appeal, see Section 6.4. Once you request an immediate review of your hospital discharge, the Quality Improvement Organization will contact us. By noon of the day after we are contacted, we will give you a Detailed Notice of Discharge. This notice gives your planned discharge date and explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date. You can get a sample of the Detailed Notice of Discharge by calling Member Services or 1- 800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1- 877-486-2048.) Or you can see a sample notice online at www.cms.gov/Medicare/Medicare- General-Information/BNI/HospitalDischargeAppealNotices. Step 2: The Quality Improvement Organization conducts an independent review of your case. • Health professionals at the Quality Improvement Organization (the reviewers) will ask you (or your representative) why you believe coverage for the services should continue. You don't have to prepare anything in writing, but you may do so if you wish. • The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and we have given to them. • By noon of the day after the reviewers told us of your appeal, you will get a written notice from us that gives you your planned discharge date. This notice also explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date. Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal. What happens if the answer is yes? • If the review organization says yes, we must keep providing your covered inpatient hospital services for as long as these services are medically necessary. • You will have to keep paying your share of the costs (such as deductibles or copayments if these apply). In addition, there may be limitations on your covered hospital services. What happens if the answer is no? • If the review organization says no, they are saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal. • If the review organization says no to your appeal and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal. kp.org