Claims for accidents and injuries

When a Kaiser Permanente member is receiving care for injuries related to a motor vehicle accident, you should bill claims directly to the member's automobile insurance carrier under their Personal Injury Protection (PIP) if available.

The use of box 10B marked yes on a CMS 1500 form or FL31 coded with 01, 02, or 03 on a CMS 1450 form identifies an auto accident. If Kaiser Permanente does not know about the accident, we will investigate and notify you if an auto insurance carrier should be primary.

The member must stay within our network system to ensure coverage by Kaiser Permanente in case the carrier rejects the claim.

If the carrier denies the claim, promptly submit the claim and a copy of the denial to Kaiser Permanente. We will only consider claims filed within the timely filing limit of one year from the date of service.

In the absence of first-party coverage, submit all bills to Kaiser Permanente for consideration. You should not bill any third-party carrier for care you provide related to a motor vehicle accident.

If you have questions about a first- or third-party accident, contact our Other Party Liability Department at 1-866-783-9594.

Most member agreements with Kaiser Permanente exclude payment for any services associated with a job-related injury or illness. Promptly notify us whenever one of our members is injured in an on-the-job accident. Please use box 10A marked yes on a CMS 1500 form or occurrence code 04 listed in FL31 of a CMS 1450 form.

Kaiser Permanente will not be responsible for payment if the member's coverage agreement excludes work-related injuries from health plan coverage.

Agreements providing work-related injury coverage

There are some Kaiser Permanente member agreements that will cover on-the-job injuries if no L&I is available (please call the Provider Assistance Unit to check member's contract). In such cases, it is recommended the member stay within our network system in the event that the Washington State Department of Labor & Industry (L&I) or other self-insured workers' compensation carrier denies/rejects the claim.

If L&I denies the claim, send a copy of the denial along with the appropriate completed CMS form for payment to:

Kaiser Permanente Claims Administration
P.O. Box 30766
Salt Lake City, UT 84130-0766

Kaiser Permanente will not be responsible for payment if the workers' compensation carrier denies payment of services because required preauthorization was not obtained.

When you are providing services to members who are covered by Washington State Industrial Insurance:

• You must submit all necessary paperwork for the initial and subsequent visits to L&I or, for self-insured employers, to the appropriate carrier.
• Filing an accident report or rendering treatment to an injured worker constitutes acceptance of L&I rules and fees.

If the member works for an employer who is self-insured for work-related injuries or if the member cannot identify the workers' compensation carrier, you may call the L&I provider hotline.

Please refer to the Washington state Attending Doctor's Handbook available from L&I.

Contact the Other Party Liability Department or send the following information to assist with related claims to Kaiser Permanente Claims Administration:

• Member name and identification number
• Date of injury and claim number
• Name and telephone number of employer
• Nature of injury

If you are providing services to Kaiser Permanente members who are covered by Idaho Workers' Compensation:

• The member must report the injury or illness to the employer. The employer then files a claim.
• Contact the Idaho Industrial Commission Compliance Division to obtain the name of the insurance carrier that handles claims for the member's employer.