Multiple health plans

To comply with Washington State Office of the Insurance Commissioner regulations, health plan carriers coordinate benefits so that when an individual has more than one Kaiser Permanente plan, each plan pays its share of the medical expenses.

If your patient is covered by two or more health plans, we can coordinate benefits with the other health plans to help the patient receive the full benefit of those plans. By coordinating benefits, we may be able to waive or reduce out-of-pocket expenses for covered services.

Dual Kaiser Permanente plans

When caring for a Kaiser Permanente member with dual Kaiser Permanente plans, identify the primary health plan following Washington Administrative Code Standards for Coordination of Benefits (WAC 284-51). If you are unsure which health plan is the primary health plan, contact the Provider Assistance Unit.

Kaiser Permanente as secondary carrier

If Kaiser Permanente is the secondary to another health plan, submit the claim to the primary health plan first. All Kaiser Permanente coverage and criteria requirements apply, regardless of whether Kaiser Permanente is the primary or secondary health plan.

When a member has primary insurance, the secondary plan may be required to waive the gatekeeper requirement when the primary plan's requirements have been met.

For FEHB Core and Self-Funded Core plans that follow the maintenance of benefits rule, the amount paid by the primary insurance is used to reduce the amount that Kaiser Permanente would pay as the secondary. Members must follow the network and authorization rules of their Kaiser Permanente plan for claim payment, even if it is not the primary plan. Members will be responsible for cost-shares determined by the plan.

When a Kaiser Permanente Medicare-eligible member is not eligible for our Medicare Advantage plans, we will coordinate benefits with traditional Medicare.

When Medicare is the primary payer, you must bill Medicare directly for services through the Medicare crossover process.

Note: Do not bill Kaiser Permanente for claims that will crossover electronically. This creates duplicate billing or payment. Remember to check your Medicare explanation of payment form, Reason Code MA18.

When Kaiser Permanente has referred the service, we will provide payment for all covered balances.

CMS Qualified Medicare Beneficiary Program

The Qualified Medicare Beneficiary (QMB) program provides Medicare coverage of Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries. In 2017, 7.7 million people (more than one out of eight people with Medicare) were in the QMB program.

Billing Protections for QMBs

Federal law forbids Medicare providers and suppliers, including pharmacies, from billing people in the QMB program for Medicare cost sharing. Medicare beneficiaries enrolled in the QMB program have no legal obligation to pay Medicare Part A or Part B deductibles, coinsurance, or copays for any Medicare-covered items and services.

Federal law bars Medicare providers and suppliers from billing an individual enrolled in the QMB program for Medicare Part A and Part B cost-sharing under any circumstances (see Sections 1902(n)(3)(B), 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social Security Act [the Act]). The QMB program provides Medicaid coverage of Medicare Part A and Part B premiums and cost sharing to low-income Medicare beneficiaries. QMB is an eligibility category under the Medicare Savings Programs. In 2016, 7.5 million individuals (more than one out of eight beneficiaries) were enrolled in the QMB program.

Providers and suppliers may bill State Medicaid agencies for Medicare cost-sharing amounts. However, as permitted by Federal law, States can limit Medicare cost-sharing payments, under certain circumstances. Regardless, persons enrolled in the QMB program have no legal liability to pay Medicare providers for Medicare Part A or Part B cost-sharing. Medicare providers who do not follow these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions (see Sections 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Act).

Kaiser Permanente, along with other payers participating in the Washington Healthcare Forum, has agreed to accept secondary claims electronically with no explanation of benefits (EOB) as long as the appropriate electronic fields are populated. See the Worksmart Institute's Claims Processing Policies and Guidelines for how to submit electronic and paper claims.

Participating health plans will not require providers to submit paper EOBs with electronic secondary claims as long as the primary payer is a commercial insurance company and necessary EOB information is included with the claim.

With the exception of Medicare COB, Kaiser Permanente also will accept UB-04 and CMS 1500 paper claims without a paper EOB if these guidelines are followed in completing the paper claim.

Required claim fields for secondary billing

If you leave any of the following fields empty or blank on your claim, we will deny the claim.

Form locator (FL) for CMS-1500 claims

• 9, 9a, and 9d: Other Insured Information — insurance name, identifying number, and payer ID
• 10a and 10b: Auto accidents, personal injuries, and employment-related injuries
• 19: Note - Must contain COBZ or COB = Z if the primary health plan paid zero
• 21: E code to highest level of specificity describing the accident or injury in 10a and 10b
• 29: Must contain a dollar amount or zero
• 33a: Billing provider NPI field

Form locator (FL) for UB-04 claims

• 32: Auto accidents, personal injuries, and employment-related injuries
• 50a, 50b, or 50c: Payer name — primary, secondary, and tertiary
• 54a, 54b, or 54c: Must contain a dollar amount or zero
• 56: Pay-to provider NPI
• 58a, 58b, or 58c: Insured's name — required if other insurance or Medicare secondary payer
• 60a, 60b, or 60c: Insured's unique ID: Kaiser Permanente member ID number
• 77: E code to highest level of specificity describing accident
• 80: Note - Must contain COBZ or COB = Z if the primary health plan paid zero
• 81a-d: Billing Provider and miscellaneous NPI and taxonomy fields