Provider Manual

The provider manual is not intended for any use by any party other than as a resource for Kaiser Permanente Washington's contracted providers in fulfilling their obligations under provider contracts. Kaiser Permanente intends for the manual to be accurate for its intended purpose but doesn't guarantee accuracy. Providers should comply with the terms of their provider contracts and any legal requirements in the event of an inconsistency between the manual and a requirement in their provider contracts or the law.

  1. 1. Welcome to Kaiser Permanente Washington
    1. 1.1. Introduction
    2. 1.2. About Kaiser Permanente (Washington Region)
    3. 1.3. Our Relationship with Network Providers
  2. 2. Working with Kaiser Permanente
    1. 2.1. Inform Us of Your Practice Changes
      1. 2.1.1. Alternative Medicine Providers
      2. 2.1.2. Mental Health Providers
      3. 2.1.3. Delegated Organizations
      4. 2.1.4. All Other Providers/Organizations
      5. 2.1.5. Termination
      6. 2.1.6. Add A Practitioner
    2. 2.2. Provider Responsibilities
      1. 2.2.1. Commitment To Quality Improvement
      2. 2.2.2. Communicating with Our Members
      3. 2.2.3. Notification of Emergency Hospital Admissions
      4. 2.2.4. Patient Experience Surveys
      5. 2.2.5. Practice Expectations - Timely and Adequate Patient Care
      6. 2.2.6. Professional Conduct
      7. 2.2.7. Provider Directory
      8. 2.2.8. Race, Ethnicity and Language Equity
      9. 2.2.9. Self-Treatment of Immediate Family Members
      10. 2.2.10. Use of Third-Party Apps for Billing Services
    3. 2.3. Medical Records and Documentation Standards
      1. 2.3.1. Authorship and Authentication of Dictated Reports
      2. 2.3.2. Clinical Performance Reviews
      3. 2.3.3. Confidentiality Language
      4. 2.3.4. Documentation Standards
      5. 2.3.5. Faxing Medical Records
      6. 2.3.6. Information Security Measures
      7. 2.3.7. Medical Records Standards
      8. 2.3.8. Password Security
      9. 2.3.9. Protected Health Information
      10. 2.3.10. Providing Documentation of Referral Encounters
      11. 2.3.11. Securing Confidential Information
    4. 2.4. New Provider Orientation
    5. 2.5. Credentialing
      1. 2.5.1. Initial Credentialing and Recredentialing
      2. 2.5.2. HDO Credentialing
      3. 2.5.3. Your Rights
      4. 2.5.4. Dispute Resolution Process (Nonreportable Events)
      5. 2.5.5. Appeals (Reportable Events)
    6. 2.6. Provider Communications
      1. 2.6.1. Provider Notices
      2. 2.6.2. Provider eNews
  3. 3. Coverage and Eligibility
    1. 3.1. Kaiser Permanente Identification Cards
    2. 3.2. Kaiser Permanente Plans and Networks
      1. 3.2.1. Kaiser Permanente Health Plan of Washington
      2. 3.2.2. Kaiser Foundation Health Plan of Washington Options, Inc.
      3. 3.2.3. Kaiser Permanente Networks
  4. 4. Member Rights
    1. 4.1. Advance Directives
    2. 4.2. Interpretive and Translation Services
      1. 4.2.1. Policy
      2. 4.2.2. Payment for Services
      3. 4.2.3. Contracting for Interpreter Services
      4. 4.2.4. Minimum Interpreter Standards
      5. 4.2.5. Video Interpretation
      6. 4.2.6. Telephone Interpretation
      7. 4.2.7. Documentation
      8. 4.2.8. Interpretation Vendors
      9. 4.2.9. Translation
      10. 4.2.10. Translation Vendors
    3. 4.3. Informed Consent
    4. 4.4. Physical Restraints and Seclusion
    5. 4.5. Right to an Appeal
      1. 4.5.1. Expedited Appeals
      2. 4.5.2. Standard Appeals
      3. 4.5.3. Subsequent Appeal Levels
    6. 4.6. Right to a Second Opinion
    7. 4.7. Member Rights and Responsibilities
    8. 4.8. Member Concerns or Complaints
    9. 4.9. Reporting Quality of Care Concerns
    10. 4.10. Member Access and Corrections to Their Medical Records
      1. 4.10.1. Request for Access
