Post-service: Claims payment review & reconsideration process

If you disagree with the final disposition of a claim, you may request a review by contacting the Provider Assistance Unit at 1-888-767-4670. Please have your remittance advice available.

This process is used for claims denied for:

• Coding review
• Contract denials
• Pricing disputes
• Timely Filing

Claims denied with Member Liability follow the member appeals process.

Request for reconsideration (first-level review)

• You can send your request multiple ways:
• Electronically using the online form.
• Fax or mail by downloading the Claims Reconsideration Form.
• Calling the Provider Assistance Unit at 1-888-767-4670 to initiate first-level over the phone.
• If it's determined the claim needs to be re-processed, it will be adjusted to show up in a future remittance advice and a written health plan decision letter will be sent. If the denial stands, you will receive a written health plan decision letter.

For corrected claims or claim adjustments requests please follow our timely filing guidelines. Requests for first-level reconsideration review follow the below time frames.

Commercial members:

• Provider has 24 months from the notification date of denial
• If coordination of benefits is involved, the provider has 30 months from the notification date of denial
• If your claim was paid but you are disputing the amount paid, please contact our Provider Assistance Unit at 1-888-767-4670.

Medicare members:

• Contracted providers have 24 months from the notification date of denial
• Non-contracted providers have 60 days from the notification date of denial and will follow the member appeals process
• If coordination of benefits is involved, the provider has 30 months from the notification date of denial
• If your claim was paid but you are disputing the amount paid, please contact our Provider Assistance Unit at 1-888-767-4670.

Request for reconsideration (second-level review)

• If you disagree with the first-level review, you may request a second-level reconsideration. This process allows you to submit additional information that may change the outcome of the initial decision.

For corrected claims or claim adjustments requests please follow our timely filing guidelines. Requests for second level reconsideration review follow the below time frames.

Commercial members:

• Provider has 24 months from the notification date of denial
• If coordination of benefits is involved, the provider has 30 months from the notification date of denial
• If your claim was paid but you are disputing the amount paid, please contact our Provider Assistance Unit at 1-888-767-4670.

Medicare members:

• Contracted providers have 24 months from the notification date of denial and should follow the second level provider reconsideration process: Retroactive authorizations, extenuating circumstances, and provider reconsideration requests
• Non-contracted providers have 60 days from the notification date of denial and will follow the member appeals process
• If coordination of benefits is involved, the provider has 30 months from the notification date of denial
• If your claim was paid but you are disputing the amount paid, please contact our Provider Assistance Unit at 1-888-767-4670.

Denials not related to no prior authorization or medical necessity

Complete the Claims second-level reconsideration form and be sure to include your previous call reference # and any supporting documentation with your request.

Note: If you are changing any data on your claim, submit your request as a corrected claim in order to promptly facilitate a payment determination. For more information, see Corrected billing.

For requests that require post service review, it is required that supporting documentation related to the denied claim and services performed, be submitted at the time of your request in order for a thorough review to be completed. Lack of supporting documentation may result in the denial being upheld.

Claims trend escalation

This process is intended to allow for a retrospective review once all avenues have been exhausted and when you feel there has been an incorrect or incomplete review of the claim in question. Please refer to the Complex Claims Trends Escalation Huddle Card (PDF) for further instructions on how to submit these trends for review.

Dispute resolution

A formal OIC-approved process is defined in your contract that we use in response to requests for escalation by the health plan or contracted provider regarding the terms of the provider contract. This process may be used to re-evaluate a health plan action or any issue evolving from the provider agreement.

Medicare Advantage non-contracted provider appeal rights:

If you do not agree with this determination you have the right to file an appeal. Written requests for appeal (reconsideration) of a zero-payment determination must be submitted within 60 calendar days of the date of this notice and must include a signed Waiver of Liability. The form can be found at https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf.

Reconsideration requests for denied claims, along with your supporting documentation (e.g. copy of this notice, clinical records) must be submitted in writing to:

Kaiser Foundation Health Plan of WA
Attn: Provider Appeals
PO Box 34593
Seattle, WA 98124-1593

Medicare Advantage non-contracted provider payment disputes:

Written requests to dispute a payment must be received within 120 calendar days from the date of this notice. Corrected claims should not be submitted as a dispute or appeal.

Requests for payment disputes, along with your supporting documentation (e.g. copy of original claim, copy of this notice, clinical records) must be submitted in writing to:

Kaiser Foundation Health Plan of WA
Attn: Claims Reconsideration
PO Box 30766
Salt Lake City, UT 84130-0766

Reconsiderations not related to Post service: Claims payment review & reconsideration process

• Retroactive authorizations, extenuating circumstances, and provider reconsideration requests
• Pre-payment claims review process

Diagnosis Related Group (DRG) payment and review

We may perform DRG reviews on claims which are reimbursed by MS-DRG, APDRG, and APR-DRG to validate that the diagnosis and procedural information leading to the DRG assignment is supported by the medical record. The purpose of DRG validation is to ensure diagnostic and procedural information and discharge status of the patient, as coded and reported by the hospital on its claim, matches both the attending physician's description and the information contained in the patient's medical records. Please refer to the DRG payment and review policy located under More Resources on this page for more information on these claims reviews.

We have engaged the services of Cotiviti to conduct these inpatient claims reviews on our behalf. If you have received a communication from Cotiviti and Kaiser Permanente requesting claims records, please refer to the Cotiviti Upload Portal Job Aid located under More Resources on this page for instructions on how to submit the requested records via Cotiviti’s upload portal.