Claims Submission and Processing

You can check claim status using our Claims Status Inquiry tool regardless of whether the claim was submitted electronically or on paper. You also can review an electronic file from your billing service or clearinghouse for all pending claims, or contact the Provider Assistance Unit.

If you have checked the status of a claim submitted to Kaiser Permanente and we do not show it in our system, the following steps will help you locate your claim.

Paper claims

Paper claims sent within the last week may not be entered in our system yet. You can resubmit a claim if it has been two weeks or more since you submitted it and you have verified that it is not in our system.

Electronic claims

If you submit claims electronically using a billing service or clearinghouse, check the report for rejected claims caused by data submission errors. If errors are found, contact the service or clearinghouse for resolution. Refer to "Electronic Segment Information" in the CMS-1500 or UB-04 required fields forms to assist you in your discussion with the clearinghouse or billing service.

Data errors may occur if information is entered into the wrong box on the claim form or if any of the following information is missing or incorrect:

• NPI number
• Taxonomy
• Provider tax ID number
• Kaiser Permanente member ID number (front-filled with zero's to make eight digits)
• Member's name

The member's name must be exactly the way it appears on the member's ID card and in our system, including spaces and punctuation.

If you have electronic confirmation that Kaiser Permanente received the claim, contact the Provider Assistance Unit to initiate an investigation. Be ready to provide the following information:

• Provider tax ID number
• Kaiser Permanente member ID number
• Date of service
• Total charges submitted
• NPI number
• The name and contact information of your billing service or clearinghouse
• Type of claim (professional or institutional)
• Date and time of file submittal or expected transmittal
• Whether the missing claims are in a series or just a few out of a batch
• Start/end or pattern of problems
• Patient account number
• Contact name and phone number

If you wish to request an adjustment to a claim that you think was incorrectly processed, follow the provider reconsideration process or contact the Provider Assistance Unit (PAU) at 1-888-767-4670.

If the adjustment involves an overpayment by Kaiser Permanente, the overpayment may be available immediately to offset future reimbursements.

Adjustments

We may also initiate adjustments if we determine that we processed a claim incorrectly or as a part of a reconciliation.

The adjustment process involves:

• Cancelling the original payment and creating a credit balance to the provider.
• Processing the claim a second time to pay the correct amount or to deny the claim, whichever is appropriate.

When the adjustment results in additional money owed to you, you will be paid in one of three ways (depending upon the amount of your current credit balance):

1. Issuing a check.
2. Using money from outstanding credit balance to pay the current claim (offset process).
3. Using a combination of money by a check and application of outstanding credit balance to pay the claim (check and offset process).

If it results in overpayment, we will create a credit balance to apply to a future claim payment. If Kaiser Permanente initiated overpayment, RCW 48.43.600 will apply.

There are some instances in which a credit balance may not be resolved by applying to a future claim. When overpayments are not paid back by future claim payment, you will need to send a check to pay off the overpayment.

Note:

• Credit balances created by self-funded employer group claims can only be applied to future claims from the same employer group.
• Credit balances created by FEP claim can only be resolved by applying to future FEP claims.

Initiating an adjustment

See Timely filing of claims.

Contesting an adjustment

If a contracted non-facility provider fails to contest the request in writing within 30 days of the provider's receipt of the request, we will deem the request accepted and will proceed with the adjustment process.

If a contracted non-facility provider contests the refund request, we may not require payment of the disputed adjustment amount any sooner than six months from the date of the original notice from the carrier. However, nothing precludes you from permitting us to apply the offset at an earlier date.

Notices regarding adjustments should be sent to:

Kaiser Permanente Claims Administration
Attn: Claims Reconsideration
P.O. Box 30766
Salt Lake City, UT 84130-0766

You can receive your 835 remittance advice (RA) weekly by electronic batch transaction with remittance information auto-posted to patient accounts or by paper Explanation of Payment (EOP) mailed to your office. Providers not electing Electronic funds transfer will receive a check via U.S. Postal Service.

Our electronic 835 remittance advice must use only the HIPPA-compliant action codes. As of Jan. 8, 2014, our paper EOP will contain only HIPPA-compliant action codes and will no longer display Kaiser Permanente-specific codes. If you have difficultly interpreting the codes, check the Washington Publishing Company's code lists or review your claim via OneHealthPort for Kaiser Permanente-specific codes. If you need additional assistance, contact our Provider Assistance Unit.

Denied claims

We may deny claims for a variety of reasons. Please refer to your 835 RA/EOP for the denial reason.

Members' financial responsibilities

A member's financial responsibilities (cost shares) vary depending on the specific plan benefits, copayments, coinsurance, and deductibles. You can check this information using our Eligibility Inquiry tool.

