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Claims, complaints, grievances, and appeals - Washington plans in easy printable form Requesting medical services and benefits
Post-service claims - Services you already received If you have a medical bill from a non-Kaiser Permanente (non- Plan) provider or facility, Claims Administration will handle the claim. Membership Services can assist you with questions about a specific claim or about the claim procedures in general.
If you receive non-Plan services following an authorized referral from Kaiser Permanente, the non- plan provider will send the bill to Claims Administration directly. You are not required to file the claim.
If you receive services from a non- Plan provider or facility without an authorized referral, and you believe Kaiser Permanente should cover the services:
*Send a completed Non-Plan Care Information form (claim form) and the itemized bill to:
Claims Administration Kaiser Permanente 500 NE Multnomah St., Suite 100 Portland, OR 97232
*You can request a claim form from Membership Services or download it from our Web site. To download a claim form, go to kaiserpermanente.org and select the appropriate link.
*When you submit the claim, include a copy of your medical records from the non-Kaiser Permanente facility if you have them. If you don't submit the medical records and we determine they are necessary to decide your claim, we will notify you.
*The non-Kaiser Permanente provider may bill us directly. We accept the CMS 1500 claim form
Page 1 for professional services and UB- 92 form for hospital claims. You still need to send the Non-Plan Care Information form even if the provider bills us directly.
*You must submit a claim within 90 days after receiving care, or as soon as reasonably possible.
*We will not review a claim if we do not receive a complete application within 12 months from the time the completed claim form is due, unless you lack legal capacity to file the claim within 12 months.
We will reach a decision on your claim and pay the covered charges within 30 calendar days unless additional information is required to make a decision. If the 30-day period must be extended, you will be notified in writing with an explanation about why. The written notice will tell you how long the time period may be extended depending on the requirements of applicable state and federal laws, including the Employee Retirement Income Security Act of 1974 (ERISA). Refer to the next page for important information and explanations about ERISA.
You will receive written notification regarding the claim determination. This notification will provide an explanation for any unpaid amounts. It will also tell you how to appeal the determination if you are not satisfied with the outcome, along with other important disclosures required by state and federal laws.
If you. have questions or concerns about a bill from Kaiser Permanente, contact Membership Services for an explanation. If you believe the charges are not appropriate, Membership Services will advise you how to proceed. If you believe charges are not appropriate due to concerns involving our services or your benefits, you may file a grievance. If you think the charges are in error (such as a bill for services you did not receive or that you paid at the time of service), Membership Services can assist you. If it is determined the charges are accurate, you will be given an explanation along with information about how to file a grievance. Refer to "Complaints, Grievances, and Appeals" for more information on filing a grievance.
Pre-service claims-Requesting future care or service When you need care, talk with your health care provider about your medical needs or request for medical services. We provide treatment and services based on medical necessity and appropriateness. Your health care provider will use his or her judgment to determine if a treatment or service is medically appropriate. Some treatments and services are subject to approval through utilization review, based on criteria developed by the Kaiser Permanente medical group or another organization. If you think you need a specific treatment or service, talk with your Kaiser Permanente health care provider. Your health care provider will discuss your needs with you and recommend the most appropriate course of treatment. If your request for treatment, service, or equipment is urgent, we will respond to the request on the same day the request is received.
*If you request treatment, service, or equipment that your health care provider believes is not medically appropriate or necessary and you disagree, you may ask for a second opinion from another health care provider. For primary care services, you can request a different health care provider at any time. You also have the right to request a pre-service determination in writing. Contact the manager in the area where your health care provider is located. Membership Services can connect you with the correct manager, who will listen to your issues and discuss your request with your health care provider. If your health care provider continues to believe the treatment, service, or equipment you requested is not medically necessary, we will send you a denial letter within two business days of your contact with the manager. The letter will explain the reason for the determination along with instructions for filing a first-level appeal.
*If you request treatment, service, or equipment that must be approved through utilization review as described above and your health care provider believes it is medically necessary, your health care provider will submit the request for review on your behalf. If the request is denied, we will send you a letter within two business days of the doctor's request for approval. The letter will explain the reason for the determination along with instructions for filing a first-level appeal.
*If you request treatment, service, or equipment but you learn there may be coverage limitations or exclusions, and you have questions or disagree, contact Membership Services. If you are not satisfied after talking with Membership Services, you may request a pre-service benefit determination in writing. We will generate a benefit determination within two business days. If you are not satisfied after receiving the benefit determination, you may file a grievance.
Page 2 If you are covered under an ERISA benefit plan and additional information is required to make a determination on your pre-service request, you will be notified and given a specified period of time to provide the information. This may extend the decision period past two business days. Refer to "Complaints, Grievances, and Appeals" for important explanations about ERISA.
Expedited procedures are available if your request for service is considered urgent. A request is urgent if the normal decision time frames would cause a delay that would seriously jeopardize your life, health, or ability to regain maximum function. It also applies if a health care provider who is familiar with your medical condition believes the delay would subject you to severe pain that cannot be adequately managed without the care or treatment at issue. In urgent situations, we will respond to you as quickly as your condition requires, not to exceed two business days or 72 hours whichever is shorter. Certain requests to extend previously approved treatment that involves urgent care (such as continuing inpatient or skilled nursing facility services) are responded to within 24 hours of receipt.
