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1...We need the documents Paula cites for identifying Millie's appeal
2...We need Kaiser's "initial determination" and evidence Kaiser relies on
CONTACTS
SUBJECTS
Kaiser Regional Appeals Committee Hearing Aleged Patient Request 07
0503 -
0503 - ..
0504 - Summary/Objective
0505 -
050501 - Follow up ref SDS 22 0000. ref SDS 20 0000.
050502 -
050503 -
050504 -
050505 -
050506 -
050508 - ..
0506 -
0507 -
0508 - Progress
0509 -
050901 - Millie received ref DRT 1 0001 from Paula, following up the call from
050902 - Kaiser MCRC on 071006. ref SDS 22 TL5U
050904 - ..
050905 - Kaiser's letter from Paula says...
050906 -
050907 - 1. This letter is written to acknowledge receipt of your request
050908 - for appeal received on October 1, 2007 for Health Plan coverage
050909 - for services provided by the UCSF Medical Center from January
050910 - 20, 2007 through June 21, 2007. ref DRT 1 0001
050912 - ..
050913 - We need the documents Paula cites for identifying Millie's appeal
050914 - received by Kaiser on 071001.
050915 -
050916 - [On 071025 Millie responded to Kaiser's letter, and
050917 - submitted authorization for representation. ref SDS 26 AM3K
050919 - ..
050920 - Millie has not submitted a request for appeal. Paula seemed to
050921 - indicate in her call on 071006 that she received "faxed" information
050922 - from the letter to CMS on 071002. ref SDS 22 Z87L There is nothing in
050923 - the record that Millie has "requested an appeal." We need to find out
050924 - what Kaiser has constructed into an appeal?
050925 -
050926 - [On 071030 Paula confirmed that the date of 071001 in
050927 - Kaiser's letter today was mistake, since Kauser framed an
050928 - appeal for Millie based on the letter to CMS dated 071002
050929 - which CMS sent to Kaiser. ref SDS 29 V26V
050931 - ..
050932 - Possible 16 legal issues raised by Kaiser's failure to pay for
050933 - prescribed treatments are listed on 070927. ref SDS 19 WU6M
050935 - ..
050936 - Kaiser's MCRC letter from Paula continues...
050937 -
050938 - 2. The Regional Appeals Committee will review your request for
050939 - appeal. If the Committee upholds the initial determination
050940 - that your request should be denied, your case will be forwarded
050941 - to The MAXIMUS Federal Services, Inc., a reconsideration
050942 - contractor for the Centers for Medicare and Medicaid Services
050943 - (CMS), for further review and a final determination. I will
050944 - advise you of the status of your request within 60 days.
050945 - ref DRT 1 DQ6G
050947 - ..
050948 - We need Kaiser's "initial determination" and evidence Kaiser relies on
050949 - in reaching such determination, since Millie has not filed an appeal,
050950 - per above. ref SDS 0 KJ9O
050952 - ..
050953 - There appears to be a California agency where patients can seek
050954 - assistance for Kaiser in applying requirements correctly...
050955 -
050956 - Department of Managed Health Care
050957 -
050958 - http://www.dmhc.ca.gov/
050960 - ..
050961 - MCRC letter from Paula continues...
050962 -
050963 - 3. If you have any additional information, that you would like
050964 - this Committee to consider, we must receive it as soon as
050965 - possible, but no later than October 29, 2007. You may send
050966 - this information to my attention at the Member Relations
050967 - Department at the following address:, ref DRT 1 D164
050968 -
050969 - 4480 Hacienda Drive, 4th Floor
050970 - Pleasanton, CA 94588
050971 - ATTN: Paula McPhail
050973 - ..
