This letter is written to acknowledge receipt of your request for appeal
received on October 1, 2007 for Health Plan coverage for services provided by
the UCSF Medical Center from January 20, 2007 through June 21, 2007.
..
The Regional Appeals Committee will review your request for appeal. If the
Committee upholds the initial determination that your request should be denied,
your case will be forwarded to The MAXIMUS Federal Services, Inc., a
reconsideration contractor for the Centers for Medicare and Medicaid Services
(CMS), for further review and a final determination. I will advise you of the
status of your request within 60 days.
..
If you have any additional information, that you would like this Committee to
consider, we must receive it as soon as possible, but no later than October
29, 2007. You may send this information to my attention at the Member
Relations Department at the following address:
4480 Hacienda Drive, 4th Floor
Pleasanton, CA 94588
ATTN: Paula McPhail
..
You or your representative has the right to appear at the Regional Appeals
Committee meeting for the purpose of presenting your request. If you or your
representative would like to arrange a telephone conference, you must
call me immediately if you wish to present your case so a time can be
scheduled. ..
You may also submit this information by fax to my attention at 925 924
6887. .. What if you have a quality of care complaint? If you are concerned
about the quality of care you have received, you may also file a complaint
with the local Quality Improvement Organization, Lumetra (800 841 1602).
Quality Improvement Organizations are groups of doctors and health
professionals that monitor the quality of care provided to Medicare
beneficiaries. The Quality Improvement Organization review process is designed
to stop any improper practice.
..
You may also file a quality complaint with Kaiser Foundation Health Plan. We
will review your complaint and notify you in writing of our conclusion within
30 days, unless we notify you that additional time is necessary. This process
is separate from the appeal process.
If you have any questions or need further assistance, please contact me at 925
924 6887 Monday through Friday, excluding holidays, between the hours of 8:30
a.m. and 5:00 p.m. You may also call 1 800 443 0815 or TTY 1 800 777 1370 for
the deal and hard of hearing or speech impaired. Representatives are
available seven days a week, 7 a.m. to 8 p.m.
..
Sincerely,
Paula McPhail
Senior Case Manager
Member Case Resolution Center - MCRC
.. KAISER PERMANENTE
Kaiser Foundation Plan, Inc.
Kaiser Foundation Hospitals
The Permanente Medical Group, Inc.
Southern California Foundation Medical Group
.. STATEMENT OF AUTHORIZED REPRESENTATIVE - PAGE 1 of 2
I understand that Kaiser Permanente will not condition treatment, payment,
enrollment, or eligibility for benefits on my providing or refusing to provide
this authorization.
..
PART A: If you wish to give authority to another party to file a complaint,
grievance, Medicare Review, or an appeal on your behalf, please complete the
following information. If you wish this person to receive Protected Health
Information (PHI) regarding your treatment and care, you must check the
appropriate box(es) below and you and your representative must both sign and
date this form. Please return the completed form to the Member Services office
handling your case. ..
Your Name and Address
..
Daytime Phone #
..
Medical Record #
..
Medicare #
..
Name of Designated Person
..
Address
..
Daytime Phone #
.. x I authorize KFHP to disclose protected Health Information regarding my
mdeical condition and care and/or payment information to the above named
individual. This information must be relevant to the request filed with
Member Services on October 1, 2007 (date of request).
SPECIFY Check the box and initial to specify which type of authorization is to
be dislcosed.
.. RECORDS: x
MEDICAL INFORMATION [MAB] INITIAL
PSYCHIATRIC INFORMATION [no authorization checked]
.. SIGNATURE [no signature]
DATE [no date]
DRUG/ALCOHOL INFORMATION [no authorization checked]
SIGNATURE [no signature]
DATE [no date]
.. RESULTS OF AN HIV BLOOD TEST [no authorization checked]
SIGNATURE [no signature]
DATE [no date]
.. OTHER HEALTH INFORMATION (specify below)
Specify the records to be disclosed:
..
x This authorization shall become effective immediately and shall remain in
effect until the earlier or final resolution of my request or Dec 13, 2008
(specify date).
..
00139-000 (REV. 6-03) PAGE 1 OF 2 HIPAA COMPLIANT
FOR SPANISH USE 00139-001; CHINESE USE 00139-002
..
NS-1062 (REV. 6-03) PAGE 1 OF 2 HIPAA COMPLIANT
FOR SPANISH USE NS-1071; CHINESE USE NS-1075
.. KAISER PERMANENTE
Kaiser Foundation Plan, Inc.
Kaiser Foundation Hospitals
The Permanente Medical Group, Inc.
Southern California Foundation Medical Group
.. STATEMENT OF AUTHORIZED REPRESENTATIVE - PAGE 2 of 2 .. REVOCATION: This authorization is also subject to written revocation by the
member/patient at any time. The written revocation will be effective upon
receipt, except to the extent that the disclosing party or others have acted in
reliance upon this Authorization.
.. REDISCLOSURE: I understand that the recipient may not lawfully further use or
disclose the health information unless another authorization is obtained from
me or unless such use or disclosure is specifically required or permitted by
law.
.. Your Signature: .. Date: .. 10/13/07
PART C:
I am authorized to sign this authorization on behalf of ______________________
and on the basis of:
.. Legal Authority (Power of Attorney, etc.) [no authorization not applicable]
Written Designation by Member [no authorization not applicable]
Parent, Guardian, or other individual acting in loco parentis
[no authorization not applicable]
.. Authorized Representative: .. Date: .. Oct 13, 2007
Patient has a righ to a copy of this form.
..
00139-000 (REV. 6-03) PAGE 2 OF 2 HIPAA COMPLIANT
FOR SPANISH USE 00139-001; CHINESE USE 00139-002
..
NS-1062 (REV. 6-03) PAGE 2 OF 2 HIPAA COMPLIANT
FOR SPANISH USE NS-1071; CHINESE USE NS-1075