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Atlanta, GA 30305-1736 or fax Your Appeal to Us at: 1-404-949-5001

With respect to medical Claims, if You disagree with Our decision on Your first level appeal, Your first level adverse appeal decision notice will tell You how to submit a second level appeal.

With respect to claims arising from the optional prescription drug benefit, Our decision of Your one level of appeal is the final decision and You may be deemed to have exhausted all Your internal appeals. If You disagree with Our decision, You may have the right to request for an external review. For a detailed provision of the external review process, please refer to: External Review under this section.

Second Level of Appeal (applicable to Medical Claims only)

If Your first level appeal decision is not wholly in Your favor, You are entitled to a second level of review. We must receive Your second level appeal request within 180 days of Your receiving this notice of Our first level appeal decision. Please note that We will count the 180 days starting 5 business days from the date of the first level appeal notice to allow for delivery time unless You can prove that You received the notice after that 5 business day period. Contact Us at 877-847-7572 with any questions about Your appeal rights. You must mail Your second level appeal to:

Kaiser Permanente Insurance Company (KPIC) 1800 Harrison Street, 20th Floor

Oakland, CA 94612

Attn: Grievance and Appeals Coordinator

You may also fax this information to: KPIC Attn: KPIC Operations Grievance and Appeals Coordinator at (877) 727-9664.

Providing Additional Information Regarding Your Claim

When You Appeal, You may send Us additional information including comments, documents, and additional medical records that You believe support Your Claim. If We asked for additional information and You did not provide it before We made Our initial decision about Your Claim, then You may still send Us the additional information so that We may include it as part of Our review of Your Appeal. For first level of appeal, please send all additional information to Kaiser Permanente, Appeals Department, Nine Piedmont Center, 3495 Piedmont Road, N.E. Atlanta, GA 30305-1736 or fax Your information to: 1-404- 949-5001. For Your second level of appeal please send all additional information to Kaiser Permanente Insurance Company (KPIC) Attn: KPIC Operations, Grievance and Appeals Coordinator, 1800 Harrison Street, 20th Floor, Oakland, CA 94612 or You may also fax this information to 877-727-9664.

When You Appeal, You may give testimony in writing or by telephone. Please send Your written testimony to the address set forth above. To arrange to give testimony by telephone, You should contact Kaiser Permanente Appeals Department at 888-865-5813 for your first level of appeal or KPIC Grievance and Appeals Coordinator at 877-847-7572 for your second level of appeal.

We will add the information that You provide through testimony or other means to Your Claim file and We will review it without regard to whether this information was submitted and/or considered in Our initial decision regarding Your Claim.

Sharing Additional Information That We Collect

We will send You any additional information that We collect in the course of Your Appeal. If We believe that Your Appeal of Our initial Adverse Benefit Determination will be denied, then before We issue Our final Adverse Benefit Determination We will also share with You any new or additional reasons for that decision. We will send You a letter explaining the new or additional information and/or reasons and inform You how You can respond to the information in the letter if You choose to do so. If You do not

CLAIMS AND APPEALS PROCEDURES

respond before We must make Our final decision, that decision will be based on the information already in Your Claim file.

Time frame for Resolving Your Appeal

There are several types of Claims, and each has a time frame in resolving Your Appeal.

• Post-service Claims

• Pre-service Claims (urgent and non-urgent)

• Concurrent Care Claims (urgent and non-urgent)

In addition, there are separate Appeals procedures for Adverse Benefit Determinations due to a retroactive termination of coverage (rescission).

