Advantage organization determinations, appeals, grievances for
Asking for coverage decisions
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services. We and/or your doctor make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you.
We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
When a coverage decision involves your medical care, it is called an "organization determination."
How to ask for a coverage decision
Step 1: You or your doctor may ask our health plan to make a coverage decision on the medical care you are requesting. If your health requires a quick response, you should ask us to make a "fast decision."
Step 2: Our health plan considers your request for medical care coverage and we give you our answer.
- Generally, for a fast decision, we will give you our answer within 72 hours.
- We will respond to "standard" coverage requests within 14 days of receiving your request.
- If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no.
Step 3: If we say no to your request for coverage for medical care, you decide if you want to make an appeal.
To request an organization determination, you may call us at 1-888-901-4600 (TTY 711) from 8 a.m. to 8 p.m., 7 days a week. You may also send your request by fax to 206-901-6205.
You may also mail your request to us at:
Kaiser Permanente Medicare Member Services Department
P.O. Box 34590
Seattle, WA 98124-1589
How to request an appeal
Appeals for coverage of medical care. If we tell you that we will not pay for the medical care, you can ask for an appeal.
If you think we have made a mistake in turning down your request for coverage or for payment, you can ask for an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your coverage request.
Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. When we have completed the review we give you our decision.
If we say no to all or part of your Level 1 Appeal, your case will automatically go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to our health plan. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.
You must make your appeal request within 60 calendar days from the date on the written notice that we sent to tell you our answer to your request for a coverage decision. If you miss the deadline and have a good reason for missing it, we may give you more time to make your appeal. Include that reason in your written request.
Step 1: You contact our health plan and make your appeal
- Submit your request for a standard appeal in writing by fax, mail, or online through the Kaiser Permanente member website (see below for contact information).
- If you need a "fast" appeal due to a life-threatening situation, call us.
- You may have someone else request the appeal using the Authorization of Representative process
Step 2: Our health plan considers your appeal and we give you an answer.
- Generally, we will respond to a "fast" appeal within 72 hours after we receive your appeal.
- We will respond to a "standard" appeal within 30 calendar days unless we need to gather more information that may benefit you. This can take up to 14 more calendar days. Post-service appeals can take up to 60 days.
Step 3: If our health plan says no to part or all of your appeal, your case will automatically be sent on to the next level of the appeals process.
The independent review organization reviews the decision our health plan made when we said no to your first appeal. This organization decides whether the decision we made should be changed.
See the Medicare Evidence of Coverage for your health plan for more information about the appeals process, the types of appeals, and the level of appeals.
Hours are Monday through Friday, 8 a.m. to 5 p.m.
Medicare Appeals Coordinator
P.O. Box 34593
Seattle, WA 98124-1593
Alternatively, you can fill out a form online, but to protect the security of personal information, you must sign on to the Kaiser Permanente member website.
Online Member Appeals Request form
Filing a grievance
Making Complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.
The formal name for "making a complaint" is "filing a grievance"
Step 1: Contact us promptly — either by phone or in writing
- Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. To reach Member Services call 1-888-901-4600 or TTY 711 from 8 a.m. to 8 p.m., 7 days a week.
- If you do not wish to call (or you called and were not satisfied), you can put your complaint in
writing and send it to us. To submit written grievance requests:
Mail to: Kaiser Permanente Medicare Member Services Medicare Grievance
P.O. Box 34590
Seattle, WA 98124-1590
Or email Member Services
Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about.
Step 2: We look into your complaint and give you our answer.
- If possible, we will answer you right away.
- Most complaints are answered in 30 calendar days.
You can make complaints about quality of care to the Medicare Quality Improvement Organization as well as Kaiser Permanente.
When your complaint is about quality of care, you also have two extra options:
- You can make your complaint to the Quality Improvement Organization (QIO).
- Or, you can make your complaint to Kaiser Permanente and the QIO at the same time.
For more information about the complaint/grievance process see the Kaiser Permanente Medicare Evidence of Coverage for your health plan.
2021 Evidence of Coverage
For complete information on grievance, coverage determination (including exceptions), and appeals processes, you can refer to the Evidence of Coverage for your health plan.
You can ask anyone you want to help you with your Medicare health plan. If this person agrees to help you in this way, she or he is your authorized representative. Your authorized representative can be someone appointed to make decisions for you, such as a guardian or health care proxy, or attorney-in-fact.
If someone else will be filing a grievance or requesting an exception or an appeal on your behalf, complete the following form and submit it along with other supporting documentation.
Medicare complaint form
Use this electronic form to file a complaint directly with Medicare, instead of with Kaiser Permanente. You can also contact 1-800-MEDICARE (1-800-633-4227), 24 hours a day and 7 days a week, for assistance with complaints, grievances and information requests.
For more information
Contact Member Services at 1-800-446-8882 TTY 711, from 8 a.m. to 8 p.m., 7 days a week.
You can also refer to your Annual Notice of Change (ANOC) or Evidence of Coverage (EOC).
If you have questions about the process, or about the status of your organization determination, grievance, or appeal, call Member Services. Providers may call the Provider Assistance Unit at 509-241-7206.
To obtain information on the aggregate number of grievances, appeals, and exceptions filed with us, contact Member Services.