Appeals

All coverage determinations that result in a denial, reduction in coverage request, or a failure to provide or make payment (in part or in whole) for a benefit, contain instructions for a member appeal. Members may contact Member Services for more information.

You may request a standard appeal on the member’s behalf when the member has signed the appropriate authorization of representative form.

If you are the treating provider, you may request an expedited appeal (72 hour completion) without member permission when the standard appeal timelines (7 to 60 days) meet one of the following criteria:

• Could seriously jeopardize the life or health of the member
• Could seriously jeopardize the ability of the member to regain maximum function
• Delay would subject the member to severe pain that could not be adequately managed without the care or treatment

If you submit an expedited request, please include medical records to support your appeal and provide a valid phone number should we need to contact you for any reason.

Standard appeals
Members who receive a denial, reduction, or limitation notice for services may initiate an appeal within the specified timeframe as described in their notice of non-coverage or explanation of benefits. We resolve most non-Medicare Advantage standard appeals within 14 to 30 days. Medicare Advantage, Part C, standard pre-service reconsideration requests are decided within 30 days and post-service requests within 60 days. Medicare Advantage Part D standard pre-service redetermination requests are processed within 7 days and post-service requests within 14. Medicare Advantage Part B standard pre-service redetermination requests are processed within 7 days and post-service requests within 60.

Standard Medicare Advantage appeals must be in writing. Standard non-Medicare Advantage appeals can be submitted orally or in writing.

You may supply supporting statements and records in a member's appeal.

For standard Medicare Advantage and non-Medicare Advantage post-service appeals, with the member's permission, you may file an appeal on their behalf with AOR.

For standard pre-service Medicare Advantage appeals, with the member’s permission, you may file an appeal on their behalf without AOR.

For standard pre-service non-Medicare Advantage appeals, with the member’s permission, you may file an appeal on their behalf with AOR.

Expedited appeals
If a member's life, health, or ability to regain maximum function would be jeopardized by following the standard appeal process, you may request an expedited appeal on their behalf without AOR. You must make your request to Kaiser Permanente orally or in writing before the member receives the services in question.

Appeals criteria and time frames for resolution are identical for all members requesting an expedited appeal. Since our response time is 72 hours or less, please provide medical records to support the appeal within 24 hours or less of the request, using fax, courier, or other appropriate means.

We respond to Medicare Advantage and non-Medicare Advantage expedited appeals within 72 hours from their receipt. However, some non-Medicare Advantage contracts specify different time frames and appeal processes.

We handle requests that do not meet the expedited appeal criteria according to our standard 7-60-day redetermination/reconsideration (appeal) processes.

Subsequent appeal levels
Subsequent appeal levels vary, depending on the member's health plan group. Medicare Appeals that are upheld are automatically sent for an external review. Commercial appeals that are upheld are sent for external review at the request of the member and must be made within 180 days. These processes are described in detail in the appeal attachments sent with the denial or appeal letters.

Services provided during appeal (non-Medicare)
If a mental health practitioner provides services to an enrollee during an appeal or adverse certification process, the practitioner must provide written notification to the enrollee that payment for services is the enrollee's responsibility, unless the carrier elects to pay.