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 $40,000
  • 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 either fax (1-509-241-7506) or mail to:

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 mark box for first level and attach any additional documentation to help support services billed
  • You will receive a written response when completed

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

Pre-Payment Reconsideration Process (Second-level review)

  • If you disagree with the first review fill out the Pre-payment reconsideration form, check mark 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:

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

Reconsideration can be sent in by either fax (1-509-241-7506) or mail to:

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.

Reconsiderations not related to Pre-payment

Content on this page is from the provider manual | Disclaimer