service documentation. The Enrollee or legal surrogate may be contacted for information. Coordination of care interventions are initiated as they are identified. The reviewer consults with the health care team when more clarity is needed to make an informed medical necessity decision. The reviewer may consult with a board-certified consultative specialist and such consultations will be documented in the review text. If the requested service appears to be inappropriate based on application of the review criteria, the first level reviewer requests second level review by a physician or designated health care professional. Second Level (Practitioner) Review: The practitioner reviews the treatment plan and discusses, when appropriate, case circumstances and management options with the attending (or referring) physician. The reviewer consults with the health care team when more clarity is needed to make an informed coverage decision. The reviewer may consult with board certified physicians from appropriate specialty areas to assist in making determinations of coverage and/or appropriateness. All such consultations will be documented in the review text. If the reviewer determines that the admission, continued stay or service requested is not a covered service, a notice of non- coverage is issued. Only a physician, behavioral health practitioner (such as a psychiatrist, doctoral-level clinical psychologist, certified addiction medicine specialist), dentist, or pharmacist who has the clinical expertise appropriate to the request under review with an unrestricted license may deny coverage based on Medical Necessity. B. Administration of the Evidence of Coverage. KFHPWA may adopt reasonable policies and procedures to administer the EOC. This may include, but is not limited to, policies or procedures pertaining to benefit entitlement and coverage determinations. C. Assignment. The Enrollee may not assign this EOC or any of the rights, interests, claims for money due, benefits, or obligations here under without prior written consent. D. Confidentiality. KFHPWA is required by federal and state law to maintain the privacy of Enrollee personal and health information. KFHPWA is required to provide notice of how KFHPWA may use and disclose personal and health information held by KFHPWA. The Notice of Privacy Practices is distributed to Enrollees and is available in Kaiser Permanente medical centers, at www.kp.org/wa, or upon request from Member Services. E. Modification of the Evidence of Coverage. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of the EOC, convey or void any coverage, increase or reduce any benefits under the EOC or be used in the prosecution or defense of a claim under the EOC. F. Nondiscrimination. KFHPWA does not discriminate on the basis of physical or mental disabilities in its employment practices and services. KFHPWA will not refuse to enroll or terminate an Enrollee’s coverage and will not deny care on the basis of age, sex, sexual orientation, gender identity, race, color, religion, national origin, citizenship or immigration status, veteran or military status, occupation or health status. G. Preauthorization. Refer to Section IV. or call Member Services for more information regarding which services, equipment and facility types KFHPWA require Preauthorization. Failure to obtain Preauthorization when required may result in denial of coverage for those services; and the Enrollee may be responsible for the cost of these non-Covered services. Enrollees may contact Member Services to request Preauthorization. Preauthorization requests, including prescription requests are reviewed and approved based on Medical Necessity, eligibility and benefits. KFHPWA will generally process Preauthorization requests and provide notification for benefits within the following timeframes: • For electronic standard requests – within three calendar days, excluding holidays. PEBB HMOHSA 2024 9
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