• If we deny your appeal, our adverse benefit determination decision will tell you why we denied your appeal and will include information about any further process, including external review, which may be available to you. Post-Service Claims and Appeals Post-Service claims are requests that we pay for Services you already received, including claims for out-of- Plan Emergency Services. If you have any general questions about post-Service claims or appeals, please call Member Services. Here are the procedures for filing a post-Service claim and a post-Service appeal: Post-Service Claim • Within 12 months from the date you received the Services, mail us a letter explaining the Services for which you are requesting payment. Provide us with the following: (1) The date you received the Services; (2) Where you received them; (3) Who provided them; (4) Why you think we should pay for the Services; and (5) Copy of the bill and any supporting documents, including medical records. Your letter and the related documents constitute your claim. You may contact Member Services to obtain a claim form. You must mail your claim to the Claims Department at: Kaiser Foundation Health Plan of the Northwest National Claims Administration - Northwest P.O. Box 370050 Denver, CO 80237-9998 • We will not accept or pay for claims received from you after 12 months from the date of Service, except for the absence of legal capacity. • We will review your claim, and if we have all the information we need, we will send you a written decision within 30 calendar days after we receive your claim. We may extend the time for making a decision for an additional 15 calendar days if circumstances beyond our control delay our decision, if we notify you within 30 calendar days after we receive your claim. If more information is needed to make a decision, we will ask you for the information before the initial decision period ends, and we will give you 45 calendar days to send us the information. We will make a decision within 15 calendar days after we receive the first piece of information (including documents) we requested. 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. If we do not receive any of the requested information (including documents) within 45 calendar days after we send our request, we will make a decision based on the information we have within 15 calendar days following the end of the 45 calendar day period. • If we deny your claim (if we do not 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. EWCLGDED1983ACT0124 90 WAPEBB-CL-ACT