Non-Urgent Pre-Service Appeal • Within 180 calendar days after you receive our adverse benefit determination notice, you must tell us in writing or orally that you want to appeal our denial of your pre-Service claim. Please include the following: (1) Your name and health record number; (2) Your medical condition or relevant symptoms; (3) The specific Service that you are requesting; (4) All of the reasons why you disagree with our adverse benefit determination; and (5) All supporting documents. Your request and the supporting documents constitute your appeal. You must mail, call, or fax your appeal to us at: Kaiser Foundation Health Plan of the Northwest Member Relations Department 500 NE Multnomah St., Suite 100 Portland, OR 97232-2099 Fax: 1-855-347-7239 • We will acknowledge your appeal in writing within 72 hours after we receive it. • We will fully and fairly review all available information relevant to your appeal without deferring to prior decisions. • We will review your appeal and send you a written decision within 14 calendar days after we receive your appeal, unless you are notified that additional time is needed to complete the review. The extension will not delay the decision beyond 30 calendar days without your consent. • If we deny your appeal, our adverse benefit determination notice will tell you why we denied your appeal and will include information regarding any further process, including external review, which may be available to you. Urgent Pre-Service Appeal • Tell us that you want to urgently appeal our adverse benefit determination regarding your pre-Service claim. Please include the following: (1) Your name and health record number; (2) Your medical condition or relevant symptoms; (3) The specific Service that you are requesting; (4) All of the reasons why you disagree with our adverse benefit determination; and (5) All supporting documents. EWCLGHDHP1983ACT0124 88 WAPEBB-CD-ACT