Code edit or coding policy services reconsideration process

Kaiser Permanente has a process for providers to request a reconsideration of:

• A code edit denial on a specific claim.
• A code editing policy where the provider and Kaiser Permanente are using different nationally recognized sources or the provider and Kaiser Permanente have a different interpretation of a nationally recognized source.

Code edit denial on a specific claim

If you disagree with the application of the code edit, are requesting the edit's source information, or have additional information regarding the services billed, you can request a reconsideration by contacting Provider Assistance Unit (PAU) at 1-888-767-4670. Please be sure to indicate the following information:

• Indicate you are requesting a reconsideration of the code edit denial.
• A brief description of what and why you are asking us to reconsider (specific denial).
• The name and phone number of the point of contact within your organization.

Your reconsideration request will be reviewed by our coding specialists, RN auditors, or the medical director of Kaiser Permanente Claims Administration. You will be contacted if any additional supporting documentation is needed during our review. Examples of supporting documentation may include:

• An operative report
• Medical chart notes
• Radiology report
• Maternity records, etc.

Note: You will have 14 calendar days to supply the requested information.

We will respond to a reconsideration request of a coding policy within 30 calendar days unless additional information is needed from you. This could delay our response time up to 45 calendar days.

If your reconsideration request results in the code edit denial being overturned, we will reprocess the claim to show on your next check run. If your request results in our upholding the code edit denial, you will receive a written response from us outlining how we arrived at this decision and any source information we used which supports the decision.

The process of submitting a final level of appeal is addressed under the "Provider Dispute Resolution Process" found in your provider contract.

Coding policy reconsideration process

Kaiser Permanente has adopted the Best Practice Recommendation (BPR) for professional claims, Reconsideration of a Health Plan's Policy Regarding Code Edits (PDF), as outlined in Washington State Senate Bill 5346 and published through the administration simplification work of Washington Healthcare Forum.

This BPR provides guidelines for a provider to request a reconsideration of a code editing policy where the provider and Kaiser Permanente are using different nationally recognized sources or the provider and Kaiser Permanente have a different interpretation of a nationally recognized source.

Refer to the BPR to determine what is in the scope of this process. Some examples in scope include but are not limited to:

• Column 1 / Column 2 code edits (unbundling)
• Modifier validity
• Assistant surgeon necessity

To submit a reconsideration of a coding policy for both facility and professional claims, please be sure to include:

• Description of the issue/concern
• Explanation of why you do not agree with Kaiser Permanente's current code editing policy or the interpretation of a policy
• Relevant codes or code combinations if appropriate
• Source documentation supporting your position or links to where this information can be found
• Your expected outcome
• Name and phone number of the point of contact within your organization

Mail your request with attachments to:
Kaiser Foundation Health Plan of Washington
Attn: CEU - Code Editing
P.O. Box 204
ACN-AC6
Spokane, WA 99210-0204

Your reconsideration request will be reviewed by our coding specialists, RN auditors, or the medical director of Kaiser Permanente Claims Administration. You will be contacted if any additional supporting documentation is needed during our review. Examples of supporting documentation may include:

• Information regarding denied claims
• Operative reports
• Medical chart notes

Note: You will have 15 calendar days to supply the requested information. The reconsideration cannot be considered without this information.

We will respond to a reconsideration request of a coding policy within 60 calendar days unless additional information is needed from you. This could delay our response time up to 75 calendar days.

There could be situations where Kaiser Permanente and a provider are constructively engaged in a discussion about a reconsideration request and it is mutually agreed that they will extend the response time.

If the decision is made that Kaiser Permanente will not revise the coding policy, a written notification will be sent to the provider. The correspondence will include an explanation of the rationale behind the decision and any related source information.

If the decision is made that Kaiser Permanente will revise the coding policy, a written notification will be sent to the provider. The correspondence will include information regarding:

• Kaiser Permanente's expectations as to when and how the new policy will take effect
• Any system changes that need to occur along with the projected implementation date
• Kaiser Permanente's plan for any related denials prior to the new policy taking effect
• Any special instructions for provider claims prior to the new policy implementation

Note: Once a request for reconsideration of a coding policy has been reviewed and a decision has been communicated to the provider, additional requests related to this policy will not be reviewed unless:

• The provider submits new and/or significantly different information
• New source information has been published that has not been addressed