Kaiser Permanente payment policies
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) payment policies are designed to assist you when submitting claims to Kaiser Permanente. They are consistently updated to promote accurate coding and policy clarification. This information is to be used as a reference and not intended to address every aspect of claim reimbursement.
Kaiser Permanente recognizes industry medical societies, including but not limited to the following when processing claims and developing our payment policies.
- American Medical Association (AMA)
- American College of Obstetricians and Gynecologists (ACOG)
- American Health Information Management Association (AHIMA)
- American Academy of Professional Coders (AAPC)
- Centers for Disease Control and Prevention (CDC)
- Centers for Medicare & Medicaid Services (CMS) written policy
- CMS Local Carrier and National Carrier Determinations (LCD NCD)
- CMS Manuals and Publications
- CPT Assistant
- CPT Manual, including code definitions and associated text
- Federal Register
- HCPCS Manual, including code definitions and associated text
- Integrated Outpatient Code Editor (I/OCE)
- International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) official guidelines for coding and reporting
- Medically Unlikely Edits
- National Correct Coding Policy Manual for Part B Medicare Carriers (NCCI)
- National Physician Fee Schedule Relative Value File
- Uniform Billing Editor
Providers are responsible for accurate claims submissions. Billed codes should be fully supported in the medical records and/or office notes.
Coverage of any service is determined by a member’s eligibility, benefit limits for the service or services rendered and the application of the Plan’s Medical Policy.
Final payment is subject to the application of claims adjudication edits common to the industry and the Plan's facility services claims coding policies. Reimbursement is restricted to the provider's contract and/or the scope of practice as well as the fee schedule applicable to that provider.
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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Content on this page is from the provider manual | Disclaimer