Step 2: If the Enrollee is still not satisfied, they should write to Member Services at P.O. Box 34590, Seattle, WA 98124-1590, or call at 206-630-0107 or toll-free 1-866-648-1928. Most concerns are handled by phone within a few days. In some cases, the Enrollee will be asked to write down their concerns and state what they think would be a fair resolution to the problem. An appropriate representative will investigate the Enrollee’s concern by consulting with involved staff and their supervisors, and reviewing pertinent records, relevant plan policies and the Member Rights and Responsibilities statement. This process can take up to 30 days to resolve after receipt of the Enrollee’s written statement. If the Enrollee is dissatisfied with the resolution of the complaint, they may contact Member Services. Assistance is available to Enrollees who are limited-English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to request review or participate in the review process. VIII. Appeals Enrollees are entitled to appeal through the appeals process if/when coverage for an item or service is denied due to an adverse determination made by the KFHPWA medical director. The appeals process is available for an Enrollee to seek reconsideration of an adverse benefit determination (action). Adverse benefit determination (action) means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of an Enrollee’s eligibility to participate in a plan, and including, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not Medically Necessary or appropriate. KFHPWA will comply with any new requirements as necessary under federal laws and regulations. Assistance is available to Enrollees who are limited-English speakers, who have literacy problems, or who have physical or mental disabilities that impede their ability to request review or participate in the review process. The most current information about your appeals process is available by contacting KFHPWA’s Member Appeal Department at the address or telephone number below. 1. Initial Appeal If the Enrollee or the Enrollee’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, they must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why they disagree with the decision. The appeal must be submitted within 180 days of receipt of the denial notice. KFHPWA will notify the Enrollee of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, P.O. Box 34593, Seattle, WA 98124-1593, toll-free 1-866-458-5479. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Enrollee of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Enrollee’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Enrollee in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Enrollee’s life, health or ability to regain maximum function or subject the Enrollee to severe pain that cannot be managed adequately without the requested care or treatment. The Enrollee can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 1-866-458-5479. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Enrollee will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Enrollee’s condition meets the definition of expedited, the request will be processed as expedited. PEBB HMOHSA 2024 63