      2. 4.10.2. Denial of Access
      3. 4.10.3. Parental Access
    11. 4.11. Member-Initiated Corrections to Their Medical Records
      1. 4.11.1. Request for Correction
      2. 4.11.2. Denial of request for correction
  5. 5. Authorizations and Clinical Review
    1. 5.1. Prior Authorization
      1. 5.1.1. Accidental or Work-Related Injuries
      2. 5.1.2. Durable Medical Equipment
        1. 5.1.2.1. Billing and Payment
        2. 5.1.2.2. Authorization Process
        3. 5.1.2.3. DME Service Delivery Standards
      3. 5.1.3. Prior Authorization Requirement and Management Guidelines
        1. 5.1.3.1. New Requests
        2. 5.1.3.2. Standard Visits
        3. 5.1.3.3. Exceptions to Standard Visits
        4. 5.1.3.4. Extensions
        5. 5.1.3.5. Authorizations for Medicare Coordination of Benefits
        6. 5.1.3.6. Medicare Coordination with a Maintenance of Benefits Plan
      4. 5.1.4. Radiology Services
        1. 5.1.4.1. Advanced Imaging Services
        2. 5.1.4.2. Imaging Services Requiring Prior Authorization
        3. 5.1.4.3. Imaging Services Not Requiring Prior Authorization
      5. 5.1.5. Referring Kaiser Permanente Members for Specialty Care and Services
        1. 5.1.5.1. Specialty Care Referrals
        2. 5.1.5.2. Emergency Room
        3. 5.1.5.3. Inpatient Care
        4. 5.1.5.4. Referring to Non-Contracted Providers
      6. 5.1.6. Requesting Preauthorization for Coverage
      7. 5.1.7. Retroactive Authorizations, Extenuating Circumstances, and Provider Referral Reconsideration Requests
        1. 5.1.7.1. Retroactive Authorizations
        2. 5.1.7.2. Extenuating Circumstances
        3. 5.1.7.3. Requirements for Retroactive Preauthorization Consideration
        4. 5.1.7.4. Reconsiderations of a Denial
      8. 5.1.8. Transplant Services
        1. 5.1.8.1. Requesting a Transplant
        2. 5.1.8.2. Member Benefits
    2. 5.2. Prior Authorization - Mental Health
      1. 5.2.1. Applied Behavioral Analysis
        1. 5.2.1.1. Coverage and Referral
        2. 5.2.1.2. Authorization Process
        3. 5.2.1.3. Preauthorization Process
        4. 5.2.1.4. Initial ABA Authorizations
        5. 5.2.1.5. Continued ABA treatment
        6. 5.2.1.6. Termination of Services
        7. 5.2.1.7. Addendums to Current Authorizations
        8. 5.2.1.8. Appeals
        9. 5.2.1.9. Contact Information
      2. 5.2.2. Coordinating Mental Health Inpatient or Residential Care
      3. 5.2.3. Excluded Mental Health Services and Addiction and Recovery Service
        1. 5.2.3.1. Mental Health and Wellness Excluded Services
        2. 5.2.3.2. Addiction and Recovery Excluded Services
      4. 5.2.4. Inpatient Addiction and Recovery Treatment
      5. 5.2.5. Inpatient Mental Health Treatment
      6. 5.2.6. Medically Necessary Mental Health Services
    3. 5.3. Clinical Review Criteria
    4. 5.4. Prior Authorization and Utilization Review
      1. 5.4.1. Routine Prior Authorization Reviews
        1. 5.4.1.1. First-Level Reviews
        2. 5.4.1.2. Second-Level Reviews
        3. 5.4.1.3. Notice Of Noncoverage
      2. 5.4.2. Urgent Prior Authorization Reviews
      3. 5.4.3. Utilization Reviews
    5. 5.5. Member Appeals
      1. 5.5.1. Standard Appeals
        1. 5.5.1.1. Non-Medicare Advantage Appeals
        2. 5.5.1.2. Medicare Appeals
      2. 5.5.2. Expedited Appeals
      3. 5.5.3. Subsequent Appeal Levels
      4. 5.5.4. Services Provided During Appeal
  6. 6. Billing and Claims
    1. 6.1. Payment Policies
    2. 6.2. Claims Submission and Processing
      1. 6.2.1. Checking Claims Status
        1. 6.2.1.1. Paper Claims
        2. 6.2.1.2. Electronic Claims
      2. 6.2.2. Claims Adjustments
      3. 6.2.3. Claims Explanation of Payment/835 Remittance Advice & Reimbursement
      4. 6.2.4. Caring for Kaiser Permanente Members from Other Regions