050974 - 4. You or your representative has the right to appear at the
050975 - Regional Appeals Committee meeting for the purpose of
050976 - presenting your request. If you or your representative would
050977 - like to arrange a telephone conference, you must call me
050978 - immediately if you wish to present your case so a time can be
050979 - scheduled. ref DRT 1 D082
050980 -
050981 - [On 071025 Millie responded to Kaiser's letter, and
050982 - submitted authorization for representation. ref SDS 26 AM3K
050984 - ..
050985 - [On 071026 Millie sent email notifying Paula at Kaiser that
050986 - she had mailed the letter on 071025. ref SDS 27 WC4N
050988 - ..
050989 - [On 071030 Paula clarifies the only way patients can
050990 - "appear" before the Appeals Committee is with a 10 minute
050991 - telephone conference. ref SDS 29 FM6G
050993 - ..
050994 - 5. You may also submit this information by fax to my attention at
050995 - 925 924 6887. ref DRT 1 DQ84
050996 -
050997 - [On 071029 fax number in Paula's letter is incorrect,
050998 - ref SDS 28 PQVU; called and got correction to submit
050999 - documents lost or misplaced in Kaiser's records.
051000 - ref SDS 28 0O4O
051002 - ..
051003 - Millie may need representation to appear and assist with preparation
051004 - for meeting with the Appeals Committee...
051005 -
051006 - a. Who will be in the room during the hearing? Do people come
051007 - and go?
051008 -
051009 - b. Will the Committee hear from people (witnesses) other than
051010 - me (Rod)? Will/can all witnesses be present during
051011 - testimony of other witnesses?
051013 - ..
051014 - c. Can Millie/representative be present during the entire
051015 - meeting, ask witnesses questions?
051017 - ..
051018 - d. Will a transcript be prepared?
051020 - ..
051021 - e. Will findings and conclusions be issued?
051023 - ..
051024 - f. Are Committee members briefed to prepare for hearing the
051025 - case? or,
051027 - ..
051028 - g. Will everything be new and heard for the first time at the
051029 - hearing?
051031 - ..
051032 - h. Millie should get any briefing books prepared for the
051033 - Commiteed in order to see exactly what the Committed sees.
051035 - ..
051036 - i. Can Millie get documents the Committee sees before and
051037 - after the hearing?
051039 - ..
051040 - j. Are Committee members active doctors, nurses, lawyers,
051041 - executives, or
051043 - ..
051044 - k. Does the Appeals Committee use permenant hearing officers?
051046 - ..
051047 - l. Is the Committee assisted by counsel on lattitude deciding
051048 - what to do?
051050 - ..
051051 - m. Need copies of legal advice given to the Committee in this
051052 - matter?
051054 - ..
051055 - n. How much time is alloted for hearing this case?
051057 - ..
051058 - o. Will time be divided between my representation, and somone
051059 - appearing for Kaiser?
051061 - ..
051062 - p. Should I prepare a statement to read that lists issues and
051063 - cites relevant history, or simply show up and answer
051064 - questions posed by the Committee?
051066 - ..
051067 - [On 071012 began inquires for representation and to
051068 - research working with the MCRC Appeals Committee process,
051069 - and also legal review on 070917, ref SDS 17 596Q, which
051070 - requires further research on authority for Kaiser EOC
051071 - Section 2 requiring doctors to prescribe needed treatment
051072 - for covered services (here oncology), reviewed on 070927,
051073 - ref SDS 19 WS6M, can Kaiser avoid prescribing and paying
051074 - for needed treatment? ref SDS 23 X58I
051076 - ..
051077 - [On 071015 HICAP public service legal representation for
051078 - seniors dealing with HMO, Medicare suggested that Millie
051079 - attend the hearing, and if Kaiser fails to pay for
051080 - prescribed treatment, HICAP will represent litigation
051081 - going forward. ref SDS 24 IJ7F
051083 - ..
051084 - [On 071022 Millie contacted Sonia at N&P for ideas on
051085 - representation. ref SDS 25 HI7T
051087 - ..
051088 - Kaiser's MCRC letter from Paula continues...
