You can request a claim form from Member Services or download it from kp.org. When you submit the claim, please include a copy of your medical records from the Non-Participating Provider or Non- Participating Facility if you have them. Kaiser accepts CMS 1500 claim forms for professional Services and UB-04 forms for hospital claims. Even if the provider bills Kaiser directly, you still need to submit the claim form. You must submit a claim for a Service within 12 months after receiving that Service. If it is not reasonably possible to submit a claim within 12 months, then you must submit a claim as soon as reasonably possible, but in no case more than 15 months after receiving the Service, except in the absence of legal capacity. We will reach a decision on the claim and pay those covered Charges within 30 calendar days from receipt unless additional information, not related to coordination of benefits, is required to make a decision. If the 30-day period must be extended, you will be notified in writing with an explanation about why. This written notice will explain how long the time period may be extended depending on the requirements of applicable state and federal laws, including ERISA. You will receive written notification about the claim determination. This notification will provide an explanation for any unpaid amounts. It will also tell you how to appeal the determination if you are not satisfied with the outcome, along with other important disclosures required by state and federal laws. If you have questions or concerns about a bill from Kaiser, you may contact Member Services for an explanation. If you believe the Charges are not appropriate, Member Services will advise you on how to proceed. EMERGENCY, POST-STABILIZATION, AND URGENT CARE Emergency Services If a Member has an Emergency Medical Condition, call 911 (where available) or go to the nearest hospital emergency department, Independent Freestanding Emergency Department, or Behavioral Health Emergency Services Provider. A Member does not need prior authorization for Emergency Services. When a Member has an Emergency Medical Condition, we cover Emergency Services they receive from Participating Providers, Participating Facilities, Non-Participating Providers, and Non-Participating Facilities anywhere in the world, as long as the Services would have been covered under the “Benefit Details” section (subject to the “Benefit Exclusions and Limitations” section) if the Member had received them from Participating Providers or Participating Facilities. You pay the emergency department visit Cost Share shown in the “Benefit Summary” under “Emergency Services” for all Services received in the emergency department or from the Behavioral Health Emergency Services Provider. If you receive covered inpatient hospital Services, you pay the Cost Share shown in the “Benefit Summary” under “Inpatient Hospital Services,” regardless of whether the Services also constitute Emergency Services or Post-Stabilization Care. If you visit an emergency department and are not admitted directly as an inpatient or to Kaiser Permanente at Home™, you pay the emergency department visit Cost Share shown in the “Benefit Summary” under “Outpatient Services” for all Services received in the emergency department or from the Behavioral Health Emergency Services Provider. If you have an Emergency Medical Condition, we cover licensed ambulance Services when:  Your condition requires use of the medical Services that only a licensed ambulance can provide.  Use of all other means of transportation, whether or not available, would endanger your health.  The ambulance transports you to a hospital where you receive covered Emergency Services. EWCLGHDHP1983ACT0124 36 WAPEBB-CD-ACT