      5. 6.2.5. Claims Submission Requirements
      6. 6.2.6. CMS-1500 Claims — Coding for Services Provided
      7. 6.2.7. Coordination of Benefits
      8. 6.2.8. Copayments
      9. 6.2.9. Deductibles and Coinsurance
      10. 6.2.10. Electronic Batch Transactions
      11. 6.2.11. Electronic Funds Transfer and Electronic Remittance Advice
      12. 6.2.12. Medicare Coordination of Benefits
      13. 6.2.13. Members' Financial Responsibilities
      14. 6.2.14. Motor Vehicle Accidents
      15. 6.2.15. NPI (National Provider Identifier) and Taxonomy
      16. 6.2.16. Outpatient Prospective Payment System/Ambulatory Payment Classifications
      17. 6.2.17. Paper Claims
      18. 6.2.18. Physician Reimbursement for Medical (Non-Psychiatric), Surgical, and Anesthesia Services
      19. 6.2.19. Requests for Additional Claims Documentation
      20. 6.2.20. Submission of Claim Supporting Documents
      21. 6.2.21. Submitting Secondary Claims
      22. 6.2.22. Timely Filing of Claims
      23. 6.2.23. Work-Related Injuries
    3. 6.3. Provider Reconsiderations Conducted Within Kaiser Permanente
      1. 6.3.1. Reconsideration Time Frames for Kaiser Permanente Conducted Reconsiderations
      2. 6.3.2. Medicare Advantage Non-Contracted Provider Appeal Rights
      3. 6.3.3. Claims (Non-Authorization Related)
      4. 6.3.4. Claims (Authorization/Clinical Review Related)
      5. 6.3.5. Pre-Payment
    4. 6.4. Reconsiderations Conducted Outside Kaiser Permanente
      1. 6.4.1. Diagnosis Related Group (DRG) Payment and Review (Cotiviti)
      2. 6.4.2. Optum
      3. 6.4.3. WA Balance Billing Protection Act
      4. 6.4.4. Federal No Surprise Billing Act
  7. 7. Patient Care
    1. 7.1. Clinical Guidelines
    2. 7.2. Mental Health
      1. 7.2.1. Mind Phone
      2. 7.2.2. Measuring Quality of Mental Health Care
    3. 7.3. Complementary and Alternative Medicine
    4. 7.4. Medical Transportation
      1. 7.4.1. Emergency Situations
      2. 7.4.2. Non-Emergency Situations
      3. 7.4.3. Medical Transportation Management (formerly Access2Care)
    5. 7.5. Care Management Programs
      1. 7.5.1. Key Services
      2. 7.5.2. Program Outcomes
      3. 7.5.3. How to Refer
    6. 7.6. Home Health and In-Home Palliative Services
      1. 7.6.1. Scope Of Services
      2. 7.6.2. Admission Criteria
      3. 7.6.3. Arranging for Services
      4. 7.6.4. Contracted Providers
    7. 7.7. Hospice Services
      1. 7.7.1. Scope of Services
      2. 7.7.2. Admission Criteria
      3. 7.7.3. Arranging for Services
      4. 7.7.4. Contracted Providers
      5. 7.7.5. Hospice Information for Medicare Part D
    8. 7.8. Nursing Home Care – Long Term Care (Custodial Care)
    9. 7.9. Skilled Nursing Facility Care
      1. 7.9.1. Arranging for Services
      2. 7.9.2. Contracted Provider Expectations
    10. 7.10. Patient Education and Support Services
    11. 7.11. Specialty Services
    12. 7.12. Women's Health Care Services
      1. 7.12.1. Coverage
      2. 7.12.2. Home birth
      3. 7.12.3. Infertility/Fertility Treatment
      4. 7.12.4. Pregnancy Termination
  8. 8. Pharmacy Services
    1. 8.1. Drug Formulary
      1. 8.1.1. Drug Formulary Exception Requests
      2. 8.1.2. Drug Formulary Recommendations
      3. 8.1.3. Formulary Tools
    2. 8.2. Pharmacy & Therapeutics Committee
    3. 8.3. Pharmacy Drug Benefit Help Desk
      1. 8.3.1. How to Submit a Prior Authorization Request
      2. 8.3.2. Clinical Documentation Requirements
      3. 8.3.3. If a Prior Authorization Request is Denied
    4. 8.4. Prior Authorization Review Timeframes
      1. 8.4.1. Medicare
      2. 8.4.2. Commercial
    5. 8.5. Prior Authorization for Injectable Drugs
    6. 8.6. Self-Administered Medications
    7. 8.7. Home Infusion Pharmacy Services
    8. 8.8. Specialty Pharmacy Services