74 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) • You have received and paid for medical care that you believe should be covered by our plan, and you want to ask us to reimburse you for this care. Send us the bill. Section 5.5. • You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health. Make an appeal. Section 5.3. Note: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read Section 6 and Section 7 of this chapter. Special rules apply to these types of care. Section 5.2 – Step-by-step: How to ask for a coverage decision Legal When a coverage decision involves your medical care, it is called an organization Terms determination. A fast coverage decision is called an expedited determination. Step 1: Decide if you need a standard coverage decision or a fast coverage decision. A standard coverage decision is usually made within 14 days or 72 hours for Part B drugs. A fast coverage decision is generally made within 72 hours, for medical services, or 24 hours for Part B drugs. In order to get a fast coverage decision, you must meet two requirements: • You may only ask for coverage for medical items and/or services (not requests for payment for items and/or services already received. • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. • If your doctor tells us that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision. • If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision. If we do not approve a fast coverage decision, we will send you a letter that: ♦ Explains that we will use the standard deadlines. ♦ Explains if your doctor asks for the fast coverage decision, we will automatically give you a fast coverage decision. ♦ Explains that you can file a fast complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. Step 2: Ask our plan to make a coverage decision or fast coverage decision. • Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this. Chapter 2 has contact information. Step 3: We consider your request for medical care coverage and give you our answer. For standard coverage decisions, we use the standard deadlines. kp.org