051089 -
051090 - 6. What if you have a quality of care complaint?
051091 -
051092 - If you are concerned about the quality of care you have
051093 - received, you may also file a complaint with the local Quality
051094 - Improvement Organization, Lumetra (800 841 1602). Quality
051095 - Improvement Organizations are groups of doctors and health
051096 - professionals that monitor the quality of care provided to
051097 - Medicare beneficiaries. The Quality Improvement Organization
051098 - review process is designed to stop any improper practice.
051099 - ref DRT 1 HU9O
051101 - ..
051102 - 7. You may also file a quality complaint with Kaiser Foundation
051103 - Health Plan. We will review your complaint and notify you in
051104 - writing of our conclusion within 30 days, unless we notify you
051105 - that additional time is necessary. This process is separate
051106 - from the appeal process. ref DRT 1 DQ4Q
051108 - ..
051109 - 8. If you have any questions or need further assistance, please
051110 - contact me at 925 924 6887 Monday through Friday, excluding
051111 - holidays, between the hours of 8:30 a.m. and 5:00 p.m. You may
051112 - also call 1 800 443 0815 or TTY 1 800 777 1370 for the deal and
051113 - hard of hearing or speech impaired. Representatives are
051114 - available seven days a week, 7 a.m. to 8 p.m. ref DRT 1 VH5J
051116 - ..
051117 - 9. H0524/H6050/H6052_CBA 1304 Medicare Postservice Appeals Ack:
051118 - 06/29/07, ref DRT 1 PPYS
051120 - ..
051121 - 10. KAISER PERMANENTE
051122 - Kaiser Foundation Plan, Inc.
051123 - Kaiser Foundation Hospitals
051124 - The Permanente Medical Group, Inc.
051125 - Southern California Foundation Medical Group,
051126 - ref DRT 1 PQPS
051128 - ..
051129 - STATEMENT OF AUTHORIZED REPRESENTATIVE - PAGE 1 of 2
051131 - ..
051132 - 11. I understand that Kaiser Permanente will not condition
051133 - treatment, payment, enrollment, or eligibility for benefits on
051134 - my providing or refusing to provide this authorization.
051135 - ref DRT 1 015J
051137 - ..
051138 - 12. PART A: If you wish to give authority to another party to file
051139 - a complaint, grievance, Medicare Review, or an appeal on your
051140 - behalf, please complete the following information. If you wish
051141 - this person to receive Protected Health Information (PHI)
051142 - regarding your treatment and care, you must check the
051143 - appropriate box(es) below and you and your representative must
051144 - both sign and date this form. Please return the completed form
051145 - to the Member Services office handling your case. ref DRT 1
051146 - DR4V
051147 -
051148 - [On 071025 Millie responded to Kaiser's letter, and
051149 - submitted authorization for representation. ref SDS 26 AM3K
051151 - ..
051152 - Your Name and Address, ref DRT 1 PQRU
051154 - ..
051157 - ..
051160 - ..
051163 - ..
051164 - Medical Record #, ref DRT 1 PQSU
051165 -
051168 - ..
051169 - Medicare #
051170 -
051173 - ..
051174 - 13. Name of Designated Person, ref DRT 1 PQTV
051178 - ..
051179 - Address
051184 - ..
051185 - Daytime Phone #, ref DRT 1 PQUU
051189 - ..
051190 - 14. x I authorize KFHP to disclose protected Health Information
051191 - regarding my mdeical condition and care and/or payment
051192 - information to the above named individual. This information
051193 - must be relevant to the request filed with Member Services on
051194 - October 1, 2007 (date of request). ref DRT 1 015L
051196 - ..
051197 - 15. SPECIFY Check the box and initial to specify which type of
051198 - authorization is to be dislcosed.
051200 - ..
051201 - RECORDS: x
051203 - ..
051204 - MEDICAL INFORMATION INITIAL
051208 - ..
