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Kaiser Permanente Claims, complaints, grievances, and appeals, addresses - Processes for Oregon medical plans Requesting medical services and benefits
Post-service claims for services you have already received
If you have a medical bill from a non-Kaiser Permanente (non- plan) provider or facility, Claims Administration will handle your claim. If you have questions about a specific claim, or if you need help with the claim procedures, Membership Services can help.
Sometimes your Kaiser Permanente health care provider will refer you to a non-Kaiser Permanente health care provider "non- plan provider." If so, the non-Plan provider will send the bill directly to us. You won't need to file a claim.
If you didn't have an authorized referral, however, you will need to file a claim. This claim will ask Kaiser Permanente to cover the services you received from the non-Plan provider. To file a claim you should:
* Complete a Non-Plan Care Information form.
Membership Services can give you the Non-Plan Care Information form. Or you can download a copy from our Web site. To download a form, go to kaiserpermanente.org and select the appropriate link.
Fill out the form completely. Send it, with your itemized bill, to:
Claims Administration Kaiser Permanente 500 NE Multnomah St., Suite 100 Portland, OR 97232
Page 1 *If you have your medical records from the non-Kaiser Permanente provider, please send a copy with your claim form. If you don't send a copy and we need the records to decide your claim, we'll let you know. Your claim will be delayed while we wait for it.
*Your non-Kaiser Permanente provider may want to bill us directly. If so, your provider can send us the CMS 1500 claim form for professional services and the UB-92 form for hospital claims. You will still need to fill out the Non-Plan Care Information form and send it to us even if your provider bills us directly.
*You must submit a claim within 90 days after you've received care, or as soon as reasonably possible. *We will not review your claim if we haven't received your completed Non-Plan Care Information form within 12 months from the date you saw the non-Plan provider. The only exception is if you don't have the legal capacity to file the claim within 12 months.
We will make a decision on your claim and pay the covered charges within 30 calendar days. However, if we need more information to make the decision, it may take longer. If we have to extend the 30-day period, we'll let you know in writing and explain why. The written notice will tell you how long the time period will be extended. The length of the extension will follow applicable state and federal laws. These include the Employee Retirement Income Security Act of 1974 (ERISA). There is more information about ERISA on the next page. We will tell you about our decision on your claim in writing. In the notice we will explain any unpaid amounts. We will also tell you how to appeal if you are not satisfied with our decision.
The notice will also provide you with other information about the claim that is required by state and federal laws.
Bills for services you've already received
If you have any questions or concerns about a bill from Kaiser Permanente, contact Membership Services. If you think the charges are not appropriate, Membership Services will tell you what you can do next.
If you think the charges are not appropriate because of concerns you have about services or benefits, you can file a written grievance. If you think the charges are wrong, such as a bill for services you didn't receive, or that you already paid, Membership Services can help you.
If our records show that the charges are correct, we will give you an explanation. At the same time, we will let you know how to file a grievance if you are still not satisfied.
Pre-service claims, requests for services you want
We provide treatment and services based on medical necessity and appropriateness. If you need care, or if you think you need a specific treatment or service, talk to your Kaiser Permanente health care provider. Your health care provider will discuss your needs with you; recommend a course of treatment; and determine if a particular kind of treatment or services is medically appropriate. Some treatments and services need to go through a review process. This medical necessity review is based on criteria set by our medical group or another group of doctors, and is part of our utilization management program.
*Your health care provider may decide that a treatment, service, or equipment is not medically appropriate or necessary. If you disagree, you can ask for a second opinion from another Kaiser Permanente health care provider. Just ask the manager or the staff member making appointments in the medical office where you receive care.
Membership Services can help you find the correct manager. The manager will listen to your issues and discuss your request with your health care provider. If you need a second opinion, the manager will see that you get one.
If your health care provider still believes that the treatment, service, or medical item you want is not medically necessary, we will let you know. We will send you a denial letter within 14 days after you've talked to the manager. The letter will tell you why your health care provider made the decision. It will also tell you how to file a first-level appeal. *The treatment, service, or item your health care provider wants you to have might need the medical necessity review described earlier. If your health care provider believes a treatment, service, or item is medically necessary, he or she will ask for the review. We will let you know if the request is denied. We will send you a denial letter within two business days after your health care provider's request. The letter will tell you the reason we denied the request. It will also tell you how to file a first-level appeal.
