Claims submission

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 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

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.