Refer to the Kaiser HMO's member handbook for information on the benefits determination process including claims and appeals.

Refer to HMSA's "Guide to Benefits" document for information on the benefits determination process including claims and appeal for the Hawaii HMO and PPP plans.

For all other health care plans, see below for information on the benefits determination process including claims and appeals.

Three types of claims can be made for benefit determinations: pre-service claims, post-service claims, and claims involving urgent care.

Note, a post-service claim would never constitute a claim involving urgent care.

Note that the various headings and sub-headings in the Benefits Handbook (which produce the website navigation menus and the tables of contents in the printed version) are provided for your convenience and in no way define, limit, or otherwise describe the scope or intent of the plans. See "Administrative Details about the Plans" for the name and contact information for the Claims Administrator for each plan.

The one type of claim that can be made for benefit determinations is a post-service claim.

Note, a post-service claim would never constitute a claim involving urgent care.

Note that the various headings and sub-headings in the Benefits Handbook (which produce the website navigation menus and the tables of contents in the printed version) are provided for your convenience and in no way define, limit, or otherwise describe the scope or intent of the plans.

See "Administrative Details about the Plans" for the name and contact information for the Claims Administrator for each plan.

In the case of a pre-service claim, the Claims Administrator will notify you of the benefit determination (whether adverse or not) no later than 15 days after your claim is received. This period may be extended one time by the Claims Administrator for up to 15 days, provided that the extension is necessary due to matters beyond the control of the Claims Administrator and you are notified prior to the expiration of the initial 15-day period of the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision. If additional information is needed to process the claim, the Claims Administrator will notify you of the information needed within 15 days after the claim was received and may request a one-time extension not longer than 15 days and suspend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day timeframe, the Claims Administrator will notify you of the determination within 15 days after the information is received. If you don't provide the needed information within the 45-day period, your claim will be denied. A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, describe any additional material or information necessary to complete the claim so it may be processed, and provide the claim appeal procedures.

In the case of a post-service claim, the Claims Administrator will notify you of the benefit determination (whether adverse or not) no later than 30 days after your claim was received. This period may be extended one time by the Claims Administrator for up to 15 days, provided that the extension is necessary due to matters beyond the control of the Claims Administrator and you are notified prior to the expiration of the initial 30-day period of the circumstances requiring the extension and the date by which the Claims Administrator expects to render a decision. If additional information is needed to process the claim, the Claims Administrator will notify you within this 30-day period and may request a one-time extension of not more than 15 days and suspend your claim until all information is received. Once notified of the extension, you then have 45 days to provide this information. If all of the needed information is received within the 45-day timeframe, the Claims Administrator will notify you of the determination within 15 days after the information is received. If you don't provide the needed information within the 45-day period, your claim will be denied. A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, describe any additional material or information necessary to complete the claim so it may be processed, and provide the claim appeal procedures.

In the case of a claim involving urgent care, the Claims Administrator will notify you of the benefit determination (whether adverse or not) no later than 72 hours after your claim is received. If additional information is needed to process the claim, the Claims Administrator will notify you within 24 hours after receipt of your claim of the specific information necessary to complete the claim. Once notified of the extension, you then have 48 hours to provide this information. If all of the needed information is received within the 48-hour timeframe, the Claims Administrator will notify you of the determination within 48 hours after the information is received. If you don't provide the needed information within the 48-hour period, your claim will be denied. A denial notice will explain the reason for denial, refer to the part of the plan on which the denial is based, describe any additional material or information necessary to complete the claim so it may be processed, and provide the claim appeal procedures.

If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and the treatment involves urgent care, your request will be decided within 24 hours, provided your request is made at least 24 hours prior to the end of the approved treatment. The Claims Administrator will make a determination on your request for the extended treatment within 24 hours from receipt of your request. If you do not make a request for extended treatment involving urgent care at least 24 hours prior to the end of the approved treatment, the request will be treated as an urgent care claim and decided according to the urgent care claim benefit determination timeframes, (i.e., no later than 72 hours from receipt of your request).

If a request to extend a course of treatment beyond the period of time or number of treatments previously approved does not involve urgent care, the request will be treated as a new benefit claim and decided within the time frame appropriate to the type of claim (i.e., as a pre-service or post-service claim).

If you believe your benefits under a plan were denied improperly, you may file a written appeal for the unpaid amount within 180 days of your receipt of notification of the adverse benefit determination. The written appeal should specify the amount of the claim, include any other written comments, documents, records or other information that may be pertinent and should be sent to the Claims Administrator.

If you are not satisfied with the first level appeal decision of the Claims Administrator, you have the right to request a second level appeal from the Claims Administrator. Your second level appeal request must be submitted to the Claims Administrator within 60 days from receipt of the first level appeal decision.

For appeals of a pre-service claim, the first level appeal will be conducted, and you will be notified by the Claims Administrator of the decision within 15 days from receipt of a request for appeal of a denied claim. The second level appeal will be conducted and you will be notified by the Claims Administrator of the decision within 15 days from receipt of a request for review of the first level appeal decision.

For appeals of a post-service claim, the first level appeal will be conducted, and you will be notified by the Claims Administrator of the decision within 30 days from receipt of a request for appeal of a denied claim. The second level appeal will be conducted, and you will be notified by the Claims Administrator of the decision within 30 days from receipt of a request for review of the first level appeal decision.

Your appeal may require immediate action if a delay in treatment could significantly increase the risk to your health or the ability to regain maximum function or cause severe pain. In these urgent situations, the appeal does not need to be submitted in writing. You or your physician should call the Claims Administrator as soon as possible. The Claims Administrator will provide you with a written or electronic determination within 72 hours following receipt of your request for review of the determination taking into account the seriousness of your condition.

If you filed a pre-service or urgent care claim improperly, the Claims Administrator will notify you of the improper filing and how to correct it within five days (24 hours in the case of a failure to file a claim involving urgent care) after the pre-service claim was received.

If your claim concerns whether or not you or a family member is eligible for coverage under the plan or whether you or a family member has properly enrolled in the plan, you may file a claim with the Plan Administrator for coverage. The claim should be in writing and specify the circumstances under which you do not have coverage, why you believe you should have coverage and include any mitigating factors, documents, records or other information that may be pertinent and should be sent to the Plan Administrator. You may file a written appeal with the Plan Administrator within 180 days of your notification of an adverse claim determination. A written appeal of a denied claim should include all the information necessary for the original claim as well as any additional information you would like the plan to consider.

To the maximum extent permitted by law, the Plan is entitled to equitable or other permitted remedies, including a lien or constructive trust, to recover any amounts received as a result of a judgment, settlement or other means of compensation for conditions or injuries which have resulted in the payment of benefits under this Plan. This shall include, but is not limited to, damages for pain and suffering and lost income.

The Plan is entitled to recover these amounts from the participant, any covered family member or beneficiary, or any other person holding them, up to the amount of all payments made or payable in the future plus the costs of recovery. The Plan has a priority interest in any and all funds recovered in any full or partial recovery, including funds intended to compensate for attorney's fees and other expenses.

As a condition of receiving benefits under this Plan, you agree that: