Concurrent Care Claim • Tell us that you want to make a concurrent care claim for an ongoing course of covered treatment. Inform us in detail of the reasons that your authorized ongoing care should be continued or extended. Your request and any related documents you give us constitute your claim. You must call Member Services, mail, or fax 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 • We will notify you of our decision orally or in writing as soon as your clinical condition requires, but no later than 24 hours after we receive your claim. • 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 extending the ongoing course of treatment), our adverse benefit determination notice will tell you why we denied your claim and how you can appeal. Concurrent Care 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 adverse benefit determination. Please include the following: (1) Your name and health record number; (2) Your medical condition or relevant symptoms; (3) The ongoing course of covered treatment that you want to continue or extend; (4) All of the reasons why you disagree with our adverse benefit determination; and (5) All supporting documents. Your request and all supporting documents constitute your appeal. You must call Member Services, mail, or fax your appeal to us at: Kaiser Foundation Health Plan of the Northwest Member Relations Department 500 N.E. Multnomah St., Suite 100 Portland, OR 97232-2099 Fax: 1-855-347-7239 • When you send your appeal, you may also request simultaneous external review of our adverse benefit determination. If you want simultaneous external review, your appeal must tell us this. If you do not request simultaneous external review in your appeal, then you may be able to request external review after we make our decision regarding your appeal (see “External Review” in this “Grievances, Claims, Appeals, and External Review” section). • We will fully and fairly review all available information relevant to your appeal without deferring to prior decisions. • We will review your appeal and notify you of our decision orally or in writing as soon as your clinical condition requires, but no later than 72 hours after we receive your appeal. If we notify you of our decision orally, we will send you a written confirmation within 72 hours after that the decision is made. EWCLGDED1983ACT0124 89 WAPEBB-CL-ACT