 External review is permitted to occur simultaneously with your urgent pre-Service appeal or urgent concurrent care appeal;  Your request qualifies for expedited external review;  We have failed to comply with federal requirements regarding our claims and appeals procedures; or  We have failed to comply with the Washington requirement to make a decision regarding the appeal within 30 calendar days for non-urgent appeals and 72 hours for urgent appeals. Within 180 calendar days after the date of our appeal denial letter you must call Member Services or send your request for external review to Member Relations in writing (via mail, fax, or online through our website at kp.org). If you wish to mail or fax your request, you may send it 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 Member Relations will forward your request to the IRO no later than the third business day after the date they receive your request for review. They will include written information received in support of the appeal along with medical records and other documents relevant in making the determination. Within one day of selecting the IRO, we will notify the appellant of the name of the IRO and its contact information. You will have five business days to submit to the IRO, in writing, additional information that the IRO must consider when conducting the external review. The IRO will forward to us any additional information you submit within one business day of receipt. Your request for external review will be expedited if the your request concerns an admission, availability of care, continued stay, or health care Service for which you received Emergency Services but have not been discharged from a facility, or ordinary time period for external review would seriously jeopardize your life or health, the life or health of a fetus, or your ability to regain maximum function. If an adverse benefit determination involves our decision to modify, reduce, or terminate an otherwise covered Service that you are receiving at the time the request for review is submitted and our decision is based upon a finding that the Service or level of care is no longer Medically Necessary, we will continue to provide the Service if requested by you until a determination is made by the IRO. If the IRO affirms our adverse benefit determination, you may be responsible for the cost of the continued Service. You are not responsible for the costs of the external review, and you may name someone else to file the request for external review for you if you give permission in writing and include that with your request for external review. Kaiser will be bound by and act in accordance with the decision of the IRO notwithstanding the definition of Medically Necessary care. If we do not follow a decision of an IRO, you have the right to sue us. Experimental or Investigational Determination and Appeal Decisions on appeals about experimental or investigational Services will be communicated in writing within 20 days of receipt of a fully documented request, unless you consent in writing to an extension of time. Appeals that meet the criteria for an urgent appeal, as described in the “Urgent Pre-Service Appeal” section, will be expedited to meet the clinical urgency of the situation, not to exceed 72 hours. If, on appeal, the decision to deny Services is upheld, the final decision will specify (i) the title, specialty, and professional qualifications of the individual(s) who made the final decision and (ii) the basis for the final decision. EWCLGDED1983ACT0124 92 WAPEBB-CL-ACT