Common use of Initial Appeal Clause in Contracts

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Member’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial notice he/she receivednotice. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial notice he/she receivednotice. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-toll- free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the Member’s receipt of the denial notice he/she receiveda determination. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000-0000WA 98124- 1593, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000P.O. Box 40256, XxxxxxxOlympia, XX 00000WA 98504-0000 0256 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial notice he/she receivednotice. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA KFHPWAO decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWAKFHPWAO’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial notice he/she receivednotice. KFHPWA KFHPWAO will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWAKFHPWAO’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA KFHPWAO will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA KFHPWAO will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWAKFHPWAO’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA KFHPWAO decision denying benefits for care currently being received, KFHPWA KFHPWAO will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA KFHPWAO determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA Group Health decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWAGroup Health’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA Group Health will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWAGroup Health’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA Group Health will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA Group Health will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWAGroup Health’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA Group Health decision denying benefits for care currently being received, KFHPWA Group Health will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA Group Health determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA Group Health decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWAGroup Health’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA Group Health will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWAGroup Health’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA Group Health will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA Group Health will make a decision and communicate the decision to the Member in writing within 20 working days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWAGroup Health’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA Group Health decision denying benefits for care currently being received, KFHPWA Group Health will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA Group Health determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA Group Health decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWAGroup Health’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA Group Health will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWAGroup Health’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA Group Health will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA Group Health will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWAGroup Health’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA Group Health decision denying benefits for care currently being received, KFHPWA Group Health will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA Group Health determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA Group Health decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWAGroup Health’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA Group Health will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWAGroup Health’s Member Appeal Department, X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000WA 98124-00001593, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA Group Health will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA Group Health will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWAGroup Health’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA Group Health decision denying benefits for care currently being received, KFHPWA Group Health will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA Group Health determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000P.O. Box 40256, XxxxxxxOlympia, XX 00000WA 98504-0000 0256 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000WA 98124-00001593, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Member’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000P.O. Box 40256, XxxxxxxOlympia, XX 00000WA 98504-0000 0256 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. DRAFT If the Member or the Member’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000WA 98124-00001593, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Member’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000P.O. Box 40256, XxxxxxxOlympia, XX 00000WA 98504-0000 0256 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial notice he/she receivednotice. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000WA 98124-00001593, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000P.O. Box 40256, XxxxxxxOlympia, XX 00000WA 98504-0000 0256 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA KFHPWAO decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWAKFHPWAO’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial notice he/she receivednotice. KFHPWA KFHPWAO will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWAKFHPWAO’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA KFHPWAO will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA KFHPWAO will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWAKFHPWAO’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA KFHPWAO decision denying benefits for care currently being received, KFHPWA KFHPWAO will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA KFHPWAO determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Member’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. DRAFT The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA KFHPWAO decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWAKFHPWAO’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial notice he/she receivednotice. KFHPWA KFHPWAO will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWAKFHPWAO’s Member Appeal Department, X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000WA 98124-00001593, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA KFHPWAO will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA KFHPWAO will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWAKFHPWAO’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA KFHPWAO decision denying benefits for care currently being received, KFHPWA KFHPWAO will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA KFHPWAO determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000P.O. Box 40256, XxxxxxxOlympia, XX 00000WA 98504-0000 0256 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees with the decision. The appeal must be submitted within 180 days of the denial notice he/she received. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or the Member’s legal representative wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the date of the initial denial notice he/she receivednotice. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000, Xxxxxxx, XX 00000-0000 or at toll-free 1-800-562-6900. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.

Initial Appeal. If the Member or any representative authorized in writing by the Member’s legal representative Member wishes to appeal a KFHPWA decision to deny, modify, reduce or terminate coverage of or payment for health care services, he/she they must submit a request for an appeal either orally or in writing to KFHPWA’s Member Appeal Department, specifying why he/she disagrees they disagree with the decision. The appeal must be submitted within 180 days from the Member’s receipt of the denial notice he/she receiveddetermination. KFHPWA will notify the Member of its receipt of the request within 72 hours of receiving it. Appeals should be directed to KFHPWA’s Member Appeal Department, X.X. Xxx 00000P.O. Box 34593, XxxxxxxSeattle, XX 00000-0000WA 98124- 1593, toll-free 0-000-000-0000. A party not involved in the initial coverage determination and not a subordinate of the party making the initial coverage determination will review the appeal request. KFHPWA will then notify the Member of its determination or need for an extension of time within 14 days of receiving the request for appeal. Under no circumstances will the review timeframe exceed 30 days without the Member’s written permission. For appeals involving experimental or investigational services KFHPWA will make a decision and communicate the decision to the Member in writing within 20 days of receipt of the appeal. There is an expedited/urgent appeals process in place for cases which meet criteria or where delay using the standard appeal review process will seriously jeopardize the Member’s life, health or ability to regain maximum function or subject the Member to severe pain that cannot be managed adequately without the requested care or treatment. The Member can request an expedited/urgent appeal in writing to the above address, or by calling KFHPWA’s Member Appeal Department toll-free 0-000-000-0000. The nature of the patient’s condition will be evaluated by a physician and if the request is not accepted as urgent, the Member member will be notified in writing of the decision not to expedite and given a description on how to grieve the decision. If the request is made by the treating physician who believes the Membermember’s condition meets the definition of expedited, the request will be processed as expedited. The request for an expedited/urgent appeal will be processed and a decision issued no later than 72 hours after receipt of the request. The Member may also request an external review at the same time as the internal appeals process if it is an urgent care situation or the Member is in an ongoing course of treatment. If the Member requests an appeal of a KFHPWA decision denying benefits for care currently being received, KFHPWA will continue to provide coverage for the disputed benefit pending the outcome of the appeal. If the KFHPWA determination stands, the Member may be responsible for the cost of coverage received during the review period. The U.S. Department of Health and Human Services has designated the Washington State Office of the Insurance Commissioner’s Consumer Protection Division as the health insurance consumer ombudsman. The Consumer Protection Division Office can be reached by mail at Washington State Insurance Commissioner, Consumer Protection Division, X.X. Xxx 00000P.O. Box 40256, XxxxxxxOlympia, XX 00000WA 98504-0000 0256 or at toll-free 10-800000-562000-69000000. More information about requesting assistance from the Consumer Protection Division Office can be found at xxxx://xxx.xxxxxxxxx.xx.xxx/your-insurance/health-insurance/appeal/.