Processing claims

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.

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.

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.

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:

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.