Once we process your claim, you must bill the member for their share of the bill only, as stated on the remittance advice you receive with your payment.

Members of other Kaiser Permanente regions may receive care in any of our clinics or by one of our contracted providers in the Kaiser Permanente Washington region. Visiting members are subject to the same business practices and prior authorization rules as in the Kaiser Permanente Washington Core plan.

Please contact the Visiting Member Unit toll-free at 1-800-446-4296 or 509-241-7798 for instructions when seeing a visiting Kaiser Permanente member from another region. For prior-authorization questions, contact Review Services at 1-800-289-1363.

Please be prepared to furnish the following information:

• Member's last name, first name, middle initial
• Date of birth
• Kaiser Permanente home plan name and ID number
• Social Security Number

Please refer to the Visiting Member Guidelines (PDF) for instructions to verify eligibility, benefits, authorizations and claims processing

**Please note: For authorizations for the following services, please contact the member’s home plan:

• Infertility services
• Services related to artificial conception
• Gender confirming surgery and related services, other than services determined to be provided by all regions
• Services related to bariatric surgery and treatment
• Organ and blood/marrow transplants and related care
• Orthotics and prosthetics
• Durable Medical Equipment (DME)
• Chronic dialysis

All claims must be submitted using standard industry formats, forms, and coding, and claims data must be supported by documentation in the patient's medical record.

Claims submission standards require that we deny claims with missing or invalid information, are handwritten, have any handwritten notations, stamps, or stickers on them, or are not on an original CMS-1500 form printed in red.

The Claims Submission Standards and Specification have been updated. For specific information on requirements and recommendations, please see the Paper claim submission standards and specifications grid (PDF) .

Three essential components must be included with each submitted claim:

Patient and subscriber information: Include the patient's Kaiser Permanente member ID number and name as it appears on their ID card and your patient identification information. Include other insurance or subscriber information if applicable.

Provider information: To avoid an error or delay in claims payment, notify Provider Contracting or Provider Services as early as possible of any changes to your tax ID number (TIN), address, name, or to how you use or designate your entity National Provider Identifier (NPI). For more information, see NPI and taxonomy requirements.

Coding: We expect all claims to be submitted with industry-standard coding and that procedures be reported with the HCPCS/CPT codes that most comprehensively describe the services performed. For more information, see Standard coding for services provided (PDF).

The Kaiser Permanente Payor ID is 91051

The CMS-1450 (UB-04) form is the industry standard for submitting institutional claims for inpatient and outpatient services. CMS publishes guidelines for completing the CMS-1450 when billing for services. For more information, refer to the Medicare Claims Processing Manual: Chapter 25 – Completing and Processing the Form CMS-1450 Data Set (PDF).

The National Uniform Billing Committee maintains codes required when using the CMS-1450 form. These include revenue codes, condition codes, occurrence codes, value codes.

Kaiser Permanente also requires that all CMS-1450 claims submitted are reported using the specific code sets as adopted by HIPAA. The code sets for procedures, diagnoses, and drugs are:

• Healthcare Common Procedure Coding System (HCPCS) for ancillary services/procedures
• Current Procedural Terminology (CPT-4) for medical services and procedures performed by physicians and other qualified health professionals
• International Classification of Diseases, version 10 (ICD-10-CM) for diagnosis and hospital inpatient procedures (ICD-10 PCS)
• National Drug Codes (NDCs) are required to be included for all drugs and biologicals that have NDCs. Also required are the NDC quantity and appropriate qualifier (e.g., GR, ML, UN, F2).

Refer to each specific code set for instructions in using these codes appropriately. Some basic coding rules to keep in mind are:
Use only codes that are valid for the date of service.
Link CPT codes to revenue codes when required.
Follow OCE edit guidelines where required.
Follow all guidelines for diagnosis coding. Special attention should be given to the following requirements:

• Diagnosis codes should be coded to the highest specificity required for each code.
• Refer to (ICD-10) for Principal, Admitting, Patient Reason, Other, and External Cause of Injury diagnosis coding.

Some field elements to note include:
Field 56: List the 10-position National Provider Identifier (NPI).
Field 57: Include the appropriate taxonomy code for all lines of business.
Fields 66-67: Present on admission (POA) indicators must be submitted with primary and secondary diagnoses for acute care hospitals or other facilities subject to Center for Medicaid and Medicare Services regulations for reporting POA information. These should be reported for all lines of business. For more information, see POA indicators for inpatient claims: Provider Q&A (PDF).

Units of service

Follow guidelines for billing appropriate units for each service.
Some codes also have guidelines regarding the maximum number of units which can be billed on the code. For more information, refer to the guidelines located in the CMS documents for Medically Unlikely Edits (MUEs).