051209 - 16. PSYCHIATRIC INFORMATION [no authorization checked]
051210 -
051211 - SIGNATURE [no signature for psychiatric information]
051212 - DATE [no date]
051214 - ..
051215 - 17. DRUG/ALCOHOL INFORMATION [no authorization checked]
051216 -
051217 - SIGNATURE [no signature for drug/alchohol information]
051218 - DATE [no date]
051220 - ..
051221 - 18. RESULTS OF AN HIV BLOOD TEST [no authorization checked]
051222 -
051223 - SIGNATURE [no signature for HIV test]
051224 - DATE [no date]
051226 - ..
051227 - 19. OTHER HEALTH INFORMATION (specify below)
051229 - ..
051230 - Specify the records to be disclosed:
051232 - ..
051233 - {No other health information specified for disclosure to
051234 - representative}
051236 - ..
051237 - 20. x This authorization shall become effective immediately and
051238 - shall remain in effect until the earlier or final resolution of
051239 - my request or Dec 31, 2008 (specify date).
051240 -
051241 - [On 071025 Millie responded to Kaiser's letter, and
051242 - submitted authorization for representation. ref SDS 26 AM3K
051243 -
051244 - ***********************
051246 - ..
051247 - 21. 00139-000 (REV. 6-03) PAGE 1 OF 2 HIPAA COMPLIANT
051248 - FOR SPANISH USE 00139-001; CHINESE USE 00139-002
051249 - NS-1062 (REV. 6-03) PAGE 1 OF 2 HIPAA COMPLIANT
051250 - FOR SPANISH USE NS-1071; CHINESE USE NS-1075
051251 -
051252 -
051253 - **************************************
051255 - ..
051256 - 22. KAISER PERMANENTE
051257 - Kaiser Foundation Plan, Inc.
051258 - Kaiser Foundation Hospitals
051259 - The Permanente Medical Group, Inc.
051260 - Southern California Foundation Medical Group
051262 - ..
051263 - STATEMENT OF AUTHORIZED REPRESENTATIVE - PAGE 2 of 2
051265 - ..
051266 - 23. REVOCATION: This authorization is also subject to written
051267 - revocation by the member/patient at any time. The written
051268 - revocation will be effective upon receipt, except to the extent
051269 - that the disclosing party or others have acted in reliance upon
051270 - this Authorization.
051272 - ..
051273 - 24. REDISCLOSURE: I understand that the recipient may not lawfully
051274 - further use or disclose the health information unless another
051275 - authorization is obtained from me or unless such use or
051276 - disclosure is specifically required or permitted by law.
051278 - ..
051279 - 25. Your Signature:
051283 - ..
051284 - Date: 10/13/07
051286 - ..
051287 - 26. PART C:
051289 - ..
051290 - 27. I am authorized to sign this authorization on behalf of
051291 - ______________________ and on the basis of:
051293 - ..
051294 - 28. Legal Authority (Power of Attorney, etc.) [no authorization
051295 - not applicable]
051297 - ..
051298 - 29. Written Designation by Member [no authorization not applicable]
051300 - ..
051301 - 30. Parent, Guardian, or other individual acting in loco parentis
051302 - {no authorization not applicable}
051304 - ..
051305 - 31. Authorized Representative:
051309 - ..
051310 - Date: Oct 13, 2007
051312 - ..
051313 - 32. Patient has a right to a copy of this form.
051314 -
051315 -
051316 - ***********************
051318 - ..
051319 - 33. 00139-000 (REV. 6-03) PAGE 2 OF 2 HIPAA COMPLIANT
051320 - FOR SPANISH USE 00139-001; CHINESE USE 00139-002
051321 - NS-1062 (REV. 6-03) PAGE 2 OF 2 HIPAA COMPLIANT
051322 - FOR SPANISH USE NS-1071; CHINESE USE NS-1075
051323 -
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