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

these types of care. Here's what to read in those
situations:
♦ go to "How to Ask Us to Cover a Longer Inpatient
Hospital Stay if You Think the Doctor Is
Discharging You Too Soon"
♦ go to "How to Ask Us to Keep Covering Certain
Medical Services if You Think Your Coverage Is
Ending Too Soon." This section is about three
Services only: home health care, Skilled Nursing
Facility care, and Comprehensive Outpatient
Rehabilitation Facility (CORF) Services
For all other situations that involve being told that the
Services you have been getting will be stopped, use this
"Your Medical Care: How to Ask for a Coverage
Decision or Make an Appeal" section as your guide for
what to do.
Which of these situations are you in?
• Do you want to find out whether we will cover the
Services you want?
♦ you can ask us to make a coverage decision for
you. Go to "Step-by-step: How to ask for a
coverage decision"
• Have we already told you that we will not cover or
pay for a Service in the way that you want it to be
covered or paid for?
♦ you can make an appeal. (This means you are
asking us to reconsider.) Skip ahead to "Step-bystep:
How to make a Level 1 Appeal"
• Do you want to ask us to pay you back for Services
you have already received and paid for?
♦ you can send us the bill. Skip ahead to "What if
you are asking us to pay you for our share of a
bill you have received for Services?"
Step-by-step: How to ask for a coverage
decision (how to ask us to authorize or provide
the Services you want)
Step 1: You ask us to make a coverage decision on the
Services you are requesting. If your health requires a
quick response, you should ask us to make a "fast
coverage decision." A "fast coverage decision" is
called an "expedited determination."
How to request coverage for the Services you want
• Start by calling, writing, or faxing us to make your
request for us to provide coverage for the Services
you want. You, your doctor, or your representative
can do this
• For the details about how to contact us, go to "How to
contact us when you are asking for a coverage
decision or making an appeal or complaint about your
Services" in the "Important Phone Numbers and
Resources" section
Generally we use the standard deadlines for giving
you our decision
When we give you our decision, we will use the
"standard" deadlines unless we have agreed to use the
"fast" deadlines. A standard coverage decision means we
will give you an answer within 14 days after we receive
your request.
• However, we can take up to 14 more calendar days if
you ask for more time, or if we need information
(such as medical records from Non–Plan Providers)
that may benefit you. If we decide to take extra days
to make the decision, we will tell you in writing
• If you believe we should not take extra days, you can
file a "fast complaint" about our decision to take extra
days. When you file a fast complaint, we will give
you an answer to your complaint within 24 hours.
(The process for making a complaint is different from
the process for coverage decisions and appeals. For
more information about the process for making
complaints, including fast complaints, see "How to
Make a Complaint About Quality of Care, Waiting
Times, Customer Service, or Other Concerns" in this
"Coverage Decisions, Appeals, and Complaints"
section)
If your health requires it, ask us to give you a "fast
coverage decision"
• A fast coverage decision means we will answer
within 72 hours
♦ however, we can take up to 14 more calendar days
if we find that some information that may benefit
you is missing (such as medical records from
Non–Plan Providers), or if you need time to get
information to us for the review. If we decide to
take extra days, we will tell you in writing
♦ if you believe we should not take extra days, you
can file a "fast complaint" about our decision to
take extra days. (For more information about the
process for making complaints, including fast
complaints, see "How to Make a Complaint About
Quality of Care, Waiting Times, Customer
Service, or Other Concerns" in this "Coverage
Decisions, Appeals, and Complaints" section.) We
will call you as soon as we make the decision
• To get a fast coverage decision, you must meet two
requirements:
♦ you can get a fast coverage decision only if you
are asking for coverage for Services you have not
yet received. (You cannot get a fast coverage
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