Post-Service Appeal • Within 180 calendar days after you receive our adverse benefit determination, tell us in writing or orally that you want to appeal our denial of your post-Service claim. Please include the following: (1) Your name and health record number; (2) Your medical condition or relevant symptoms; (3) The specific Services that you want us to pay for; (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 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 • 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. We may extend the time for making a decision on your appeal for up to an additional 16 calendar days if there is good cause. • If we deny your appeal, our adverse benefit determination will tell you why we denied your appeal and will include information regarding any further process, including external review, that may be available to you. External Review If you are dissatisfied with our final adverse benefit determination, you have a right to request an external review. An external review is a request for an independent review organization (IRO) to determine whether our internal appeal decision is correct. For example, you have the right to request external review of an adverse decision that is based on any of the following:  Relies on medical judgment, including but not limited to, medical necessity, appropriateness, health care setting, level of care, or that the requested Service is not efficacious or otherwise unjustified under evidence-based medical criteria.  Concludes that a treatment is experimental or investigational.  Concludes that parity exists in the non-quantitative treatment limitations applied to behavioral health care (mental health and/or Substance Use Disorder) benefits.  Involves consideration of whether we are complying with federal law requirements regarding balance (surprise) billing and/or cost sharing protections pursuant to the No Surprises Act (Public Health Service Act sections 2799A-1 and 2799A-2 and 45 C.F.R. §§149.110 --149.130).  Involves a decision related to rescission of your coverage. You must exhaust our internal claims and appeals procedure for your claim before you may request external review unless one of the following is true: EWCLGDED1983ACT0124 91 WAPEBB-CL-ACT