Kaiser Permanente requires that all CMS-1500 claims submitted are reported using the specific code sets as adopted by HIPAA. The code sets for procedures, diagnoses, and drugs are:

Healthcare Common Procedure Coding System (HCPCS) for ancillary services/procedures.
Current Procedural Terminology (CPT-4) for medical services and procedures performed by physicians and other qualified health professionals.
International Classification of Diseases, version ICD-10 for diagnosis and hospital inpatient procedures.
National Drug Codes (NDC).

Refer to each specific code set for instructions in using codes appropriately. Some basic coding rules to keep in mind are:
Use only codes that are valid for the date of service.
Use modifiers on service lines when appropriate.
National Drug Codes (NDCs) are required to be included for all drugs and biologicals that have NDCs. Also required are the NDC quantity and appropriate qualifier (e.g., GR, ML, UN, F2).
Follow all guidelines for diagnosis coding. These can be found in any ICD-10 published materials on the market. Special attention should be given to the following requirements:

• Diagnosis codes should be coded to the highest specificity required for each code.
• Refer to appropriate ICD guidelines in determining if a diagnosis code can be billed in the primary position, secondary position or either position.
• Each diagnosis code should be "pointed" to the correct procedure code. Incorrect pointing could result in claim line denials.
• For laboratory/pathology claims, the requesting physician must supply the initial diagnosis. For lab services interpreted by a physician/pathologist they are responsible for correcting that diagnosis, if necessary, when the final results of the test are available. The final diagnosis should be billed on the claim.

CMS publishes guidelines for completing the CMS-1500 form when billing for services. Refer to Medicare Claims Processing Manual: Chapter 26–Completing and Processing the Form CMS-1500 Data Set(PDF).

Some field elements to note include:
Field 17a: Include the appropriate taxonomy code for all lines of business.
Field 17b: List the 10-position National Provider Identifier (NPI).

Units of service

Follow guidelines for billing appropriate units for each service:
Some procedure code definitions list a specific number of lesions, centimeters, and minutes. These should be taken into account when billing units.
Some codes also have guidelines regarding the maximum number of units which can be billed on the code. The guidelines can be located at CMS Medically Unlikely Edits (MUEs).
Do not submit claims with units of less than one. We do not allow partial units.

Ambulatory surgical centers

When billing for facility services on a CMS-1500 claim form, modifier SG must be billed on the service line(s) in order to identify the claim as a facility charge.

Anesthesia

Anesthesia claims must be billed using CPT-4 zero anesthesia codes. The appropriate anesthesia modifier is required on all anesthesia claims. Claims must include total minutes in the units field.

Code editing and review process

Most health plans, including Kaiser Permanente, have code editing processes in place to assure that claims are coded based on industry standard guidelines. Kaiser Permanente has adopted the best practice recommendation for Claim coding policy and edits: Standardization & transparency as outlined in Washington state Senate Bill 5346 and published through the administration simplification work of Washington Healthcare Forum.

Kaiser Permanente may, on occasion, either through the code editing process or claims audit process, review a provider's claims in more detail. It may be necessary for us to request the medical records documentation which support the services billed in order to complete these audits. Examples of coding reviews that might prompt a request for medical records documentation: codes with modifier 22, codes with modifier 59, "unlisted" codes, and high-level E&M codes.

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.

Most Kaiser Permanente plans require members to make copayments directly to the provider. Copayments for office visits, pharmacy services, emergency room care, and inpatient hospital care can be found online if you are registered through One Health Port to access Kaiser Permanente.

For members on Medicare hospice plans or contracts, copayment applies to non-hospice services only.

You should collect copayments from our members at the time service is provided. You may charge interest, a reasonable billing fee, or both on unpaid copayments as stated in your office policy. The exceptions are Medicare and Medicaid enrollees, for whom it is against federal regulation to collect such fees.

Never collect a copayment from approved Medicaid enrollees; it is against federal regulation to collect such fees.

You should collect copayments for office visits only when the member sees a physician, physician's assistant, or nurse practitioner. There is no copay for seeing a lab technician.

Some group plans cover preventive care visits in full. If a member is on such a plan, do not collect a copayment.

Outpatient services requiring copayments

• Audiology/hearing tests
• Family planning, prenatal, post-partum visits, and prenatal tests (but not if the provider bills globally)
• Injectable medications that may be self-administered at home
• Office visits and consultations
• Pharmacy services
• Physical, occupational, and speech therapies
• Radiation therapy and chemotherapy (except PEBB)
• Emergency room visits where there is no hospital admission
• Most mental health and substance use disorder visits

Outpatient services generally not requiring copayments

• Diagnostic radiology, ultrasound, and lab services. Exception: High-end radiology may have a copayment.
• Echocardiograms
• EEG and EKG cardiac tests
• Preventive care visits, depending on the group plan
• Injections and immunizations except injectable medications that may be self-administered at home
• Nursing home services
• Pulmonary function tests
• Tympanometry
• Visiting nurse services
• Psychological tests
• Methadone treatment

Contact the Provider Assistance Unit (PAU) with questions about copayments.

