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

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Complaints for Part D prescription drugs 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 complaint qualifies for a fast decision, call the Part D Unit at 1-866-206-2973, 8:30 a.m. to 5 p.m., seven days a week. 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 complaint qualifies for a fast review, fax your request to our Part D Unit at 1-866-206- 2974. For a standard complaint, write to your local Member Services office (see the Provider Directory for locations). If your complaint qualifies for a fast decision, write to: Kaiser Foundation Health Plan, Inc. Part D 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. Where to send a request asking us to pay for our share of the cost for Services or a Part D drug you have received For more information about situations in which you may need to ask us for reimbursement or to pay a bill you have received from a provider, see the "Requests for Payment" section. Note: If you send us a payment request and we deny any part of your request, you can appeal our decision. See the "Coverage Decisions, Appeals, and Complaints" section for more information. Payment Requests Call TTY 711 Write Website kp.org Medicare 1-800-443-0815 (Calls to this number are free.) Seven days a week, 8 a.m. to 8 p.m. Note: If you are requesting payment of a Part D drug that was prescribed by a Plan Provider and obtained from a Plan Pharmacy, call our Part D unit at 1-866-206-2973, 8:30 a.m. to 5 p.m., seven days a week. 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. Northern California Members Kaiser Foundation Health Plan, Inc. Claims Department P.O. Box 24010 Oakland, CA 94623-1010 Southern California Members Kaiser Foundation Health Plan, Inc. Claims Department P.O. Box 7004 Downey, CA 90242-7004 If you are requesting payment of a Part D drug that was prescribed and provided by a Plan Provider, you can fax your request to 1-866- 206-2974 or write us at P.O. Box 23170, Oakland, CA 94623-0170 (Attention: Part D Unit). How to get help and information directly from the federal Medicare program Medicare is the federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). The federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes called "CMS"). This agency contracts with Medicare Advantage organizations, including our Plan. Page 100
Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m. Medicare Call 1-800-MEDICARE or 1-800-633-4227 Calls to this number are free. 24 hours a day, seven days a week. TTY 1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Website www.medicare.gov This is the official government website for Medicare. It gives you up-to-date information about Medicare and current Medicare issues. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes booklets you can print directly from your computer. You can also find Medicare contacts in your state. The Medicare website also has detailed information about your Medicare eligibility and enrollment options with the following tools: Medicare Eligibility Tool: Provides Medicare eligibility status information. Medicare Plan Finder: Provides personalized information about available Medicare prescription drug plans, Medicare Health Plans, and Medigap (Medicare Supplement Insurance) policies in your area. These tools provide an estimate of what your out-of-pocket costs might be in different Medicare plans. You can also use the website to tell Medicare about any complaints you have about our plan. Tell Medicare about your complaint: You can submit a complaint about our plan directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm /home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you don't have a computer, your local library or senior center may be able to help you visit this website using its computer. Or, you can call Medicare and tell them what information you are looking for. They will find the information on the website, print it out, and send it to you. (You can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. State Health Insurance Assistance Program Free help, information, and answers to your questions about Medicare The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors for every state. For California, the State Health Insurance Assistance Program is called the Health Insurance Counseling and Advocacy Program (HICAP). The Health Insurance Counseling and Advocacy Program is independent (not connected with any insurance company or health plan). It is a state program that gets money from the federal government to give free local health insurance counseling to people with Medicare. The Health Insurance Counseling and Advocacy Program counselors can help you with your Medicare questions or problems. They can help you understand your Medicare rights, help you make complaints about your Services or treatment, and help you straighten out problems with your Medicare bills. The Health Insurance Counseling and Advocacy Program counselors can also help you understand your Medicare plan choices and answer questions about switching plans. Health Insurance Counseling and Advocacy Program (California's State Health Insurance Assistance Program) Call 1-800-434-0222 TTY 711 Write Calls to this number are free. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Your HICAP office for your county. Website www.aging.ca.gov Quality Improvement Organization Paid by Medicare to check on the quality of care for people with Medicare There is a Quality Improvement Organization in each state. In California, the Quality Improvement Organization is called the Health Services Advisory Group. The Health Services Advisory Group has a group of doctors and other health care professionals who are paid by the federal government. This organization is paid by E O C 1 Page 101
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