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Filed for Record 12/29/2017 11:45:18 AM - Kittitas County, WA Auditor - 201712290016 Page 7 of 16 <br />If you have questions concerning your benefits and coverage decisions, please call toll-free <br />1-888-901-4636 (TTY WA Relay: 1-800-833-6388). Para obtener asistencia en espanol, Ilame <br />al 1-888-901-4636. <br />Appeals Process for Coverage Denials <br />If you wish to appeal a decision, you must submit a request for appeal within 180 days of this <br />notice, specifying why you disagree with the decision. Kaiser Foundation Health Plan of <br />Washington ('Kaiser Permanente') will notify you of its determination or request written <br />permission for an extension of time within 30 days of receipt of the request for appeal. You <br />may submit your appeal request by mail, fax, or phone to Kaiser Permanente. A written <br />request for appeal should include copies of your medical record, physicians' letters and any <br />other printed material related to your request. <br />Kaiser Permanente <br />Member Appeals <br />P.O. Box 34593 <br />Seattle, WA 98124-1593 <br />Toll -Free: 1-866-458-5479 <br />Fax: 206-630-1859 <br />If you are not satisfied with the initial decision on appeal or if Kaiser Permanente fails to grant <br />or reject the request for review within the required timeframe, you may request another review <br />of the decision. <br />For more details on additional levels of review, please refer to your Certificate of Coverage or <br />contact Member Appeals. <br />If your health plan is governed by ERISA (most employment related health plans, other than <br />those sponsored by governmental entities or churches - ask your employer about your plan) <br />you have the right to file a lawsuit under section 502(a) of ERISA to recover benefits due to <br />you under the plan at any point after completion of the initial appeals process. <br />_--For questions about your appeal rights, this notice, or for assistance, you can contact: <br />Kaiser Permanente <br />Member Services <br />Phone: 1-888-901-4636 <br />CLKE3B - Commercial <br />