Disclosure form and evidence of coverage - Kaiser Permanente ...

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any person or organization obligated to pay for the Services. Privacy practices Kaiser Permanente will protect the privacy of your protected health information. We also require contracting providers to protect your protected health information. Your protected health information is individuallyidentifiable information (oral, written, or electronic) about your health, health care services you receive, or payment for your health care. You may generally see and receive copies of your protected health information, correct or update your protected health information, and ask us for an accounting of certain disclosures of your protected health information. We may use or disclose your protected health information for treatment, health research, payment, and health care operations purposes, such as measuring the quality of Services. We are sometimes required by law to give protected health information to others, such as government agencies or in judicial actions. In addition, protected health information is shared with the University of California only with your authorization or as otherwise permitted by law. We will not use or disclose your protected health information for any other purpose without your (or your representative's) written authorization, except as described in our Notice of Privacy Practices (see below). Giving us authorization is at your discretion. This is only a brief summary of some of our key privacy practices. Our Notice of Privacy Practices, which provides additional information about our privacy practices and your rights regarding your protected health information is available and will be furnished to you upon request. To request a copy, please call our Member Service Contact Center. You can also find the notice at your local Plan Facility or on our website at kp.org. Public policy participation The Kaiser Foundation Health Plan, Inc., Board of Directors establishes public policy for Health Plan. A list of the Board of Directors is available on our website at kp.org or from our Member Service Contact Center. If you would like to provide input about Health Plan public policy for consideration by the Board, please send written comments to: Kaiser Foundation Health Plan, Inc. Office of Board and Corporate Governance Services One Kaiser Plaza, 19th Floor Oakland, CA 94612 Telephone access (TTY) If you are hearing or speech impaired and use a text telephone device (TTY, also known as TDD) to communicate by phone, you can use the California Relay Service by calling 711 if a dedicated TTY number is not available for the telephone number that you want to call. Important Phone Numbers and Resources Kaiser Permanente Senior Advantage How to contact our Plan's Member Services For assistance, please call or write to Senior Advantage Member Services. We will be happy to help you. Member Services Call TTY 711 Write Website kp.org 1-800-443-0815 (Calls to this number are free.) Seven days a week, 8 a.m. to 8 p.m. Member Services also has free language interpreter services available for non-English speakers. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Seven days a week, 8 a.m. to 8 p.m. Your local Member Services office (see the Provider Directory for locations). How to contact us when you are asking for a coverage decision or making an appeal or complaint about your Services • A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services • An appeal is a formal way of asking us to review and change a coverage decision we have made • You can make a complaint about us or one of our network providers, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes For more information about asking for coverage decisions or making appeals or complaints about your Page 98
Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m. medical care, see the "Coverage Decisions, Appeals, and Complaints" section. Coverage decisions, appeals, or complaints for Services Call TTY 711 Fax Write 1-800-443-0815 (Calls to this number are free.) Seven days a week, 8 a.m. to 8 p.m. If your coverage decision, appeal, or complaint qualifies for a fast decision, call the Expedited Review Unit at 1-888-987-7247, 8:30 a.m. to 5 p.m., Monday through Saturday. See the "Coverage Decisions, Appeals, and Complaints" section to find out if your issue qualifies for a fast decision. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Seven days a week, 8 a.m. to 8 p.m. If your coverage decision, appeal, or complaint qualifies for a fast decision, fax your request to our Expedited Review Unit at 1-888-987-2252. For a standard coverage decision or complaint, write to your local Member Services office (see the Provider Directory for locations). For a standard appeal, write to the address shown on the denial notice we send you. If your coverage decision, appeal, or complaint qualifies for a fast decision, write to: Kaiser Foundation Health Plan, Inc. Expedited Review Unit P.O. Box 23170 Oakland, CA 94623-0170 Medicare Website. You can submit a complaint about our Plan directly to Medicare. To submit an online complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.a spx. How to contact us when you are asking for a coverage decision or making an appeal about your Part D prescription drugs • A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs • An appeal is a formal way of asking us to review and change a coverage decision we have made For more information about asking for coverage decisions or making appeals about your Part D prescription drugs, see the "Coverage Decisions, Appeals, and Complaints" section. You may call us if you have questions about our coverage decision or appeal processes. Coverage decisions or appeals for Part D prescription drugs Call TTY 711 1-866-206-2973 (Calls to this number are free.) Seven days a week 8:30 a.m. to 5 p.m. If your coverage decision, appeal, or complaint qualifies for a fast decision, call the Expedited Review Unit at 1-888-987-7247, 8:30 a.m. to 5 p.m., Monday through Saturday. See the "Coverage Decisions, Appeals, and Complaints" section to find out if your issue qualifies for a fast decision. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Seven days a week, 8 a.m. to 8 p.m. Fax 1-866-206-2974 Write Kaiser Foundation Health Plan, Inc. Part D Unit P.O. Box 23170 Oakland, CA 94623-0170 Website kp.org How to contact us when you are making a complaint about your Part D prescription drugs You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about our Plan's coverage or payment, you should look at the section above about requesting coverage decisions or making appeals.) For more information about making a complaint about your Part D prescription drugs, see the "Coverage Decisions, Appeals, and Complaints" section. E O C 1 Page 99
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Disclosure form and evidence of coverage - Kaiser Permanente ...

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