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Provider Manual Provider Manual ▪ Billing and Payment Billing and Payment Kaiser Permanente’s billing and payment policies and procedures aim to ensure that you receive timely payment for the care you provide. This section of the Manual provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If you have a question or concern about the information in this section, please call 1 -888-681-7878 or 303-338-3600. Table of Contents SECTION 5: BILLING AND PAYMENT .......................................................................... 6 5.1. CONTACTS FOR QUESTIONS ......................................................................................................... 6 5.2. METHODS OF CLAIMS FILING ...................................................................................................... 7 5.2.1 Electronic Data Interchange (EDI) ............................................................................................ 7 5.2.2 Electronic Claims Forms / Submission .................................................................................. 7 5.2.3 Supporting Documentation for EDI Claims ............................................................................. 8 5.2.4 To Initiate Electronic Claims Submissions .............................................................................. 8 5.2.5 Paper Claim Forms ................................................................................................................. 8 5.2.6 Record Authorization Number ............................................................................................................ 8 5.2.7 One Member/ Provider per Claim Form .................................................................................. 9 5.2.8 Motor Vehicle Accident/ Workers’ Compensation/Other Accident .......................................... 9 5.2.9 Record the Name of the Provider You Are Covering For ........................................................ 9 5.2.10 Submission of Multiple Page Claim ...................................................................................... 9 5.2.11 Entering Dates .................................................................................................................... 10 5.2.12 Multiple Dates of Services and Place of Services ............................................................... 10 5.2.13 Surgical and/or Obstetrical Procedures .............................................................................. 10 5.2.14 Billing Inpatient Claims That Span Different Years ............................................................. 10 5.2.15 Rates for an Episode of Care ............................................................................................. 11 5.2.16 Interim Inpatient Bills ......................................................................................................... 11 5.2.17 Supporting Documentation for Paper Claims ...................................................................... 11 5.2.18 Where to Mail Paper Claims ............................................................................................... 11 5.3. CLAIM FILING REQUIREMENTS .................................................................................................. 12 5.3.1 Clean Claims ........................................................................................................................ 12 5.3.2 Claims Submission Timeframes ........................................................................................... 13 5.3.3 Claims Processing Turn-Around Time .................................................................................. 14 5.3.4 Claim Reconsideration.......................................................................................................... 14 5.3.5 Claims Adjustments / Corrections ......................................................................................... 15 5.3.6 Incorrect Claims Payments ................................................................................................... 15 5.3.7 Rejected Claims Due to EDI Claims Error ............................................................................ 16 5.3.8 Required Identification Information ....................................................................................... 16 5.3.9 Member Cost Share.............................................................................................................. 18 5.3.10 Member Claims Inquires ..................................................................................................... 18 5.4. VISITING MEMBERS .................................................................................................................... 19 5.5. CODING FOR CLAIMS ................................................................................................................ 20 5.5.1 Coding Standards ................................................................................................................. 20 5.5.3 Claims Editing Software Program ......................................................................................... 22 5.5.4 Coding Edit Rules ................................................................................................................. 22 5.5.5 Clinical Review .................................................................................................................... 25 5.6. THIRD PARTY LIABILITY (TPL) .................................................................................................. 26 5.7. WORKERS’ COMPENSATION ...................................................................................................... 26 5.8. THIRD PARTY ADMINISTRATOR (TPA) ..................................................................................... 26 5.9. PROVIDER CLAIM PAYMENT APPEALS PROCESS ........................................................... 27 5.9.1 Claim Form Examples and Instructions .................................................................................. 27 5.10. BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES .................................. 39 5.10.1 Capitation Payments ......................................................................................................... 39 5.11. CLEAN CLAIM .................................................................................................................. 39 5.12. COORDINATION OF BENEFITS (COB) ...................................................................................... 40 5.12.1 How to Determine the Primary Payor ................................................................................ 41 5.12.2 Description of COB Payment Methodologies .................................................................... 42 5.12.3 COB Claims Submission Requirements and Procedures .................................................. 42 5.12.4 Members Enrolled in Two Kaiser Permanente Plans ........................................................ 42 5.12.5 COB Claims Submission Timeframes ............................................................................... 42 5.12.6 COB Fields on the UB-04 and UB-04 Claim Form ............................................................ 43 5.12.7 COB FIELDS ON THE CMS-1500 (HCFA-1500) CLAIM FORM ....................................... 45 5.12.8 Explanation of Payment (EOP) ........................................................................................... 47 Section 5: Billing and Payment It is your responsibility to submit itemized claims for services provided to in accordance with your Agreement, this Manual and applicable law. The Member’s Payor is responsible for payment of claims in accordance with your Agreement. Please note that this manual does not address submission of claims under tier 2 and 3 of POS product. Health Plan agrees to implement any new or revised CMS Fee Schedule within 45 calendar days after the CMS File Publish Date or CMS Implementation Date, whichever is later. 5.1. Contacts for Questions Central Referral Center 303-636-3131 or 1-877-895-2705, FAX 303-636-3101 Provides authorization prior to rendering services. Specialists are limited to procedures and services defined on the Referral Authorization Form. Members must return to Kaiser Permanente for services that have not been pre-authorized. Claims and Member Service Department 303-338-3600 or 1-800-632-9700 Provides information related to claims payment for services provided. All billings should be sent to the address listed below. Claims should be submitted on a CMS 1500 or CMS 1450 form. Clean claims will be paid or denied within the timeframes required by applicable federal or state law. Kaiser Permanente Claims and Referral Department PO Box 373150 Denver, CO 80237-6970. Member Service Department - Benefit Information 303-338-3800 or 1-800-632-9700 Provides benefits or eligibility of a Kaiser Permanente member. Providers can also find benefit information on Kaiser Permanente ID cards. All member cost share should be collected at the time services are provided. This department also documents, reports and facilitates the response to member complaints. Provider Credentialing Requirements 1-866-866-3951 Our Credentialing Committee prior to rendering services must approve all consultants contracting with Kaiser Permanente. If you add new providers to your practice, you must contact your contract manager to have them properly credentialed. If providers bill prior to being credentialed
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