Page 2 *Your medical plan might exclude or limit your coverage for treatment, service, or medical item. If you have questions about this, contact Membership Services. If you are not satisfied after you talk with Membership Services, you can ask for a written "pre-service benefit determination." We will prepare one and send it to you within 14 days of your request. If you are still not satisfied, you may file a written grievance.
We may need more information to make a decision on your pre-service request. If you are covered under an ERISA benefit plan, we will ask you in writing for this information. Our request to you will say how long you have to provide that information. It may take us more than two business days to make a decision if we have to ask you for more information.
(Please see the "Complaints, Grievances, and Appeals" section for important information about ERISA.)
Expedited procedures- If you urgently need the treatment, service, or medical item, we can review your request more quickly. Your request is considered urgent if the regular time to make a decision could seriously risk your life, health, or ability to regain maximum function.
It is also considered urgent if a health care provider who is familiar with your medical condition believes the delay would cause you severe pain that can't be adequately managed without the care or treatment requested.
In urgent situations, we will respond to you as fast as your condition requires. But in no case will our decision take more than 24 to 72 hours, depending on the state and federal laws that apply. We will respond within 24 hours to certain requests to continue previously approved treatment that includes urgent care, such as inpatient services or skilled nursing facility services.
Important information for members whose benefit plans are subject to ERISA
The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that regulates employee benefits. Among the benefits regulated by ERISA are claim and appeal procedures for benefit plans offered by certain employers. If you are not sure whether these ERISA laws apply to your benefit plan, please ask your employer.
If your employer's benefit plan is subject to ERISA:
*When you ask for care or service that must be approved before the care or service is given, you are filing a "pre-service claim" for benefits.
*When you ask to pay for services that you have already received, you are filing a "post- service claim."
*You must follow our procedures for filing claims.
*We must respond to your claim following certain rules set by ERISA.
*If you are not satisfied with our decision on your pre-service claim or post-service claim, you only have to file one appeal before you can take legal action to resolve your claim. This is a right you have under ERISA's Section 502(a). *Appeals are reviewed by an appropriate, named fiduciary *Additional levels of voluntary appeal may be available within Kaiser Permanente.
*We do not charge for any part of the appeal process.
Complaints, grievances, and appeals
Member satisfaction Everyone associated with Kaiser Permanente wants you to have the best care and service possible. Please call Membership Services at the numbers listed on page 6 of this flyer if you need help with the following: *Questions about your coverage. *Using our services. *Finding the right medical care resource.
If you have a compliment or suggestion, please call or send a letter to the administrator of the facility where you received care. The administrator will share your comments with the medical care team members who helped you and with their supervisors.
If you have any issues about your care, please talk with your health care provider or another member of your health care team. If you are not satisfied with your health care provider, you can ask for another. Membership Services can help. You always have the right to a second opinion within Kaiser Permanente.
Most issues can be resolved within your health care team. If you feel that you need extra help with an issue, we have complaint and grievances procedures for you. We will handle all complaints and grievances in confidence.
Page 3 Members who are covered by a Washington plan, the federal Employee Health Benefits Program, Medicare, or the Oregon Health Plan have different grievance and appeal procedures. Please ask Membership Services for a copy of the procedures that apply to your plan.
Oral complaints You can file an oral complaint if you are not satisfied with the availability, delivery, or quality of our services; benefits; or other administrative issues. Here are a few examples of things that a member might file a complaint about:
*Delays in getting an appointment.
*How our staff communicates with you.
*Policies and procedures you don't like.
(If you have a concern about care we've denied, you need to file an appeal instead of a complaint. Follow the procedures in the section titled "Appeals." You would file a grievance if we have denied your claim for medical services you have already received. Follow the procedure described in the section titled "Grievances.")
To file a complaint, contact the administrative office in the facility where you had the problem. You can also ask Membership Services for help. Discuss your complaint fully with the staff. Be specific about how you want the matter resolved.
Written complaints You may file a written complaint if you are not satisfied with how we responded to your oral complaint about:
*The availability of our services.
*The delivery of our services.
*The quality of our services.
