Kaiser Permanente payment policies

The Payment Policy Committee will address and guide the implementation of policies affecting provider payment for both contracted and non-contracted services. It will create a framework for provider contract pricing through expertise in payment methodologies, capitation, claims code editing, incentive and risk management, and system capabilities. The committee will monitor industry standards, regulatory guidelines, and provide data to executive sponsors to support policy decisions. The committee supports the development of new products, new benefit plans, and changes to medical management practices.

The committee provides a platform where proposals for reimbursement changes can be brought forward for review and develop supporting payment policies to ensure consistent payment adjudication.

The primary outcome of this committee will be a unified and well-communicated approach to policy adoption throughout the Health Plan value stream.

Payment policies are designed to assist you when submitting claims to Kaiser Permanente. They are consistently updated to promote accurate coding and policy clarification.

If you have questions or would like more information, contact the Provider Assistance Unit toll-free at 1-888-767-4670.

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7th Character ICD-10 and Therapy Codes (PDF)

Access, Elect, and Kaiser Permanente Options Federal plans out-of-network reimbursement (PDF)

Allergen Immunotherapy (PDF)

Ambulance Services (PDF)

Annual Well Visit Billed With Preventive Medicine Evaluation (PDF)

Applied Behavioral Analysis (ABA) Therapy (PDF)

Assistant Surgeon (PDF)

Associate Level Mental Health Care (PDF)

BRACAnalysis Large Rearrangement Test (BART) (PDF)

Chromoendoscopy and Narrow Band Imaging (PDF)

Code Editing (PDF)

Computer-aided Detection (CAD) for Mammography (PDF)

Cosmetic Procedures (PDF)

Critical Care When Patient is Discharged to Home (Facility) (PDF)

Diagnosis Related Group (DRG) Payment and Review (PDF)

Drug Waste (PDF)

Durable Medical Equipment (PDF)

Early Elective Deliveries (PDF)

Emergency Department (ED) Facility Evaluation and Management (E/M) Coding Policy (PDF)

Evaluation & Management (E&M) Services with Preventive Services (PDF)

Facility Charges for Evaluation and Management Services (PDF)

Fetal Non-stress Tests (PDF)

Fracture Care Without Manipulation (PDF)

High Level Evaluation and Management Services with a Diagnosis of "No Abnormal Findings" (PDF)

Hospital-Acquired Conditions, Never Events & Adverse Events (PDF)

Influenza Vaccinations (PDF)

Initial Hospital E&M Upcoding (PDF)

Injectable Drugs (PDF)

Manipulative Services (Chiropractic) (PDF)

Modifiers (PDF)

Modifiers JA and JB (PDF)

Multiple Procedure Payment Reduction (MPPR) - Outpatient Hospital Claims (PDF)

Multiple Procedure Payment Reduction (MPPR) - Multiple Diagnostic Imaging (PDF)

National Drug Code (NDC) Billing Requirements (PDF)

Neurostimulator Electrode (PDF)

Non-Contracted Provider Reimbursement (PDF)

Non-Covered Services (PDF)

Non-Preventive Services Provided During a Preventive Visit (PDF)

Pharmacist Reimbursement (PDF)

Prepayment Bill Review - Line Item Deduction (LID) (PDF)

Prepayment Bill Review - Medical Necessity (PDF)

Prepayment Bill Review - Trauma (PDF)

Revenue Code Billed Without Required Procedure Code (PDF)

Robotic Assisted Surgery (PDF)

Self-Treatment or Treatment of Immediate Family Members (PDF)

Services Incidental to Inpatient Admissions (PDF)

Shared Medical Appointments (Group Visits) (PDF)

Split Night Sleep Study (PDF)

Surgical Codes - Anatomical Modifiers (Professional Claims) (PDF)

Telehealth Services (Medicare) (PDF)

Telemedicine Services (Commercial) (PDF)

Thirty Day Readmission (PDF)

Unlisted Codes (PDF)

Urine Drug Screen (PDF)

Venipuncture (PDF)

Virtual Care (PDF)

Women's Health (PDF)

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