GRIEVANCES, CLAIMS, APPEALS, AND EXTERNAL REVIEW Terms We Use in this Section The following terms have the following meanings when used in this “Grievances, Claims, Appeals, and External Review” section:  A claim is a request for us to: • Provide or pay for a Service that you have not received (pre-Service claim); • Continue to provide or pay for a Service that you are currently receiving (concurrent care claim); or • Pay for a Service that you have already received (post-Service claim).  An adverse benefit determination includes: • Any decision by our Utilization Review organization that a request for a benefit under our Plan does not meet our requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness or is determined to be experimental or investigational and the requested benefit is therefore denied, reduced, or terminated or payment is not provided or made, in whole or in part for the benefit; • The denial, reduction, termination, or failure to provide or make payment, in whole or in part, for a benefit based on a determination by us or our designated Utilization Review organization regarding a covered person’s eligibility to participate in our health benefit Plan; or • Any prospective review or retrospective review determination that denies, reduces, or terminates or fails to provide or make payment in whole or in part for a benefit.  An internal appeal is a request for us to review our initial adverse benefit determination. Grievance Procedure We want you to be satisfied with the Services you receive from Kaiser Permanente. We encourage you to discuss any questions or concerns about your care with your Provider or another member of your health care team. If you are not satisfied with your Provider, you may request another. Contact Member Services for assistance. You always have the right to a second opinion from a qualified Provider at the applicable Cost Share. A grievance is a written complaint submitted by or on behalf of a covered person regarding Service delivery issues other than denial of payment for medical Services or nonprovision of Services, including dissatisfaction with medical care, waiting time for Services, provider or staff attitude or demeanor, or dissatisfaction with Service provided by the health carrier. If you are not satisfied with the Services received at a particular medical office, or if you have a concern about the personnel or some other matter relating to Services and wish to file a complaint, you may do so by following one of the procedures listed below:  Call Member Services; or  Send your written complaint to Member Relations at: Kaiser Foundation Health Plan of the Northwest Member Relations Department 500 NE Multnomah St., Suite 100 Portland, OR 97232-2099 Fax: 1-855-347-7239 All complaints are handled in a confidential manner. EWCLGDED1983ACT0124 83 WAPEBB-CL-ACT