You should submit corrected claims only when information has changed on the claim. For example:

• Errors were found involving diagnosis, procedure, date, or modifier.
• Claims contained missing, incorrect, or incomplete data according to our claim submission criteria.
• Services were missed in original submission.
• Post-adjudication audits detected incorrect DRG (diagnosis-related group) or other billing errors.

Rebilling

If there are no changes to a claim, do not rebill until you have confirmed that we have not received your claim. For more information, see Checking claims status.

Correcting electronic claims

You can submit corrected professional and institutional claims electronically by entering the original claim number in the notes and indicating Frequency code 7 as follows:

• Professional claims CMS-1500: Enter Frequency code 7 in Loop 2300 Segment CLM05-3.
• Institutional claims UB-04: Submit with the last character of the Type of Bill as 7, to indicate Frequency code 7.

Correcting paper claims

You can correct professional and institutional paper claims as follows:

• Professional claims CMS-1500: Stamp "Corrected Billing" on the CMS 1500 form.
• Institutional claims UB-04: Submit with the third digit of Type of Bill as 7 to indicate Frequency code 7.

Voiding previously adjudicated claim via EDI

You can request a void, or full reversal, of a previously paid claim by submitting an identical claim, entering the original claim number in the notes, and indicating Frequency code 8 as follows:

• Professional claims CMS-1500: Enter Frequency Code 8 in Loop 2300 Segment CLM05-3.
• Institutional claims UB-04: Submit with the last character of the Type of Bill as 8, to indicate Frequency code 8.

Some health plans require deductibles, coinsurance, or both. In both cases:

• The member is responsible for paying any applicable deductible or coinsurance.
• You may bill for deductibles and coinsurance after you receive a remittance statement explaining how much to collect from the member.

While a Medicare hospice election is in effect, we will pick up the covered balances (deductible or coinsurance) after Medicare makes payment for non-hospice related services.

Any billings to the member for deductibles, copayments, or coinsurance must be at the lesser of the negotiated rate for covered services, as defined in your contract with Kaiser Permanente, or the billed amount. Payment from Kaiser Permanente will be made at the negotiated rate minus any applicable copayments, coinsurance, or deductibles.

Kaiser Permanente uses the following:

Direct

Authorized users can sign on via OneHealthPort to:

• Monitor the status of claims
• Manage referrals
• Check member eligibility

Electronic funds transfer/electronic remittance advice (EFT/ERA)

Kaiser Permanente offers EFT/ERA through our business partner, U.S. Bank.

Electronic funds transfer / electronic remittance advice (EFT/ERA)

Clearinghouse/direct connections

Business-to-business electronic data interchange (EDI) to facilitate our claims processing, patient billing, and care management systems.

Clearinghouse/direct connections

Rebilling

If there are no changes to a claim, do not rebill until you have confirmed that we have not received your claim by using either our

Claims Status Inquiry tool  or contacting the Provider Assistance Unit. For more information, see Checking claims status.

Kaiser Permanente uses electronic fund transfer (EFT) and electronic remittance advice (ERA) for its business services. EFT/ERA results in faster payment, reduced administrative costs, and increased efficiency. Providers currently receiving ERA through a clearinghouse can continue to do so, and sign up for EFT to receive additional benefits.

Get paid faster and reduce costs by eliminating paper checks and remittance advice by receiving free ERA/EFT with U.S. Bank Payment Accelerator, powered by InstaMed.

Get paid faster with claims payments directly deposited into your bank account.
Automate payment posting to streamline processes.
Automate reconciliation of payments and remittances.
Access reporting 24/7 to simplify your workflow.

Enroll with U.S. Bank payment accelerator

1. Enroll online and start receiving benefits immediately
2. Download and complete the network funding agreement from U.S. Bank
3. Attach a voided check
4. Fax or mail the form to U.S. Bank

Toll-free fax: 1-877-755-3392
Mail to:
U.S. Bank Payment Accelerator (c/o InstaMed)
P.O. Box 58790
Philadelphia, PA 19102

Updates to existing enrollment

To add or change Tax Identification or NPI numbers already enrolled with InstaMed for electronic funds transfer, please do the following:

1. Email support@instamed.com with the updated information.
2. Notify Kaiser Permanente of these changes by completing an external demographic form.

