Appeals
HMOs
If you have been denied a claim or believe you have been denied a benefit to which you may be entitled under an HMO's plan, you must go through the appeals steps provided by your HMO. You should refer to your EOC or call your HMO at the phone number listed on your ID card or the phone number listed in the summary of benefits chart for specific instructions on how and where to file an appeal. Be sure to follow these procedures carefully.
After you have initiated an appeal, in accordance with the steps outlined in your HMO's Evidence of Coverage (EOC), the HMO must respond to you within the prescribed time frames. The response you receive from your HMO will outline further steps available to you should your appeal be denied.
Because HMOs are not self-insured by the Company, HMO members do not have legal recourse to formally appeal to the Company after they have gone through all the appeals steps provided by the HMO. Although you should always feel free to bring issues relating to an HMO's service or quality of care to the Company's attention, the Company does not review formal appeals for benefits provided by HMOs.
For issues relating to eligibility or participation in an HMO, please refer to the Health Care Participation section.
Kaiser EPO
You may appeal a denied claim by submitting a written request for review to the Plan. You must make the appeal request within 180 days after the date of the denial notice. Send the written request to the Plan at:
Kaiser Permanente Insurance Company -- Appeals
3701 Boardman-Canfield Road
Canfield Ohio 44406
You may instead fax your appeal to 614-212-7110.
To appeal a pharmacy claim, submit your form to:
Kaiser Permanente
Attn: SFAS National Self Funding
3840 Murphy Canyon Rd
San Diego, CA 92123
Fax: 858-614-7912
The request must explain why you believe a review is in order and it must include supporting facts and any other pertinent information. The Plan may require you to submit such additional facts, documents, or other material as it may deem necessary or appropriate in making its review.
After you have initiated an appeal, in accordance with the steps outlined in the Kaiser EPO Summary Plan Description (SPD), the plan must respond to you within the prescribed time frames. The response you receive from the Kaiser EPO will outline further steps available to you should your appeal be denied. After exhausting the appeals process through Kaiser, if you are not satisfied with the outcome, the final step in the process is to appeal to PG&E. You have 90 days from the date of receipt of the final decision from Kaiser to elect PG&E's Claims and Appeals Review Process.
For a full description of the appeals process for PG&E's Kaiser EPO plan, including the PG&E Claims and Appeals Review Process, please refer to your Kaiser EPO SPD.