1) Post-service Appeal

o Within 180 days after You receive Our Adverse Benefit Determination, tell Us in writing that You want to Appeal Our denial of Your Post-service Claim. Please include the following: (1) Your name and Medical Record Number, (2) Your medical condition or symptoms, (3) the specific Covered Services that You want Us to pay for, (4) all of the reasons why You disagree with Our Adverse Benefit Determination, and (5) include all supporting documents. Your request and the supporting documents constitute Your Appeal. Your must mail Your first level appeal to:

Kaiser Permanente Appeals Department Nine Piedmont Center 3495 Piedmont Road, N.E. Atlanta, GA 30305-1736 or fax Your Appeal to Us at: 1-404-949-5001

If Your first level appeal decision is not wholly in Your favor, You are entitled to a second level of review. Contact Us at 877-847-7572 with any questions about Your appeal rights. You must mail Your second level Appeal to:

Kaiser Permanente Insurance Company (KPIC) Attn: Grievance and Appeals Coordinator 1800 Harrison Street 20th _Floor

Oakland, CA 94612

You may also fax this information to: KPIC Attn: KPIC Operations Grievance and Appeals Coordinator at (877) 727-9664.

o We will review Your Appeal as follows:

o For Appeals involving medical claims - We will review Your Appeal and send you a written decision of each level of Your two level appeal process within a reasonable period of time appropriate to the circumstances, but in no event later than 15 days from the date that we receive your request for our review at that level unless we inform you otherwise in advance.

o For appeals involving claims arising from the outpatient prescription drug benefit - We will review Your Appeal and send You a written decision within a reasonable period of time appropriate to the circumstances, but in no event later than 30 days from the date that we receive Your request for our review unless we inform you otherwise in advance.

o If We deny Your Appeal, Our Adverse Benefit Determination notice will tell You why We denied Your Appeal and will include information regarding any further process, including external review, that may be available to You.

CLAIMS AND APPEALS PROCEDURES

2) Non-urgent Pre-service Appeal

o Within 180 days after You receive Our Adverse Benefit Determination notice, You must tell Us in writing that You want to Appeal Our denial of Your pre-service Claim. Please include the following: (1) Your name and Medical Record Number, (2) Your medical condition or relevant symptoms, (3) the specific Service that You are requesting, (4) all of the reasons why You disagree with Our adverse benefit denial, and (5) all supporting documents. Your request and the supporting documents constitute Your Appeal. You must mail Your first level appeal to:

Kaiser Permanente Appeals Department Nine Piedmont Center 3495 Piedmont Road, N.E. Atlanta, GA 30305-1736 or fax Your Appeal to Us at: 1-404-949-5001.

If Your first level appeal decision is not wholly in Your favor, You are entitled to a second level of review. Contact Us at 877-847-7572 with any questions about Your appeal rights. You must mail Your second level appeal to:

Kaiser Permanente Insurance Company (KPIC) Attn: Grievance and Appeals Coordinator 1800 Harrison Street, 20th Floor

Oakland, CA 94612

You may also fax this information to: KPIC Attn: KPIC Operations Grievance and Appeals Coordinator at (877) 727-9664

o We will review Your appeal as follows:

o For Appeals involving medical claims - Because You have not yet received the services or equipment that You requested, we will review Your Appeal and send You a written decision of each level of Your two (2) level appeal process within a reasonable period of time appropriate to the circumstances, but in no event later than 15 days from the date that we receive Your request for our review at that level unless we inform You otherwise in advance.

o For appeals involving claims arising from the outpatient prescription drug benefit - We will review Your Appeal and send You a written decision within a reasonable period of time appropriate to the circumstances, but in no event later than 30 days from the date that we receive Your request for our review unless we inform You otherwise in advance.

o If We deny Your Appeal, Our Adverse Benefit Determination notice will tell You why We denied Your Appeal and will include information regarding any further process, including external review, that may be available to You.

3) Urgent Pre-service Appeal

o Within 180 days after You receive Our Adverse Benefit Determination notice, You must tell Us that You want to urgently Appeal Our Adverse Benefit Determination regarding Your pre-service Claim. Please include the following: (1) Your name and Medical Record Number, (2) Your medical condition or symptoms, (3) the specific Service that You are requesting, (4) all of the reasons why You disagree with Our Adverse Benefit Determination, and (5) all supporting documents. Your request and the supporting documents constitute Your Appeal. You must submit Your Appeal by calling Our Expedited Review Unit at 1-404-364-4862 or fax Your request to 1-404-364-4743. You may also mail Your first level appeal to:

Kaiser Permanente

CLAIMS AND APPEALS PROCEDURES