Questions?

For questions about the enrollment process, contact the U.S. Bank Payment accelerator team toll-free at 1-877-833-6821, or send an email to connect@instamed.com.

For more information about EFT/ERA, see Electronic funds transfer and remittance advice FAQs.

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.

Medicare effective in the middle of inpatient stay

When Medicare becomes effective and Primary in the middle of an inpatient confinement, providers are not allowed to bill any other parties for dates preceding entitlement

Medicare will pay for all the claims as outlined in the Medicare Claim Processing Manual, Publication 100-04, Chapter 3, Section 40.

Being that Medicare part A became effective during the time of their inpatient stay, if there is one full day of overlap, Medicare will pay for the entire stay.

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).

A member's financial responsibilities (cost shares) vary depending on the specific plan benefits, copayments, coinsurance, and deductibles.

You can check member eligibility using our Eligibility Inquiry tool. After your search, scroll to the bottom of the Eligibility Inquiry Results page and click Summary of Benefits. You can also check a member's eligibility by calling the Provider Assistance Unit at 1-509-241-7206 or toll-free at 1-888-767-4670.

Once we process your claim, you must bill the member for their share of the bill only, as stated on the Remittance Advice you receive with your payment.

When a Kaiser Permanente member is receiving care for injuries related to a motor vehicle accident, you should bill claims directly to the member's automobile insurance carrier under their Personal Injury Protection (PIP) if available.

The use of box 10B marked yes on a CMS 1500 form or FL31 coded with 01, 02, or 03 on a CMS 1450 form identifies an auto accident. If Kaiser Permanente does not know about the accident, we will investigate and notify you if an auto insurance carrier should be primary.

The member must stay within our network system to ensure coverage by Kaiser Permanente in case the carrier rejects the claim.

If the carrier denies the claim, promptly submit the claim and a copy of the denial to Kaiser Permanente. We will only consider claims filed within the timely filing limit of one year from the date of service.

In the absence of first-party coverage, submit all bills to Kaiser Permanente for consideration. You should not bill any third-party carrier for care you provide related to a motor vehicle accident.

If you have questions about a first- or third-party accident, contact our Other Party Liability Department at 1-866-783-9594.

Kaiser Permanente adheres to the Center for Medicare & Medicaid Services (CMS) outpatient prospective payment system/ambulatory payment classifications (OPPS/APC) for outpatient facility service billing requirements. We ask that hospitals submit OPPS/APC data for non-Medicare as well as Medicare claims.

We require that you bill modifier SG for facility charges on your CMS-1500 forms, even though CMS no longer requires it.

We must capture the data requirements listed in NPI and Taxonomy Requirements and General Medicare Data Requirements to meet CMS encounter data requirements. Please refer to UB-04 (CMS-1450) required fields (PDF) for field designations.

Kaiser Permanente strongly recommends submitting claims electronically. Electronic billing is available for primary and secondary billings for all Kaiser Permanente patients and offers the following advantages:

Decreased data errors
Reduced administrative costs
Improved cash flow
Reduced paperwork
Expedited claims processing and account reconciliation
Confirmation reports for submitted, received, and denied claims (subject to clearinghouse transaction agreements)

Claims submission must be received within one year of the date of service. Claims received more than one calendar year from the date of service will be denied as being past the timely filing deadline.

Claims must be submitted on an appropriate original CMS-1500 or UB-04 red claim form. When completing claims, refer to either CMS-1500 required fields (PDF) or UB-04 (CMS-1450) required (PDF).

We enforce our policy of not accepting paper claim forms that are completely handwritten or have any handwritten notations, stamps, or stickers on them. Some exceptions apply — see the paper claim submission standards and specifications grid (PDF).

Any claims outside this policy will be rejected and returned to the provider with a letter of explanation.

Claims are generally processed within 30 days after receipt. You may check receipt status by contacting our Provider Assistance Unit at 1-888-767-4670 or by logging into the Claim Status Inquiry tool.

If you cannot submit claims electronically, send all paper claims to:

Kaiser Permanente Claims Administration
P.O. Box 30766
Salt Lake City, UT 84130-0766

Kaiser Permanente calculates allowable reimbursement at the lower of charges or the maximum amount allowable on the pertinent Kaiser Permanente Washington provider reimbursement schedule described below.

Paid amounts shall reflect the maximum allowable amount less any applicable coinsurance, copayments, and deductible amounts.

Medicare services
The Kaiser Permanente provider reimbursement schedule for services provided to Medicare members will generally reflect prevailing Medicare payment levels as they are revised in accordance with the Centers for Medicare and Medicaid Services'(CMS) fee schedule and payment methodology.

