Coverage and claims appeals

If Kaiser Permanente denies coverage for a medical service or payment of a claim, you have the right to appeal that decision. Disputes are reviewed through a first-level appeal process, with an optional second-level review available. You can use this appeal process, unless your contract states otherwise.

If you're not satisfied:
Appeals that are not resolved to your satisfaction may be eligible for independent review by a state-certified independent review organization or plan-specified entity. Kaiser Permanente pays for this review, unless provided through the specific purchaser (and then you must abide by the independent review organization's decision).

Medicare and federal plan members follow the independent review process administered by the Medicare and federal programs. Refer to your current coverage agreement for more information regarding your appeal rights.

The appeal process is not designed for resolving billing issues — these should be directed to Kaiser Permanente Member Services at 1-888-901-4636.

Self-funded plans may offer one level of internal appeal through Kaiser Permanente and must provide for an independent review at the next level.

Plans in Idaho include a Kaiser Permanente appeal board review on initial appeal, and an independent review through an organization assigned by the Idaho Department of Insurance.

How to initiate an appeal

Complete the Member Appeal Request form and return it to the Member Appeals department.

Fax:
206-630-1859

Mail:
Kaiser Permanente Member Appeals
P.O. Box 34593
Seattle, WA 98124-1593

Online
Sign on to the secure Kaiser Permanente member website and submit the Online Member Appeal Request form

Call Member Services at 1-866-458-5479 for assistance.

Expedited reviews

If any delay could seriously impact your health, you or your physician can request an expedited review. A determination is typically issued within 24-72 hours, depending on your plan's requirements. You can also request a simultaneous independent review, if applicable. Call Kaiser Permanente's Member Appeals Unit at 1-866-458-5479 for more information.

Requests on behalf of a member

If you are submitting a request on behalf of a member, you must complete and sign the following Kaiser Permanente member appeals forms:

If the member is unable to sign the Appointment of Representation or Authorization to Release Health Care Information forms:
Send a Healthcare and/or Financial Dependent Power of Attorney (authorized to appeal on behalf of the member.)

If you are the treating provider submitting this request on behalf of the member:
You must provide an Appointment of Representative form, signed by both you and the member, and an Authorization to Release Health Care Information form signed by the member (only required if post-service)

If the denial document states the payment is the provider's responsibility (not the member's):
The provider must submit a reconsideration request in writing to the Provider Assistance Unit. The member may not appeal on behalf of the provider.