* Other administrative matters.
For example, you might have a complaint about delays in getting care, or about not hearing back from your health care provider's office. Send your written complaint to Member Relations at the address listed on page 6.
Grievances A grievance is a written complaint requesting a specific action. Usually the action would involve the way we billed you for services you received, eligibility problems, or benefit interpretations. You can submit a grievance, or someone else can submit a grievance for you.
You can file a written grievance:
*If you disagree with charges on a bill from Kaiser Permanente. (This is considered an initial claim for benefits under ERISA.)
*If you disagree with a decision we made to deny your claim for services you received from a non-Kaiser Permanente provider or facility. You must file the grievance within 185 days of the date on the denial notice from the Claims Administration Department. (This is a post- service appeal under ERISA.) *If you received a written denial of coverage for benefits or services because of the reasons listed below:
*You are not eligible for benefits.
*Your plan excludes certain procedures.
*Your plan does not include special benefits such as prescription drugs or vision hardware.
You have reached the maximum amount of a particular benefit. You must file the grievance within 185 days of the denial notice. (These are pre-service appeals under ERISA.)
You should follow the directions under "Appeals" if we denied coverage in writing for services or items you or your health care provider requested, and we denied coverage because of one or both of these reasons:
*The services or item were not medically necessary.
*The services or item did not meet medical criteria for coverage.
Grievance procedures. To file a written grievance, write down your concerns. Be specific about what you want us to do. You may submit any written comments, documents, records, and other information related to your grievance. If you need help filing a written grievance, contact Membership Services, (see page 6).
Send your grievance to Member Relations at the address listed on page 6. We will let you know that we received your grievance within seven working days. We will forward your grievance to the correct manager or department for a resolution. We will conduct an independent review, and will let you know of our decision in writing.
Page 4 We will give you a decision within 30 days, except:
*If your grievance is an initial pre-service claim under ERISA and we need more information to make a decision, we will ask you in writing for it. You will then have 50 days to give us the information. We will make a decision within 15 days after you've given us the information we need. If you don't give us the information, we will make a decision within 15 days after the end of the 50-day period.
*We will respond to all grievances according to how urgent the situation is. But if your grievance is about care you need urgently that we have denied, we will respond to the grievance within 72 hours (see "Expedited Procedures" described earlier.)
If we deny a specific request you've made in a grievance, we will let you know in writing. Our notice to you will include the reasons for the decision. We'll tell you how to appeal the decision. We also will tell you how you can file a complaint with the Oregon Department of Consumer and Business Services.
(For members who have a plan that is covered by ERISA, additional appeals are considered voluntary unless your grievance was classified as an initial claim.)
Appeals If you disagree with the decision made on your grievance, follow these appeal steps. Or follow these steps if we have denied care that you want or your health care provider wants you to have.
We've developed these procedures according to state and federal laws. We will let you know we have received your appeal within seven days.
If your plan is covered under ERISA, you only have to file one appeal before you can take legal action.
If your plan is not covered under ERISA, you have two levels of appeal if:
*We have denied your grievance. *We have denied you care or service because it was not considered medically necessary, or did not meet medical criteria.
These appeals are called "first-level" and "second-level" appeals.
First-level appeals
If you are covered under an ERISA plan, this level of appeal is voluntary if you filed a grievance that was denied. You can voluntarily follow the procedure outlined below. Exception: If your grievance was about a bill from Kaiser Permanente, this is the one required level of appeal under ERISA.
For other members not covered under an ERISA plan, you must follow this appeal procedure if you want to have a denial reviewed. *You have 185 days from the time of the denial notice to submit a first-level appeal if you disagree with our decision: *to deny your grievance, or *to deny care that you or your health care provider requested, as explained in the denial letter you received.
You may ask for an expedited appeal if it is about urgently needed care (see "Expedited Procedures" explained earlier). You may ask orally or in writing. To submit an appeal, follow the instructions that we will include in the denial notice we send you. Send your appeal to Member Relations at the address listed on page 6. You may include any other information you have about your claim. This could include written comments, documents, records, or other information.
*We will decide your first-level appeal within 30 days after we receive it.
*If you've asked for an expedited appeal, how quickly we respond depends on how urgent the situation is. But it will not take more than 72 hours if we agree it is urgent.