Commercial services
The Kaiser Permanente Washington provider reimbursement schedule for services provided to commercial members is generally based on the CMS Resource-Based Relative Value Scale (RBRVS) relative value units (RVUs), payment policies and methodology.

Final RVU values reflect adjustments for:
Geographic adjustments (GPCI), using values for King County and "Rest of Washington"Non-Facility Practice and Facility Practice Expense RVU differential for site-of-service

The final RVU calculation is rounded to two decimal places.

Where CMS does not provide an RBRVS-based RVU, gap filler methodology is applied. When no gap-filler is available, Kaiser Permanente Washington will price the service at a percent of the billed charges until CMS assigns an RVU or the gap-filler methodology provides a value. Codes that are considered "by report" will be reviewed for medical necessity and priced accordingly if appropriate.

Kaiser Permanente Washington updates its professional provider reimbursement schedule periodically by adding new codes and deleting retired codes. In most instances, RVUs are assigned to new and revised codes in accordance with CMS geographically adjusted RBRVS schedule, other CMS schedules, and gap filler methodology.

Discrete facility charges for evaluation and management services provided to commercial managed-care members are not reimbursable, nor is the member liable for these charges. The Kaiser Permanente provider reimbursement schedule utilizes the prevailing Medicare Part B Drug Payment Allowance Pricing File, updated quarterly, for drugs furnished incident to physician services.

The Kaiser Permanente Washington provider reimbursement schedule utilizes the American Society of Anesthesiologists (ASA) base units and 5 time units per hour in calculating reimbursement for anesthesia services billed with base units and time. Time units are rounded to the first decimal place. For neuraxial labor anesthesia, 5 units are assigned to the first hour and 1 unit for each additional hour or partial hour. Relative value units for procedures and pain management services provided by anesthesiologists are derived from the RBRVS system described above.

Facility charges for evaluation and management services
Discrete facility charges for evaluation and management services provided to commercial managed-care members are not reimbursable. Such services, when provided to Medicare managed-care members, shall continue to follow Medicare payment rules.

1. Evaluation and management services are defined as Current Procedural Terminology codes 99201-99215, 99381-99395, 99401-99429, 99495-99496, 99078, G0463, payment for which is allowed only when billed on a CMS-1500.
2. Discrete facility charges associated with evaluation and management services are not reimbursable for commercial managed-care members, regardless of revenue code billed. Commercial managed-care members shall not be liable for these charges.
3. Professional services for evaluation and management services are reimbursed under the Kaiser Permanente Washington provider reimbursement schedule.

For more information about facility charges for evaluation and management services, see Kaiser Permanente payment policies.

If you disagree with the final disposition of a claim, you may request a review by contacting the Provider Assistance Unit at 1-888-767-4670. Please have your remittance advice available.

This process is used for claims denied for:

• Coding review
• Contract denials
• Pricing disputes
• Timely Filing

Claims denied with Member Liability follow the member appeals process.

Request for reconsideration (first-level review)

• You can send your request multiple ways:
• Electronically using the online form.
• Fax or mail by downloading the Claims Reconsideration Form.
• Calling the Provider Assistance Unit at 1-888-767-4670 to initiate first-level over the phone.
• If it's determined the claim needs to be re-processed, it will be adjusted to show up in a future remittance advice and a written health plan decision letter will be sent. If the denial stands, you will receive a written health plan decision letter.

For corrected claims or claim adjustments requests please follow our timely filing guidelines. Requests for first-level reconsideration review follow the below time frames.

Commercial members:

• Provider has 24 months from the notification date of denial
• If coordination of benefits is involved, the provider has 30 months from the notification date of denial
• If your claim was paid but you are disputing the amount paid, please contact our Provider Assistance Unit at 1-888-767-4670.

Medicare members:

• Contracted providers have 24 months from the notification date of denial
• Non-contracted providers have 60 days from the notification date of denial and will follow the member appeals process
• If coordination of benefits is involved, the provider has 30 months from the notification date of denial
• If your claim was paid but you are disputing the amount paid, please contact our Provider Assistance Unit at 1-888-767-4670.

Request for reconsideration (second-level review)

• If you disagree with the first-level review, you may request a second-level reconsideration. This process allows you to submit additional information that may change the outcome of the initial decision.

For corrected claims or claim adjustments requests please follow our timely filing guidelines. Requests for second level reconsideration review follow the below time frames.

Commercial members:

• Provider has 24 months from the notification date of denial
• If coordination of benefits is involved, the provider has 30 months from the notification date of denial
• If your claim was paid but you are disputing the amount paid, please contact our Provider Assistance Unit at 1-888-767-4670.

