2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 87 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) • Ask for help if you need it. If you have questions or need help at any time, please call Member Services. Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance. During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It decides if the end date for your care is medically appropriate. The Quality Improvement Organization is a group of doctors and other health care experts who are paid by the federal government to check on and help improve the quality of care for people with Medicare. This includes reviewing plan decisions about when it's time to stop covering certain kinds of medical care. These experts are not part of our plan. Step 1: Make your Level 1 appeal: contact the Quality Improvement Organization and ask for a fast-track appeal. You must act quickly. How can you contact this organization? • The written notice you received (Notice of Medicare Non-Coverage) tells you how to reach this organization. Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2. Act quickly: • You must contact the Quality Improvement Organization to start your appeal by noon of the day before the effective date on the Notice of Medicare Non-Coverage. • If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to file an appeal, you must make an appeal directly to us instead. For details about this other way to make your appeal, see Section 7.5. Step 2: The Quality Improvement Organization conducts an independent review of your case. Legal Detailed Explanation of Non-Coverage. Notice that provides details on reasons for Term ending coverage. What happens during this review? • 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 review organization will also look at your medical information, talk with your doctor, and review information that our plan has given to them. • By the end of the day the reviewers tell us of your appeal, you will get the Detailed Explanation of Non-Coverage from us that explains in detail our reasons for ending our coverage for your services. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.