Non-urgent Pre-Service Claim • You may request a pre-service benefit determination on your own behalf. Tell us in writing or orally that you want to make a claim for us to provide or pay for a Service you have not yet received. Your request and any related documents you give us constitute your claim. You may email your request to us at https://healthy.kaiserpermanente.org/oregon-washington/support, call us, or mail your claim to us at: Kaiser Foundation Health Plan of the Northwest Attn: Utilization Management500 N.E. Multnomah St., Suite 100 Portland, OR 97232-2099 Fax: 1-877-899-4972 If you want us to consider your pre-service claim on an urgent basis, your request should tell us that. We will decide whether your claim is urgent or non-urgent. If we determine that your claim is not urgent, we will treat your claim as non-urgent. Generally, a claim is urgent only if using the procedure for non-urgent claims (a) could seriously jeopardize your life or health, the life or health of a fetus, or your ability to regain maximum function; (b) would, in the opinion of a physician with knowledge of your medical condition, subject you to severe pain that cannot be adequately managed without the Services you are requesting; or (c) your attending provider requests that your claim be treated as urgent; or (d) involves a request concerning admissions, continued stay, or other health care Services if you have received Emergency Services but have not been discharged from a facility. • We will review your claim and, if we have all the information we need, we will make a decision within three calendar days if your request was received electronically and within five calendar days if your request was received orally or in writing. If more information is needed to make a decision, we will ask you for the information within one calendar day after we receive your claim, and we will give you 45 calendar days to send the information. We will make a decision and send notification within 15 calendar days after we receive the first piece of information (including documents) we requested or by the deadline for receiving the information, whichever is sooner. • We encourage you to send all the requested information at one time, so that we will be able to consider it all when we make our decision. • We will send written notice of our decision to you, and if applicable, to your provider. Urgent Pre-service Claim • If your pre-service claim was considered on an urgent basis, we will make a decision within one calendar day if your request was received electronically and within two calendar days if your request was received orally or in writing. • If more information is needed to make a decision, we will ask you for the information within one calendar day after we receive your claim, and we will give you seven calendar days to send the information. We will notify you of our decision within 48 hours of receiving the first piece of requested information or by the deadline for receiving the information, whichever is sooner. If we notify you of our decision orally, we will send you, and, if applicable, your provider, written confirmation within three calendar days after the oral notification. • If we deny your claim (if we do not agree to provide or pay for all the Services you requested), our adverse benefit determination notice will tell you why we denied your claim and how you can appeal. EWCLGHDHP1983ACT0124 87 WAPEBB-CD-ACT