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

Member Service Contact Center: toll free 1-800-443-0815 (TTY users call 711) seven days a week 8 a.m.–8 p.m.
Claims Administrator
Claims and appeals for benefits under the Plan are
processed by Kaiser Foundation Health Plan, Inc. and
Kaiser Foundation Health Plan, Inc. has full and final
discretion and authority to determine whether and to
what extent enrollees are entitled to benefits under the
Plan. If you have a question about benefits under the
Plan or about a specific claim, please refer to the appeal
section found in this document and/or contact Kaiser
Foundation Health Plan, Inc. at the following address
and phone number:
Kaiser Foundation Health Plan, Inc.
Special Services Unit
P.O. Box 23280
Oakland, CA 94623
This Plan is administered in accordance with the
University of California Group Insurance Regulations,
applicable contracts/service agreements, evidence of
coverage booklets, and applicable state and federal laws.
No person is authorized to provide benefits information
not contained in these source documents, and
information not contained in these source documents
cannot be relied upon as having been authorized by the
Plan Administrator or Claims Administrator, as
applicable. The terms of those documents apply if
information in this document is not the same. The
University of California Group Insurance Regulations
will take precedence if there is a difference between its
provisions and those of this document and/or the group
insurance contracts. What is written in this document
does not constitute a guarantee of plan coverage or
benefits--particular rules and eligibility requirements
must be met before benefits can be received.
Group Contract Number
• Northern California Region
The Group contract numbers for the University
of California, Northern California Region, are
603601, 603602, 603603, 603604, 603605,
603607, 603608, 603609, 603610, 603611,
603612, 603613, 603614, and 603616.
• Southern California Region
The Group contract numbers for the University
of California, Southern California Region, are
102601, 102602, 102603, 102604, 102605,
102607, 102608, 102609, 102610, 102612,
102613, 230154, and 230156.
Type of Plan
This plan provides group medical care benefits. This
plan is one of the benefit plans offered under the
University of California Health and Welfare Programs
for eligible Faculty and Staff.
Plan Year
The plan year is January 1 through December 31.
Continuation of the Plan
The University of California intends to continue the plan
of benefits described in this booklet indefinitely but
reserves the right to terminate or amend the benefits
provided under this or any University-sponsored plan at
any time. Plan benefits are not accrued or vested benefit
entitlements. Any such amendment or termination shall
be carried out by the President or his or her delegates.
The portion of the premiums that University pays is
determined by UC and may change or stop altogether,
and may be affected by the state of California’s annual
budget appropriation.
Financial Arrangements
The benefits under the Plan are provided by Kaiser
Foundation Health Plan, Inc. under a Group Service
Agreement.
The cost of the premiums is currently shared between
you and the University of California.
Agent for Serving of Legal Process
Legal process may be served on Kaiser Foundation
Health Plan, Inc. at the following addresses:
Northern California Region Members:
Kaiser Foundation Health Plan, Inc.
Legal Department
1950 Franklin St., 17th Floor
Oakland, CA 94612
Southern California Region Members:
Kaiser Foundation Health Plan, Inc.
Legal Department
393 E. Walnut St.
Pasadena, CA 91188
Your Rights under the Plan
As a participant in a University of California plan, you
are entitled to certain rights and protections. All Plan
participants shall be entitled to:
• Examine, without charge, at the Plan
Administrator's office and other specified sites,
all Plan documents, including the Group Service
Agreement, at a time and location mutually
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