Medicare members:

• Contracted providers have 24 months from the notification date of denial and should follow the second level provider reconsideration process: Retroactive authorizations, extenuating circumstances, and provider reconsideration requests
• Non-contracted providers have 60 days from the notification date of denial and will follow the member appeals process
• If coordination of benefits is involved, the provider has 30 months from the notification date of denial
• If your claim was paid but you are disputing the amount paid, please contact our Provider Assistance Unit at 1-888-767-4670.

Denials not related to no prior authorization or medical necessity

Complete the Claims second-level reconsideration form and be sure to include your previous call reference # and any supporting documentation with your request.

Note: If you are changing any data on your claim, submit your request as a corrected claim in order to promptly facilitate a payment determination. For more information, see Corrected billing.

For requests that require post service review, it is required that supporting documentation related to the denied claim and services performed, be submitted at the time of your request in order for a thorough review to be completed. Lack of supporting documentation may result in the denial being upheld.

Claims trend escalation

This process is intended to allow for a retrospective review once all avenues have been exhausted and when you feel there has been an incorrect or incomplete review of the claim in question. Please refer to the Complex Claims Trends Escalation Huddle Card (PDF) for further instructions on how to submit these trends for review.

Dispute resolution

A formal OIC-approved process is defined in your contract that we use in response to requests for escalation by the health plan or contracted provider regarding the terms of the provider contract. This process may be used to re-evaluate a health plan action or any issue evolving from the provider agreement.

Medicare Advantage non-contracted provider appeal rights:

If you do not agree with this determination you have the right to file an appeal. Written requests for appeal (reconsideration) of a zero-payment determination must be submitted within 60 calendar days of the date of this notice and must include a signed Waiver of Liability. The form can be found at https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf.

Reconsideration requests for denied claims, along with your supporting documentation (e.g. copy of this notice, clinical records) must be submitted in writing to:

Kaiser Foundation Health Plan of WA
Attn: Provider Appeals
PO Box 34593
Seattle, WA 98124-1593

Medicare Advantage non-contracted provider payment disputes:

Written requests to dispute a payment must be received within 120 calendar days from the date of this notice. Corrected claims should not be submitted as a dispute or appeal.

Requests for payment disputes, along with your supporting documentation (e.g. copy of original claim, copy of this notice, clinical records) must be submitted in writing to:

Kaiser Foundation Health Plan of WA
Attn: Claims Reconsideration
PO Box 30766
Salt Lake City, UT 84130-0766

Reconsiderations not related to Post service: Claims payment review & reconsideration process

• Retroactive authorizations, extenuating circumstances, and provider reconsideration requests
• Pre-payment claims review process

Diagnosis Related Group (DRG) payment and review

We may perform DRG reviews on claims which are reimbursed by MS-DRG, APDRG, and APR-DRG to validate that the diagnosis and procedural information leading to the DRG assignment is supported by the medical record. The purpose of DRG validation is to ensure diagnostic and procedural information and discharge status of the patient, as coded and reported by the hospital on its claim, matches both the attending physician's description and the information contained in the patient's medical records. Please refer to the DRG payment and review policy located under More Resources on this page for more information on these claims reviews.

We have engaged the services of Cotiviti to conduct these inpatient claims reviews on our behalf. If you have received a communication from Cotiviti and Kaiser Permanente requesting claims records, please refer to the Cotiviti Upload Portal Job Aid located under More Resources on this page for instructions on how to submit the requested records via Cotiviti’s upload portal.

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. (When submitting supporting documentation via email or fax, the subject line should include the claim number and type of documentation.)

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

We developed the following procedures to help facilitate the process of sending and matching hard copy documentation requested for certain electronic or paper claims when additional information is needed.

Send reports or additional documentation only when requested.

Send any requested documentation to the appropriate address listed on the Claims supporting documentation form (PDF) .

Completely fill out the claims supporting documentation form. You must include the claim number, if available, so we can successfully match any new documentation with the appropriate claim.

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

To expedite billing and claims processing, we ask that your claims be sent to Kaiser Permanente within 30 days of providing the service. The Washington State Office of the Insurance Commissioner (OIC) requires health carriers to meet specific claims-payment timeliness standards. Carriers failing to achieve those standards must pay interest to contracted providers. We exceed OIC standards with our policy of paying interest on any clean claim that is not paid within 60 days of receipt.

Clean claims

The OIC defines a clean claim as "having no defect or impropriety, does not lack any required substantiating documentation, or does not have any particular circumstances requiring special treatment that prevents timely payment."

The Centers for Medicare and Medicaid Services (CMS) defines a clean claim as "a claim that has no defect or impropriety, including lack of required substantiating documentation for non-contracting providers and suppliers, or particular circumstances requiring special treatment or that prevents timely payment from being made on the claim. The claim must include information necessary for purposes of encounter data requirements."

