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.

You may download the May 2023 PDF version if necessary. Updates are made to the Provider Manual throughout the year. For the most up-to-date information, please refer to the online content throughout this website.

Introduction

Kaiser Permanente service delivery standards

Billing and claims

Claims procedures

Electronic transactions

Electronic batch transactions

Electronic funds transfer and electronic remittance advice

Payment policy

Kaiser Permanente payment policies

Processing claims

Checking claims status

Claims adjustments

Claims explanation of payment/835 remittance advice and reimbursement

Claims submission requirements

Corrected billing

Post service: Claims payment review & reconsideration process

Pre-payment claims review process

Requests for additional claims documentation

Timely filing of claims

Multiple health plans

Coordination of benefits

Submitting secondary claims

Non-Washington region Kaiser Permanente health plans

Caring for members from other Kaiser Permanente regions

Claims for accidents and injuries

Motor vehicle accidents

Work-related injuries

Member cost shares

Deductibles and coinsurance

Members' financial responsibilities

Government programs (claims procedures)

Introduction to Medicare data requirements

Medical students providing care

Medicare coordination of benefits

Outpatient prospective payment system/ambulatory payment classifications

Codes and standards

General codes and standards

Administrative simplification

CMS-1450 (UB-04) claims: Coding for services provided

CMS-1500 claims: Coding for services provided

Code edit or coding policy services reconsideration process

Code editing and review process for professional claims

Physician reimbursement for medical (non-psychiatric) surgical and anesthesia services

Variations to code edits or coding policy for claims

Mental health

Mental health care coding

National Provider Identifier

Applying for an NPI

Kaiser Permanente NPI billing requirements

NPI and taxonomy requirements

Government programs (codes and standards)

CMS-1500 claims data reporting requirements

General Medicare data requirements

Referrals and clinical review

Review services

Prior authorization

Applied Behavioral Analysis Provider Information

Follow-up care with a specialist

Injectable drugs requiring prior authorization

Prior authorization for accidental or work-related injuries

Prior authorization for durable medical equipment

Prior authorization requirements and management guidelines

Radiology services requests

Referring Kaiser Permanente members for specialty care and services

Requesting preauthorization for coverage

Retroactive authorizations, extenuating circumstances, and provider reconsideration requests

Transplant Services

Review process

Appointments for referrals and urgent prior authorization requests

Clinical review criteria

Prior authorization reviews

Utilization review

Utilization management

Appeals

Appeals for noncoverage

Mental health and Medicare appeals

Provider reconsideration process

Coverage and eligibility

Kaiser Permanente plans

Comparison of Kaiser Permanente plan networks

Identifying members

Kaiser Permanente plans overview

PPO plan overview

Government health plans

Kaiser Permanente Government Programs Department

Prevention of fraud, waste, and abuse

Medicare

Kaiser Permanente Medicare Advantage plans (HMO)

Medicare Part D Prescription Drug Coverage

Summary of Requirements for Our Medicare Advantage Plans

Medicaid

Prenatal care options for all Medicaid members

Patient care

Mental health

Overview and obtaining services

Coordinating mental health inpatient or residential care

Mental Health Access Center overview

Mental health medication and service requests

Mental health, including addiction and recovery

Obtaining outpatient mental health care

Prior authorization for inpatient mental health care

Administrative expectations

Coordination of members' mental health care

Emergency mental health practitioner accessibility

Measuring quality of mental health care

Mental health records and documentation

Practitioner skills

Mental health licensing, credentialing, and training

Types of mental health care and practitioners

Clinical necessity and coverage

Clinically necessary mental health care

Excluded mental health care

Care management

Care professionals

Care management nurses

Hospital care

Elective and emergency hospital admissions

Medical transportation

Continuing care

Outpatient case management/gender health referrals

Home health and in-home palliative care services

Hospice services

Nursing home care - long term care (custodial care)

Skilled nursing facility care

Pharmacy

About the drug formulary

Clinician prescribing tools

Kaiser Permanente Washington Specialty Home Infusion Pharmacy

Kaiser Permanente Washington Specialty Pharmacy

Pharmacy Drug Benefit Help Desk

Clinical guidelines

Clinical guidelines

Home birth

Eligibility and obtaining home birth services

Home birth antenatal care

Home birth consultation and prior authorization

Home birth criteria

Home birth intrapartum care

Home birth intrapartum urgent or emergency care

Home birth maternal and newborn medical records

Home birth newborn care

Home birth post-partum care

Home birth ultrasound guidelines

Interpretive services

Guidelines for choosing an interpreter

Interpretive services policy

Translating printed materials

Member rights

Basic rights

Advance directives

Informed consent

Member concerns or complaints

Physical restraints and seclusion

Reporting quality of care concerns

Responsibilities to members

Right to an appeal

Right to a second opinion

Statement of member rights and responsibilities

Medical records access

Member access to medical records

Member-initiated corrections and amendments to their records

Specialty and wellness services

Complementary and alternative medicine

Patient education and support services

Specialty services

Women's health care services

Working With Kaiser Permanente

Medical records

Authorship and authentication of dictated reports

Clinical performance reviews

Faxing medical records

Information security measures

Medical records and documentation standards

Medical records reviews

Protected Health Information

Credentialing

Credentialing health care delivery organizations

Dispute resolution process for nonreportable events

Fair hearing and appeal process for reportable events

Practitioner credentialing

Provider responsibilities

Provider-Member interaction

Self-treatment or treatment of immediate family members

About Kaiser Permanente

Our commitment to quality

Member communication

Communicating with our members