Transparency in Coverage

Certain services require authorization before you get them. In these cases, your participating provider can help you get authorization for care he or she considers medically necessary. We determine when covered services are medically necessary based upon certain standards that take into account your medical condition as well as generally accepted standards of care.

When you receive covered services for which you do not have prior authorization or that you receive from non-participating providers or from non-Plan Facilities that have not been approved by us in advance, we will not pay for them except in an emergency.

Some services need special approval through a utilization review. If you need services that require a review and your participating provider believes they’re medically necessary, he or she may submit a request for a utilization review for you, or you may submit a request. We will respond to your request within 14 calendar days.

If the request is denied, Kaiser Permanente will send you a letter. It will explain the reason for our decision and give instructions for filing an appeal if you don’t agree with the determination.

When you get care from participating providers, you won’t be responsible for paying any amounts except for any cost sharing (deductibles, copayments or coinsurance) amounts that you owe. However, you will need to pay for any noncovered services you receive, whether you get them from a participating or a non-participating provider.

If you get covered services without prior authorization — or if you get them from a non-participating provider we haven’t approved in advance — we won’t pay for them, except in an emergency. Charges for these services will be your financial responsibility, and you may be billed directly by the provider for any balance you owe.

If you have chosen for Kaiser Permanente to receive advance payments of your premium tax credit, your monthly premium payment will be reduced by that amount. You need to pay any part of the premium that isn’t covered by the advance payment. If we don’t get your portion of the monthly premium by the due date, you’ll have a 3-month grace period in which to pay the late premium as well as the premiums owed for the additional 2 months of the grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full.

If you qualify for a grace period, we’ll send you a notice with details. During the first month of the grace period, we’ll pay all appropriate claims for covered services. For the second and third months, we may choose not to pay for services if we don’t get your payment for any outstanding premiums by the end of the grace period. However, you generally won’t have to file a claim if a Kaiser Permanente provider provides the services. A participating provider will send the bill/claim directly to Kaiser Permanente, and we’ll process the claim unless you don’t pay your premium and we have indicated to your participating provider that we may not pay their claim (pended the participating provider’s claim).

In certain cases, a claim may be denied retroactively — for example, if you fail to pay your premium or you get services after your membership ends. In the event of a retroactive denial, you’ll be financially responsible for the covered services you received. To ensure a claim is not retroactively denied, premiums must be paid on time. If you have questions about a claim that’s been denied, please contact Member Services.

If we terminate your membership, we’ll refund any premium payments you made after your membership ended. We’ll also pay you any amounts we owe for claims while you were a member. When making these payments, we may deduct any amounts you owe Kaiser Permanente or any participating providers. Refunds for overpayment of premium are provided based on the method of payment used by the member. If you believe you have overpaid your premium and are due a refund, please contact Member Services.

We cover generic and brand name drugs, including those for specialty and biological drugs. Plan Pharmacies will substitute a generic equivalent for a Brand Name Drug when a generic equivalent is on our Preferred Drug List unless one of the following is met;

• The Provider has prescribed a Brand Name Drug and has indicated “dispense as written,” also sometimes referred to as “(DAW)” on the prescription;
• Brand Name Drug is listed on our Preferred Drug List;
• Brand Name Drug is prescribed by a:
  • Plan Physician;
  • Non-Plan Physician to whom you have an approved referral;
  • Dentist; and
    • There is no equivalent Generic Drug, or an equivalent Generic Drug has:
    • Been ineffective in treating the disease or condition of the Member; or
    • Caused or is likely to cause an adverse reaction or other harm to the Member.

The Health Plan will treat the drug(s) obtained as prescribed above as an Essential Health Benefit, including by counting any Cost-Sharing toward the Plan’s annual limitation on Cost-Sharing.

If you request a Brand Name Drug for which none of the above conditions has been met, you will be responsible for the Non-Preferred Brand Drug Cost Share.

We cover preferred brand and non-preferred brand drugs, including those for specialty and biological drugs.
Plan Pharmacies will dispense drugs from our Preferred Drug List unless the following criteria are met:
The Non-Preferred Brand Drug is prescribed by a:

• Plan Physician;
• Non-Plan Physician to whom you have a referral; or
• Dentist; and
  • There is no equivalent drug in our Preferred Drug List; or
  • An equivalent Preferred Drug List drug has:
    • Been ineffective in treating the disease or condition of the Member; or
    • Caused or is likely to cause an adverse reaction or other harm to the Member.

If you request a Non-Preferred Brand Drug, the Non-Preferred Brand Drug Cost Share will apply.