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, including the claim and appeal procedures for benefit plans offered by certain employers. If your employer's benefit plan is subject to ERISA, each time you request care or services that must be approved before the care or service is provided, you are filing a "pre-service claim" for benefits. You are filing a "post-service claim" when you ask us to pay for or cover services that you have already received. You must follow our procedures for filing claims, and we must follow certain rules established by ERISA for responding to your claim.
If you are not satisfied with the decision made on your pre-service or post-service claim, you are only required to file one appeal before you have the right to take legal action under Section 502 (a) of ERISA. Your appeal will be reviewed by an appropriate named fiduciary. Additional levels of voluntary appeal are available within Kaiser Permanente. We do not impose fees as part of any appeal process. If you are not sure whether these ERISA laws apply to your benefit plan, please contact your employer for more information.
Complaints, grievances, and appeals
Member satisfaction Everyone associated with Kaiser Permanente wants you to receive the best care and service possible. If you have questions about your coverage or how to use our services, or if you need help finding the right health care resource, call Membership Services. If you have a compliment or suggestion, please call or send a letter to the administrator of the facility where you received care. We'll share your comments with the employees who assisted you and their supervisors.
Discuss any issues about your care with your health care provider or another member of your health care team. If you are not satisfied with your health care provider, you may request another. Contact Membership Services for assistance. You always have the right to a second opinion within Kaiser Permanente.
Most issues can be resolved with your health care team. If you feel that additional assistance is needed, complaint and grievance procedures are available to help. All complaints and grievances are handled in a confidential manner Members who are covered by an Oregon plan, the Federal Employee Health Benefits Program, Medicare, or Oregon Health Plan have different grievance and appeal procedures. Please contact Membership Services for a copy of the procedures that apply to your plan. ************************ Oral complaints If you want to talk with someone because you are dissatisfied with the availability, delivery, or quality of our services, benefits, or other administrative matters, you can file an oral complaint. Examples include, but are not limited to, things like appointment delays, the manner of communication by our staff, or concerns about our policies and procedures. If you have a concern involving a denial of future care, refer to "Appeals." If your concern involves a denial for services you already received, refer to "Grievances."
To file a complaint, contact the administrative office in the facility where you are having the problem or contact Membership Services for assistance. Discuss your complaint fully with the staff and be specific about how you want the matter to be resolved.
If you remain dissatisfied, you can file an oral or written grievance. If you decide to file a grievance, follow the procedures described under "Grievances."
Grievances A grievance is an oral or written complaint requesting a specific action, submitted by or on behalf of a member.
You can file a grievance: *If you are not satisfied with our response to your complaint regarding the availability, delivery, or quality of our services, benefits, or other administrative matters.
Page 3 Examples include complaints that you want reported and resolved, such as, a delay in hearing back from your doctor's office or about receiving an appointment in a timely manner.
*If you disagree with charges on a bill from Kaiser Permanente. (This is an initial claim for benefits under ERISA.)
*If we denied your claim for services that you received from a non-Kaiser Permanente provider or facility and you disagree with the claim determination. You must file the grievance within 185 days of the denial notice. (These grievances are post-service appeals under ERISA.)
*If we issued a benefit denial in writing after you requested a pre- service benefit determination. This includes things like a pre-service adverse benefit determination based on a decision that you are not eligible for benefits. Or, it could be a pre-service denial based on any number of specific coverage exclusions such as, certain excluded infertility procedures, lack of special benefits like prescription drugs, vision hardware coverage, or due to benefit limitations like a maximum number of covered mental health visits in a benefit period. You must file the grievance within 185 days of the denial notice. (These grievances are pre- service appeals under ERISA.)
Grievance procedures. To file a grievance, outline your concerns in writing and be specific about your request. You may submit any written comments, documents, records, and other information related to your grievance. Send your grievance to:
Member Relations Kaiser Permanente 500 NE Multnomah St., Suite 100 Portland, OR 97232
Or to file an oral grievance, call Member Relations at 503-813-4480 or toll free at 1-800-813-2000. and ask for Member Relations. If you need assistance filing a written grievance, or if your grievance is urgent, contact Member Relations. We will acknowledge receipt of your grievance within five working days. Member Relations will forward your grievance to the correct manager or department for resolution. An independent review will be conducted, and we will provide you with a written response. If your grievance is classified as an initial claim under ERISA, a decision will be provided within 30 days except as follows. If you fail to provide necessary information to make a determination on a grievance that is an initial claim under ERISA, we will allow you 50 days from the date on our written notification to submit the information. A decision will be reached within 15 days after receiving the information or within 15 days after the end of the 50 day period if we don't receive the information. If your grievance is classified as an appeal under ERISA, a decision will be provided within 14 days after we receive your grievance unless you are notified that additional time is needed to complete the review. In this case, the extension will not delay the decision beyond 30 days.
