Pre-payment claims review process

Subject to your contract terms, Kaiser Permanente may conduct a pre-payment review of claims submitted by contracted providers that meet the following criteria:

• Inpatient facility charges
• Outpatient facility charges
• Billed charges exceeding $20,000
• Medicare or Commercial member and DRG contains outlier
• % of charge payment reimbursement

Please review these pre-payment review policies for more information:
Prepayment Bill Review - Line Item Deduction (LID) (PDF)
Prepayment Bill Review - Medical Necessity (PDF)

Documentation required for this review and where to send:

• If it is determined that a review is needed, you may be contacted for additional documentation such as itemizations and/or medical records.
• Information to include:
• Member's name
• Patient's 8-digit member ID
• Date of service
• Claim number

Requested documentation can be sent in by email (preferred), fax, or mail:

Email: pre-pay-inbox@kp.org

Fax: 1-877-779-4861

Mail:
Kaiser Permanente
Attn: Provider Assistance Unit ACN17
P.O. Box 204
Spokane WA 99210

Pre-Payment Reconsideration Process (First-level review)

• Fill out the Pre-payment reconsideration form
• Check the box indicating first level review
• Attach only any additional documentation to help support services billed (not the entire chart)
• You will receive a written response when completed

Requests for a first-level review must be made within:

• 24 months from the notification date of denial
• For adjustments please follow our timely filing guidelines

Pre-Payment Reconsideration Process (Second-level review)

• If you disagree with the first review fill out the Pre-payment reconsideration form, check the box for second level and attach any additional documentation not included with the first review to help support services billed
• You will receive a written response when completed

Requests for a second-level review or adjustment must be made within:

• 24 months from the notification date of denial
• For adjustments please follow our timely filing guidelines

To submit a Pre-Payment reconsideration, please fill out the Pre-pay review provider reconsideration (Word) form:

Reconsideration can be sent in by email, fax, or mail:

Email: pre-pay-inbox@kp.org

Fax: 1-877-779-4861

Mail:
Kaiser Permanente
Attn: Provider Assistance Unit ACN17
P.O. Box 204
Spokane WA 99210

If you have any questions, please contact the Provider Assistance Unit at 1-888-767-4670.

For all claims pre-payment questions and inquiries

Please email the Claims department directly at pre-pay-inbox@kp.org for questions or assistance with claims. For the quickest response, do not submit questions to your Provider Services consultant, as they will simply forward questions to this inbox on your behalf, thus slowing your wait time for an answer.

Reconsiderations not related to Pre-payment

• Post service: Claims payment review & reconsideration process
• Retroactive authorizations, extenuating circumstances, and provider reconsideration requests