2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage 85 Chapter 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Step 4: If we say no to your appeal, your case will automatically be sent on to the next level of the appeals process. Step-by-step: Level 2 alternate appeal process Legal The formal name for the independent review organization is the Independent Term Review Entity. It is sometimes called the IRE. The independent review organization is an independent organization hired by Medicare. It is not connected with our plan and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: We will automatically forward your case to the independent review organization. We are required to send the information for your Level 2 appeal to the independent review organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. Section 9 in this chapter tells you how to make a complaint.) Step 2: The independent review organization does a fast review of your appeal. The reviewers give you an answer within 72 hours. • Reviewers at the independent review organization will take a careful look at all of the information related to your appeal of your hospital discharge. • If this organization says yes to your appeal, then we must pay you back for our share of the costs of hospital care you received since the date of your planned discharge. We must also continue our plan's coverage of your inpatient hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services. • If this organization says no to your appeal, it means they agree that your planned hospital discharge date was medically appropriate. ♦ The written notice you get from the independent review organization will tell how to start a Level 3 appeal with the review process, which is handled by an Administrative Law Judge or attorney adjudicator. Step 3: If the independent review organization turns down your appeal, you choose whether you want to take your appeal further. • There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 appeal, you decide whether to accept their decision or go on to Level 3 appeal. • Section 8 in this chapter tells you more about Levels 3, 4, and 5 of the appeals process. 1-877-221-8221 (TTY 711), 7 days a week, 8 a.m. to 8 p.m.