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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 .......................................................................... 8 CONTACTS FOR QUESTIONS ............................................................................................................... 8 5.1. METHODS OF CLAIMS FILING ........................................................................................... 8 5.1.1 Electronic Data Interchange (EDI) ........................................................................................................ 8 5.1.2 Electronic Claims Forms / Submission .................................................................................. 9 5.1.3 Paper Claim Forms ............................................................................................................................... 10 5.1.4 Record Authorization Number ............................................................................................. 10 5.1.5 One Member/ Provider per Claim Form .............................................................................. 10 5.1.6 No Fault/ Workers’ Compensation/Other Accident .............................................................. 10 5.1.7 Record the Name of the Provider You Are Covering For .................................................... 10 5.1.8 Submission of Multiple Page Claim ..................................................................................... 11 5.1.9 Entering Dates. Below is an example of how to enter dates on the CMS-1500 (HCFA- 1500) Claim Form. ........................................................................................................................... 11 5.1.10 Multiple Dates of Services and Place of Services ............................................................. 11 5.1.11 Surgical and/or Obstetrical Procedures ............................................................................. 11 5.1.12 Billing Inpatient Claims That Span Different Years ............................................................ 12 5.1.13 Interim Inpatient Bills ......................................................................................................... 12 5.1.14 Supporting Documentation for Paper Claims .................................................................... 12 5.1.15 Where to Mail Paper Claims .............................................................................................. 12 5.2 CLAIM FILING REQUIREMENTS ....................................................................................... 13 5.2.1 Clean Claims .......................................................................................................................................... 13 5.2.2 Claims Submission Timeframes .......................................................................................................... 13 5.2.3 Claims Processing Turn-Around Time .............................................................................................. 15 5.2.4 Claim Reconsideration ......................................................................................................................... 15 5.2.5 Claims Adjustments / Corrections ...................................................................................................... 15 Kaiser Permanente Provider Manual 2017 3 5.2.6 Incorrect Claims Payments .................................................................................................................. 16 5.2.7 Rejected Claims Due to EDI Claims Error ......................................................................................... 16 5.2.8 Required Identification Information .................................................................................................. 17 5.2.8.1 Federal Tax ID Number ....................................................................................................... 17 5.2.8.2 Changes in Federal Tax ID Number ................................................................................... 18 5.2.8.3 National Provider Identification (NPI) .............................................................................. 18 5.2.9 Member Cost Share ............................................................................................................................... 18 5.2.10 Member Claims Inquires ...................................................................................................................... 18 5.4.1 Coding Standards ................................................................................................................................. 20 5.4.2 Modifiers in CPT and HCPCS ............................................................................................................. 21 5.4.3 Claims Editing Software Program ...................................................................................................... 23 5.4.4 Coding Edit Rules ................................................................................................................................. 24 5.5 Clinical Review ...................................................................................................................................... 28 5.6 THIRD PARTY LIABILITY (TPL) ................................................................................................... 28 5.7 WORKERS’ COMPENSATION ....................................................................................................... 29 5.8 THIRD PARTY ADMINISTRATOR (TPA) ...................................................................................... 29 5.9 Provider Claim Payment Appeals Process ........................................................................................ 29 5.9.1 CLAIM FORM EXAMPLES AND INSTRUCTIONS ........................................................................ 29 5.9.1.1 CMS 1500 .............................................................................................................................................. 29 5.9.1.2 CMS-1450 (UB-04) Field Descriptions ................................................................................ 39 5.10 BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES ................................. 44 5.10.1 Capitation Payments ............................................................................................................................ 44 5.10.2 Evaluation Management (E/M) Services ............................................................................................ 44 5.10.2.2 Inpatient E/M Services: .................................................................................................. 45 5.10.2.3 Surgical Procedure that Include E/M Services: ............................................................. 46 Kaiser Permanente Provider Manual 2017 4 5.10.3 Preventive Medicine Services: .......................................................................................... 50 5.10.4 Emergency Rooms ................................................................................................................................ 51 5.10.4.1 Two Physicians Involved in Admitting a Patient from the ER ......................................... 51 5.10.4.2 “Emergency” in the Office Setting................................................................................... 51 5.10.4.3 “Non-Emergency” Services Provided in the Emergency Department ............................. 51 5.10.4.4 Emergency Room and Urgent Care Services Submitted on a UB-04 ............................ 52 5.10.5 Critical Care Services ............................................................................................................................ 52 5.10.5.1 Patient Located in a Critical Care Unit Not Receiving Critical Care Services ................. 52 5.10.6 Observation Services ............................................................................................................................ 52 5.10.7 Injection/ Immunizations ..................................................................................................................... 52 5.10.7.1 Vaccine Immunizations .................................................................................................. 52 5.10.7.2 Allergy Immunotherapy .................................................................................................. 53 5.10.8 Obstetrical Services ............................................................................................................................... 53 5.10.8.1 Admissions for False Labor ............................................................................................ 53 5.10.8.2 Anesthesia Services Provided with Deliveries ................................................................ 54 5.10.8.3 Multiple Physicians Provide Different Components of the Obstetrical Care .................. 54 5.10.8.4 Antepartum Care ............................................................................................................ 54 5.10.9 Newborn Services ................................................................................................................................
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