Claims adjustments

If you wish to request an adjustment to a claim that you think was incorrectly processed, follow the provider reconsideration process or contact the Provider Assistance Unit (PAU) at 1-888-767-4670.

If the adjustment involves an overpayment by Kaiser Permanente, the overpayment may be available immediately to offset future reimbursements.

Adjustments

We may also initiate adjustments if we determine that we processed a claim incorrectly or as a part of a reconciliation.

The adjustment process involves:

• Cancelling the original payment and creating a credit balance to the provider.
• Processing the claim a second time to pay the correct amount or to deny the claim, whichever is appropriate.

When the adjustment results in additional money owed to you, you will be paid in one of three ways (depending upon the amount of your current credit balance):

1. Issuing a check.
2. Using money from outstanding credit balance to pay the current claim (offset process).
3. Using a combination of money by a check and application of outstanding credit balance to pay the claim (check and offset process).

If it results in overpayment, we will create a credit balance to apply to a future claim payment. If Kaiser Permanente initiated overpayment, RCW 48.43.600 will apply.

There are some instances in which a credit balance may not be resolved by applying to a future claim. When overpayments are not paid back by future claim payment, you will need to send a check to pay off the overpayment.

Note:

• Credit balances created by self-funded employer group claims can only be applied to future claims from the same employer group.
• Credit balances created by FEP claim can only be resolved by applying to future FEP claims.

Initiating an adjustment

See Timely filing of claims.

Contesting an adjustment

If a contracted non-facility provider fails to contest the request in writing within 30 days of the provider's receipt of the request, we will deem the request accepted and will proceed with the adjustment process.

If a contracted non-facility provider contests the refund request, we may not require payment of the disputed adjustment amount any sooner than six months from the date of the original notice from the carrier. However, nothing precludes you from permitting us to apply the offset at an earlier date.

Notices regarding adjustments should be sent to:

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