Filing guidelines by health plan

We follow both the CMS guidelines and the Revised Code of Washington (RCW) for timely filing of original and adjustment claims. These requirements are outlined here by type of health plan. To expedite claims processing, we encourage you to submit claims using electronic transactions.

Medicaid

Original claims: The claim must be received by Kaiser Permanente within 12 months from the date of services.

Adjustment requests: The request must be received within 24 months from the date the claim was processed (RCW 48.43.605).

The Patient Protection and Affordable Care Act requires that Medicare and Medicaid overpayments be reported and returned within 60 days after they are identified by the provider.

Medicare Advantage HMO and PPO

Original claims: As a result of the Patient Protection and Affordable Care Act of 2010, the maximum period for submission of Medicare claims is reduced to not more than 12 months. Submission processes need to be adjusted to ensure that:

• Claims with dates of service prior to Oct. 1, 2009, will be subject to pre-PPACA timely filing rules.
• Claims with dates of service Oct. 1, 2009, through Dec. 31, 2009, received after Dec. 31, 2010, will be denied as being past the timely filing deadline.
• Claims with dates of service Jan. 1, 2010, and later received more than one calendar year from the date of service will be denied as being past the timely filing deadline.

Adjustment requests: The request must be received within 12 months from the date of service. Kaiser Permanente, as a Medicare carrier, may initiate an adjustment at any time.

The Patient Protection and Affordable Care Act requires that Medicare and Medicaid overpayments be reported and returned within 60 days after they are identified by the provider.

Commercial/PPO/POS

Original claims: The claim must be received by Kaiser Permanente within 12 months from the date of service.

Adjustment requests: The request must be received within 24 months from the date the claim was processed. Kaiser Permanente may initiate an adjustment within 24 months from the date the claim was processed (RCW 48.43.605).

Self-funded

Original claims: The claim must be received by Kaiser Permanente within 12 months from the original primary payment.

Adjustment requests: The request must be received within 24 months from the date the claim was processed (RCW 48.43.605). Kaiser Permanente may initiate an adjustment at any time.

Claims with COB involvement

Original claims: The claim must be received by Kaiser Permanente within 12 months from the original primary payment. If Kaiser Permanente receives information of primary insurance for a member, we may initiate an adjustment within 12 months from the date of notification.

Adjustment requests: The request must be received within 30 months from the date the claim was processed (RCW 48.43.605).

Self-funded: Timely filing limits vary. Please check with the employer group or the Provider Assistance Unit at 509-241-7206 or 1-888-767-4670 for filing deadlines.

Most member agreements with Kaiser Permanente exclude payment for any services associated with a job-related injury or illness. Promptly notify us whenever one of our members is injured in an on-the-job accident. Please use box 10A marked yes on a CMS 1500 form or occurrence code 04 listed in FL31 of a CMS 1450 form.

Kaiser Permanente will not be responsible for payment if the member's coverage agreement excludes work-related injuries from health plan coverage.

Agreements providing work-related injury coverage

There are some Kaiser Permanente member agreements that will cover on-the-job injuries if no L&I is available (please call the Provider Assistance Unit to check member's contract). In such cases, it is recommended the member stay within our network system in the event that the Washington State Department of Labor & Industry (L&I) or other self-insured workers' compensation carrier denies/rejects the claim.

If L&I denies the claim, send a copy of the denial along with the appropriate completed CMS form for payment to:

Kaiser Permanente Claims Administration
P.O. Box 30766
Salt Lake City, UT 84130-0766

Kaiser Permanente will not be responsible for payment if the workers' compensation carrier denies payment of services because required preauthorization was not obtained.

When you are providing services to members who are covered by Washington State Industrial Insurance:

• You must submit all necessary paperwork for the initial and subsequent visits to L&I or, for self-insured employers, to the appropriate carrier.
• Filing an accident report or rendering treatment to an injured worker constitutes acceptance of L&I rules and fees.

If the member works for an employer who is self-insured for work-related injuries or if the member cannot identify the workers' compensation carrier, you may call the L&I provider hotline.

Please refer to the Washington state Attending Doctor's Handbook available from L&I.

Contact the Other Party Liability Department or send the following information to assist with related claims to Kaiser Permanente Claims Administration:

• Member name and identification number
• Date of injury and claim number
• Name and telephone number of employer
• Nature of injury

If you are providing services to Kaiser Permanente members who are covered by Idaho Workers' Compensation:

• The member must report the injury or illness to the employer. The employer then files a claim.
• Contact the Idaho Industrial Commission Compliance Division to obtain the name of the insurance carrier that handles claims for the member's employer.