requirements, the applicable Cost Share shown in the “Benefit Summary” and “Benefit Details,” and the exclusions, limitations and reductions described in this EOC. For more information about receiving care in other Kaiser Foundation Health Plan service areas, including availability of Services, and provider and facility locations, please call our Away from Home Travel Line at 951-268-3900. Information is also available online at kp.org/travel. POST SERVICE CLAIMS – SERVICES ALREADY RECEIVED In general, if you have a medical or pharmacy bill from a Non-Participating Provider, Non-Participating Facility, or non-participating pharmacy our Claims Administration Department will handle the claim. Member Services can assist you with questions about specific claims or about the claim procedures in general. If you receive Services from a Non-Participating Provider following an authorized referral from a Participating Provider, the Non-Participating Provider will send the bill to Claims Administration directly. You are not required to file a claim. If you receive Services from a Non-Participating Provider or Non-Participating Facility without an authorized referral, or from a pharmacy that is not a Participating Pharmacy, and you believe Kaiser should cover the Services, you need to send a completed medical claim form and the itemized bill to: Kaiser Permanente National Claims Administration - Northwest PO Box 370050 Denver, CO 80237-9998 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 EWCLGDED1983ACT0124 35 WAPEBB-CL-ACT