The Health Plan will treat the drug(s) obtained as prescribed above as an Essential Health Benefit, including by counting any Cost Sharing towards the Plan's annual limitation on Cost Sharing.

Sometimes you may need a prescription drug that is not covered on Kaiser Permanente’s formulary (list of covered drugs). If you request a prescription for a non-formulary drug, and your Kaiser Permanente provider does not give you the prescription, then you may request review through the non-formulary exception review process. You or your Kaiser Permanente provider may submit the request to us with information as to why the non-formulary drug is medically necessary so that we may review your request.

To submit a non-formulary exception request to Kaiser Permanente, please contact Member Services. You must submit medical information supporting your request in order for us to complete our review. For most requests (standard requests), we will respond within 72 hours, but when exigent circumstances exist (i.e., your life, health or ability to regain maximum function would be seriously jeopardized without the non-formulary drug, or when you are already taking the non-formulary drug), then we will expedite your review request and respond to your request within 24 hours after our receipt of the request. If we grant your request, we will cover the non-formulary drug for the duration of the prescription, including refills. If exigent circumstances exist, we will cover the non-formulary drug for the duration of the exigent circumstance.

If after our review of your non-formulary drug exception request, you feel that we have denied your request for the non-formulary drug incorrectly, you may ask us to submit the case for external review. This external review may be requested by you, your authorized representative or the prescribing provider by following the instructions for an Independent External Review below.

An independent review organization will review your external review request within 72 hours, or 24 hours for exigent circumstances. If the external review results in your non-formulary drug being approved, we will cover it for the either duration of the exigent circumstances or the duration of the prescription, as applicable.

A member may file for an Independent External Appeal with the State Corporation Commission’s Bureau of Insurance

• If all of the Health Plan’s Appeal procedures described above have been exhausted; or
• If the Member’s Adverse Decision involves cancer treatment or a medical condition where the timeframe for completion of an expedited internal appeal of an Adverse Decision would seriously jeopardize the life or health of the Member or would jeopardize the Member’s ability to regain maximum function; or
• If the Member requested an Expedited Appeal and Health Plan determined that the standard appeal timeframes should apply; or
• When an Expedited Appeal is reviewed and is denied.

A member may request an expedited emergency review prior to exhausting our internal Appeal process if:

• An Adverse Decision that was based on a determination that services are experimental/investigational may be expedited with written certification by the treating physician that services would be less effective if not initiated promptly;
• The Health Plan fails to render a standard internal appeal determination within thirty (30) or sixty (60) days and you, your Authorized Representative or Health Care provider has not requested or agreed to a delay; or
• The Health Plan waives the exhaustion requirement.

An expedited emergency review for denials due to medical necessity, appropriateness, healthcare setting, level of care, or effectiveness may be requested simultaneously with an expedited internal review. The Independent Review Organization will review and determine if an internal appeal should be completed prior to expedited emergency review. The forms and instructions for filing an emergency review are provided to the Member along with the notice of a final Adverse Decision. To file an Appeal with the Bureau it must be filed in writing within one-hundred twenty (120) days from the date of receipt of your Health Plan decision letter using the forms required by the Bureau. The request is mailed to the following address:

Virginia State Corporation Commission Bureau of Insurance
Life and Health Consumer Services Division
P. O. Box 1157 Richmond, VA
23218 804-371-9691 (Phone) 804-671-9944 (Fax)
www.scc.virginia.gov (Website)

The decision resulting from the external review will be binding on both the member and Health Plan to the same extent to which we would have been bound by a judgment entered in an action of law or in equity, with respect to those issues which the external review entity may review regarding a final Adverse Decision of Health Plan.

An Explanation of Benefits (EOB) is a summary of services you’ve received during a specific period. It shows the charges, the date of your visit, and the name of the provider you visited. An EOB is not a bill. It’s available to help you understand the payments made for your covered services and to help you keep track of your expenses. EOBs are sent at least once a month after the Member receives services and the claim is received by Kaiser Permanente to be processed.

If you have health coverage under more than one plan, the Coordination of Benefits process helps you make the most of your coverages to make sure you get the care you need. It determines the order in which different plans pay for services, which can make it easier to get and pay for care.

The plan that pays first is the primary plan. It’s responsible for paying first regardless of whether another plan covers some expenses so long as the care is covered. The secondary plan pays next. Based on how much the primary plan pays, it may reduce what it pays so the amounts from both plans don’t total more than the allowable expense for specific services.

If you have any questions or want more information about any of the topics covered here, please contact Member Services. One of our representatives will be happy to help.