We will expedite a response on all grievances according to the clinical urgency of the situation, not to exceed 72 hours, if your grievance involves a denial of urgently needed care.
If your grievance included a specific request and that request is denied, the decision letter you receive will include detailed information about the basis for the decision and how to appeal the decision. (For members covered under an ERISA benefit plan, additional appeals are considered voluntary unless your grievance was classified as an initial claim under ERISA as described previously.) Appeals The process for requesting reconsideration of a denied grievance or a denial of care or service following a utilization review determination requested by your health care provider is outlined in the following appeal procedures. These procedures reflect the requirements of state and federal laws. Members who are not covered under an ERISA benefit plan have two levels of appeal following any denied grievance or following a denial of care or service because it was not considered medically necessary or it did not meet medical criteria (utilization review determinations). These appeals are referred to as "first-level" and "second level" appeals. Members covered under an ERISA benefit plan are only required to file one appeal before having a right to take legal action under ERISA. Receipt of appeals will be acknowledged within five working days.
First-level appeals.
* If you disagree with the decision rendered following a written grievance, you have 185 days from the date of the denial notice to submit a first-level appeal either orally or in writing. (For members covered under an ERISA benefit plan, this level of appeal is considered voluntary. Exception: If the grievance was a dispute regarding a bill from Kaiser Permanente, this appeal is the one required level of appeal under ERISA.)
*If you disagree with a denial for future care or service following a utilization review determination requested by your health care provider, you have 185 days from the date of the denial notice to submit a first-level appeal.
*If your appeal involves urgently needed care, a request for an expedited appeal may be submitted orally or in writing.
Page 4 To submit an appeal, follow the instructions in the denial letter you receive, or call or send your appeal to Member Relations. They will direct it to the appropriate location for handling. You have the right to include with your first-level appeal any written comments, documents, records, and other information relating to the claim.
First-level appeals will be decided within 14 days after we receive your appeal unless you are notified that additional time is needed to complete the review. The extension will not delay the decision beyond 30 days. A decision will be expedited to meet the clinical urgency of the situation, not to exceed 72 hours if it involves a denial of urgently needed care. Member Relations or the area manager will conduct an independent review of your first- level appeal and provide a written response. If your first-level appeal is denied, the written notice you receive will explain the basis for the decision, along with information about further appeal rights and other important disclosures.
Second-level appeals. If you disagree with the decision rendered on your first-level appeal, you have the right to submit a second-level oral or written appeal. If you decide to submit a second-level appeal, call or send your appeal in writing to Member Relations within 60 days of the date of the decision letter.
You have the right to include with your appeal any written comments, documents, records, and other information relating to the claim. You have the right to appear in person or by telephone before the review panel. If you wish to participate in person or by telephone, you must indicate this in your written second- level appeal. You must also list anyone who will attend with you, including your relationship to them. Member Relations will conduct an independent review and provide a written response.
Second-level appeals will be decided within 14 days after we receive your appeal unless you are notified that additional time is needed to complete the review. The extension will not delay the decision beyond 30 days. A decision will be expedited to meet the clinical urgency of the situation, not to exceed 72 hours if it involves a denial of any urgently needed care. If your second-level appeal is denied, written notification will explain the basis for the denial and will advise you how to request additional independent external review by an independent review organization (IRO).
External review by an IRO under Washington law Certain adverse determinations made by Kaiser Permanente may be eligible for review by a certified IRO after all appeals have been exhausted within Kaiser Permanente, or after the timeline for responding to a grievance has been exhausted without good cause and without a decision. For members covered under an ERISA benefit plan, external review is considered another "voluntary" level of appeal and is only available once all voluntary appeals have been exhausted.
The adverse determinations eligible for review by an IRO are decisions by Kaiser Permanente to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services or benefits including the admission to or continued stay in a facility.
If you are dissatisfied with an adverse determination and have exhausted your appeal rights within Kaiser Permanente, you may ask for an external review within 185 days of the date on the final denial letter. To determine if your appeal is eligible for external review or to file your request for external review, contact Member Relations. Member Relations will forward your request to the IRO. They will include written information received in support of the appeal along with medical records and other documents relevant in making the determination.
Your request for external review will be expedited if the ordinary time period for external review would seriously jeopardize your life, health, or your ability to regain maximum function.
You are not responsible for the costs of the external review, and you may name someone else to file the appeal for you if you give permission in writing and include that with your request for external review. While you are encouraged to use our complaints, grievances, and appeals procedure, you have the right to
Page 5 contact the Washington Office of the Insurance Commissioner. Contact them by mail, telephone, or over the Internet:
P.O. Box 40255 Olympia, WA 98504 1-800-562-6900
Added Choice® members For questions regarding in-network care, in-network benefits, or emergency claims, follow the procedures described in this flyer. For questions regarding out-of- network care, benefits, or non- emergency claims, contact Kaiser Permanente Membership Services (phone numbers listed at right) and ask who 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
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 (previous page) or Member Relations (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 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 6 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 503-494-9000
Providence St. Vincent Medical Center 503-216-1234
St. John Medical Center 360-414-7578
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 KAISER PERMANENTE