*Member Relations will independently review your appeal and include other staff or physicians in the review as needed. They will tell you in writing of their decision. If your appeal is denied, the written notice will explain the reasons for the decision. It will also tell you how to file a complaint with the Oregon Department of Consumer and Business Services, and give you other information that state and federal laws require.
Second-level appeals
If you don't agree with the decision about your first-level appeal, you may submit a second-level appeal. *You must file your second-level appeal in writing to Member Relations. *You must file your second-level appeal within 60 days after the date on the letter denying your first-level appeal. *You may include any other information relating to your claim that may be helpful. This could include written comments, documents, records, or more.
Page 5 You have the right to speak directly to the review panel. *You may speak to the review panel in person or by telephone. *You must tell us in your written second-level appeal if you plan to speak directly to the review panel. *You also must tell us in your written second-level appeal the name of anyone who will attend with you, and his or her relationship to you.
We will decide your second-level appeal within 30 days after we receive it. *We will expedite a decision if your appeal is about care you urgently need that we have denied (see "Expedited Procedures" described earlier). *How quickly we expedite your appeal depends on the medical urgency of your situation. It will never be more than 72 hours.
If we deny your second-level appeal, we will notify you in writing. *The notice we send you will explain the reasons for the decisions.
*The notice will tell you how to ask for an additional external review by an independent review organization (IRO) and whether your appeal meets criteria for an IRO review. *It will also tell you how to file a complaint with the Oregon Department of Consumer and Business Services. External review by an IRO For certain kinds of requests, Oregon law gives you rights to an external review by an IRO. You can have such a review for these requests if we have denied both your first-level and second-level appeals.
If your plan is covered under ERISA, an external review is considered another voluntary level of appeal. It is only available after you have used all your other voluntary appeals.
You have the right to a review by an IRO if:
*Your second-level appeal is denied, and *Our reason involved one or more of these decisions: *Whether the course or plan of treatment is experimental, investigational, or medically necessary. *Whether the course or plan of treatment is necessary to continue care when a health care provider's contract with us has been terminated.
You must ask for an external review by an IRO in writing. *Send your request within 185 days after the date on our final letter telling you of our denial. *Send your letter to Member Relations at the address listed on page 6. Within two days after Member Relations receives your letter, they will forward it to the director of the Oregon Department of Consumer and Business Services (DCBS). The Oregon DCBS will assign an IRO the next business day after the director receives your request from us.
*The DCBS will give the IRO any authorization it needs to complete your review. *The DCBS will let you know in writing about the IRO it has assigned. It will also tell you more information about the review process.
* The DCBS will let us know about the IRO.
We will forward to the IRO any documents and other information we used to make the decision you've challenged. If we don't have an appropriate authorization to disclose your protected health information, we must get written authorization (or permission) from you. This information could include medical records that are needed for the review.
You can have an expedited review if the regular time to make a decision would cause a delay that could seriously risk your life, health, or ability to regain maximum function. Your request also will be considered urgent if a health care provider who is familiar with your medical condition believes the delay would cause you severe pain that can't be adequately managed without the care or treatment requested.
You don't have to pay for the external review.
Page 6 You can ask someone else to request the IRO review. If you do, you must give your permission in writing. You must include your signed permission when you send us the written request for external review. You must sign the written request for external review even if someone else prepares it for you.
We will implement the decision of the IRO.
Help from the Oregon Insurance Division You have the right to ask for help from the Consumer Protection Unit of the Oregon Insurance Division. You may also file a complaint with them. To contact them, use the information below.
Mailing address:
DCBS Insurance Division Consumer Protection Unit Room 440-2 350 Winter St. NE Salem, OR 97301-3883
503-947-7984 or 1-800-877-4894 www.cbs.state.or.us/external/ins/ E-mail: DCBS.INSMAIL@state.or.us
Added Choice® members In-network questions--If you have questions about in-network care from Kaiser Permanente, in- network benefits, or emergency claims, follow the procedures in this flyer.
Out-of-network questions--If you have questions about out-of-network care or benefits, or nonemergency claims, contact Membership Services. They can tell you whom you should contact. Membership Services If you have questions or need help, call Membership Services. We're available by telephone 8 a.m. to 6 p.m., Monday through Friday.
