Provider reconsideration process for Washington State

(Submitting requests and/or documents electronically will greatly reduce processing times)

RECONSIDERATION TIME FRAMES

Commercial members:

  • Member liability – 180 days from the notification date of denial will follow the member appeals process.
  • Provider liability – 24 months from the notification date of denial.
  • Coordination of benefits – 30 months from the notification date of denial.

Medicare members:

  • Contracted providers - 24 months from the notification date of denial.
  • Non-contracted providers – 60 days from the notification date of denial will follow the member appeals process.
  • Coordination of benefits – 30 months from the notification date of denial.

CLAIMS (NON-AUTHORIZATION RELATED)

EXAMPLES

  • Code review
  • Pricing dispute
  • Diagnosis code not commonly associated with the procedure
  • Units billed do not match
  • Modifier listed is invalid
  • Timely filing

Note: Does not include all; purpose is for example only.

WHERE TO SEND YOUR RECONSIDERATION

First Level Reconsideration:

Second Level Reconsideration:

CLAIMS (AUTHORIZATION/CLINICAL REVIEW RELATED)

EXAMPLES

  • No authorization obtained
  • Quantity exceeds authorization
  • Date of service does not fall within dates of authorization
  • Service exceeds authorization
  • Type of Service/Place of Service does not match
  • Service not medical necessary

Note: Does not include all; purpose is for example only.

DENIAL CODE/REASON

  • N435, N4351, and MA30
  • N372

Note: Does not include all; purpose is for example only.

WHERE TO SEND YOUR RECONSIDERATION

Reconsideration:

All requests must include a detailed reconsideration letter stating the extenuating circumstances that prevented your facility from obtaining a provider authorization.

  • Missing or incomplete information will result in rejection of your reconsideration request.

Inpatient / observation required document for review

  • Registration and verification of insurance (if we are not notified of the stay)
  • Procedures or operative reports
  • ER notes
  • Daily MD process notes
  • History & physical
  • Discharge summary
  • Consultations

If the reconsideration has been reviewed and upheld, the reconsideration is complete.

Providers seeking additional consideration will need to reach out to their organization’s Contracting department to escalate. The Provider Assistance Unit and Provider Services are unable to assist if all levels of reconsideration have been exhausted.

PRE-PAYMENT

EXAMPLES

  • Inpatient facility charges
  • Outpatient facility charges
  • Billed charges exceeding $20,000
  • Medicare or Commercial member and DRG contains outlier
  • Percentage of charge payment reimbursement
  • Unsolicited 277 response (tentative)

MEDICAL RECORDS AND ITEMIZATION SUBMISSIONS REASON CODE

  • N366, N26, and N221

Note: Does not include all; purpose is for example only.

MEDICAL RECORDS AND ITEMIZATION SUBMISSIONS

DENIAL CODE/REASON

  • N661, N163, N22, and M15

Note: Does not include all; purpose is for example only.

WHERE TO SEND YOUR RECONSIDERATION

First Level Reconsideration:

Second Level Reconsideration:

If both levels of reconsideration have been reviewed, and denials upheld, providers have exhausted their allowance of reconsideration attempts and the reconsideration process is no longer available for consideration.

Providers seeking additional consideration will need to reach out to their organization’s Contracting department to escalate. The Provider Assistance Unit and Provider Services are unable to assist if all levels of reconsideration have been exhausted.

COTIVITI

EXAMPLES

  • DRG (Diagnosis Related Group) Reviews

DENIAL CODE/REASON

  • N221 and N10

Note: Does not include all; purpose is for example only.

SEND YOUR RECONSIDERATION

Note: All inquiries regarding Cotiviti claims reviews must go directly to Cotiviti

If both levels of reconsideration have been reviewed, and denials upheld, providers have exhausted their allowance of reconsideration attempts and the reconsideration process is no longer available for consideration.

Providers seeking additional consideration will need to reach out to their organization’s Contracting department to escalate. The Provider Assistance Unit and Provider Services are unable to assist if all levels of reconsideration have been exhausted.

BALANCE BILLING PROTECTION ACT

EXAMPLES

  • The charge(s) for this service was processed in accordance with Federal/State, Balance Billing/No Surprise Billing regulations. As such, any amount identified with OA, CO, or PI cannot be collected from the member and may be considered provider liability.

DENIAL CODE/REASON

  • N830

WHERE TO SEND YOUR RECONSIDERATION

First Level Reconsideration:

  • Reconsideration time frame: Providers have 30 days from the notification date of denial
  • Email to: Balance-Billing-Arbitration@kp.org
  • Mail to: Kaiser Permanente
    Attn: Balance Billing Arbitration
    P.O. Box 30766
    Salt Lake City, UT 84130

Second Level Reconsideration:

    Reconsideration Time Frame: Providers have 40 days from the notification date of denial

    • Office of Insurance Commissioner at: 1-800-562-6900

    Note: All inquiries regarding Second Level Reconsiderations for the Balance Billing Protection Act will need to go directly to the OIC

    If both levels of reconsideration have been reviewed, and denials upheld, providers have exhausted their allowance of reconsideration attempts and the reconsideration process is no longer available for consideration.

    Providers seeking additional consideration will need to reach out to their organization’s Contracting department to escalate. The Provider Assistance Unit and Provider Services are unable to assist if all levels of reconsideration have been exhausted.

FEDERAL NO SURPRISE BILLING ACT

EXAMPLES

  • The Federal no Surprise Billing Act qualified payment amount (QPA) was used to calculate the members cost share(s).

DENIAL CODE/REASON

  • N860

WHERE TO SEND YOUR NEGOTIATION

Negotiation time frame: If you wish to initiate a 30 business-day open negotiation period for purposes of determining the amount of total payment, as applicable, please contact the appropriate person or office*.

If the negotiation period does not result in an agreement as to the amount of total payment, you may initiate the independent dispute resolution process within 4 business days after the end of the open negotiation period.

Claims with note(s) - PAID PER MULTIPLAN

Claims with note(s) - PAID PER QPA (FH) or PAID PER QPA (A)

AIR AMBULANCE CLAIMS

The qualifying payment amount was determined to comply with applicable federal requirements.

EXAMPLES

  • Pricing
  • Allowed Amount

WHERE TO SEND YOUR NEGOTIATION

Negotiation time frame: 30-business-day open negotiation period.

  • Email to: Air-Ambulance-Appeals@kp.org
  • Or by calling Relation Insurance Services (formerly Employer's Mutual Incorporated) at 888-505-0468.