Portland area.......... 503-813-2000 All other areas ..... 1-800-813-2000
Member Relations Send written complaints, grievances, and appeals to:
Member Relations Kaiser Permanente 500 NE Multnomah St., Suite 100 Portland, OR 97232
Hours: Monday through Friday, 8 a.m. to 5 p.m.
Portland area.......... 503-813-4480 All other areas ..... 1-800-813-2000 FAX......................... 503-813-3985
TTY All areas............... 1-800-735-2900
Language interpretation services All areas 1-800-324-8010 Contact your medical facility administrator To contact the administrator of a specific facility, call the number listed for that medical facility. Press "0" when you are given the list of options and ask to speak to the administrator about your concerns. You may also call Membership Services (see page 6) or Member Relations (see this page). Medical office administration
Beaverton Medical Office 503-643-7565
Cascade Park Medical Office 360-418-6001
Clackamas Eye Care 503-653-1442
Division Medical Office 503-777-3311
Eastman Parkway Office 503-571-0725
Fisher's Landing Medical Office 360-418-6001
Interstate Medical Office Central 503-285-9321
Interstate Medical Office East 503-285-9321
Interstate Medical Office South 503-285-9321 Interstate Medical Office West 503-285-9321
Lake Road Nephrology Center 503-786-1167
Longview-Kelso Medical Office 360-636-2400
Mill Plain One Medical Office 360-418-6001
Mother Joseph Plaza 503-203-2040
Page 7 Mt. Scott Medical Office 503-652-2880
Mt. Talbert Medical Office 503-652-2880
North Lancaster Medical Office 503-361-5400
One Town Center 503-513-4400
Rockwood Medical Office 503-669-3900
Salmon Creek Medical Office 360-418-6001
Skyline Medical Office 503-361-5400
Sunnyside Medical Office 503-652-2880
Sunset Medical Office 503-645-2762
Tualatin Medical Office 503-885-7300
Vancouver Medical Office 360-418-6001
Hospital administration
Kaiser Sunnyside Medical Center 503-652-2880
OHSU's Doernbecher Children's Hospital 503-494-8311
Providence St. Vincent Medical Center 503-216-1234
St. John Medical Center 360-636-4894
Salem Hospital 503-561-5765
Southwest Washington Medical Center 360-514-2286 Portland area 503-972-3000 ext. 2286
Dental facility administration Aloha Dental Office 503-259-3160
Beaverton Dental Office 503-626-4148
Cascade Park Dental Office 360-896-4484
Clackamas Dental Office 503-353-3900
Eastmoreland Dental Office 503-238-4418
Glisan Dental Office 503-257-5959
Grand Avenue Dental Office 503-280-2877
Longview-Kelso Dental Office 360-575-4801
North Interstate Dental Office urgent care, prosthetics, and TMD treatment 503-286-6860
North Lancaster Dental Office 503-370-4843
Rockwood Dental Office 503-661-5210
Salmon Creek Dental Office 360-571-3139
Skyline Dental Office 503-588-6560
Sunset Dental Office 503-690-5009
Tigard Dental Office 503-684-9274
Dental administration Kaiser Permanente Building 503-813-4900
Member Relations 503-813-4480 1-800-813-2000 and ask for Member Relations
KAISER SUGGESTED FORMAT FOR SUBMITTING GRIEVANCE OR APPEALS
Kaiser Permanente Northwest Member Relations Grievance & Appeal FormPlease print. Subscriber's name___________________________________________________
Patient's name______________________________Health Record No.__________
Is this a medical issue _ Dental issue _ Oilier issue _ ( please check)
What is your specific request?___________________________________________ __________________________________________________________________
Has this been reviewed by another Kaiser Permanente department? No _ Yes _
If you answered yes, who reviewed it?____________________________________
If you are requesting payment/reimbursement, what is the approximate amount? $___________
Please describe your concern: (Include names of persons you have talked with. names of providers. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
Signature__________________________________Today's date:______________________
Return completed form to:
Member Relations 500 NE Multnomah. Suite 100 Portland, OR 97232
Please use reverse if you need additional space.
KPB Word Processing MS-05-2A (1/26/98)