Provider Manual . Billing and Payment 8/31/2011 Billing and Payment This section of the Manual was created to help guide you and your staff in working with Kaiser Permanente’s billing and payment policies and procedures. It provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If, at any time, you have a question or concern about the information in this Manual, you can reach our Claims Customer Service Department by calling 303- 338 -3600. 5 8/31/2011 Table of Contents TABLE OF CONTENTS ............................................................................................................. 3 SECTION 5: BILLING AND PAYMENT ............................................................................... 6 5.1 WHOM TO CONTACT WITH QUESTIONS ...................................................................................................... 6 5.2 METHODS OF CLAIMS FILING ...................................................................................................................... 8 5.3 PAPER CLAIM FORMS ................................................................................................................................... 8 5.4 RECORD AUTHORIZATION NUMBER ............................................................................................................ 8 5.5 ONE MEMBER/ PROVIDER PER CLAIM FORM ................................................................................................ 8 5.6 NO FAULT/ WORKERS’ COMPENSATION/OTHER ACCIDENT ..................................................................... 8 5.7 RECORD THE NAME OF THE PROVIDER YOU ARE COVERING FOR.............................................................. 9 5.8 SUBMISSION OF MULTIPLE PAGE CLAIM ...................................................................................................... 9 5.9 ENTERING DATES ......................................................................................................................................... 9 5.10 MULTIPLE DATES OF SERVICES AND PLACE OF SERVICES ......................................................................... 9 5.11 SURGICAL AND/OR OBSTETRICAL PROCEDURES ......................................................................................... 9 5.12 BILLING INPATIENT CLAIMS THAT SPAN DIFFERENT YEARS .................................................................... 9 5.13 SUPPORTING DOCUMENTATION FOR PAPER CLAIMS .............................................................................. 10 5.14 WHERE TO MAIL/FAX PAPER CLAIMS ...................................................................................................... 10 5.15 ELECTRONIC DATA INTERCHANGE (EDI) ............................................................................................... 12 5.16 ELECTRONIC CLAIMS FORMS ..................................................................................................................... 12 5.17 SUPPORTING DOCUMENTATION FOR EDI CLAIMS ................................................................................... 12 5.18 TO INITIATE ELECTRONIC CLAIMS SUBMISSIONS ..................................................................................... 13 5.19 ELECTRONIC SUBMISSION PROCESS ........................................................................................................ 13 8/31/2011 KAISER PERMANENTE 5.20 HIPAA REQUIREMENTS ........................................................................................................................... 14 5.21 CLEAN CLAIMS......................................................................................................................................... 14 5.22 CLAIMS SUBMISSION TIMEFRAMES ........................................................................................................... 15 5.23 CLAIMS PROCESSING TURN-AROUND TIME ............................................................................................ 15 5.25 PROOF OF TIMELY CLAIMS SUBMISSION ................................................................................................. 16 5.26 CLAIM ADJUSTMENTS/ CORRECTIONS .................................................................................................... 16 5.27 Incorrect Claims Payments ................................................................................................................... 18 5.28 REJECTED CLAIMS DUE TO EDI CLAIMS ERROR ..................................................................................... 18 5.29 FEDERAL TAX ID NUMBER ....................................................................................................................... 18 5.30 CHANGES IN FEDERAL TAX ID NUMBER .................................................................................................. 20 5.31 NATIONAL PROVIDER IDENTIFICATION (NPI)......................................................................................... 20 5.33 Member Claims Inquiries ...................................................................................................................... 20 5.34 Visiting Members .................................................................................................................................. 20 5.35 Coding for Claims .................................................................................................................................. 21 5.36 Coding Standards .................................................................................................................................. 21 5.37 Modifiers in CPT and HCPCS ............................................................................................................... 22 5.38 Modifier Review .................................................................................................................................... 23 5.39 CODING & BILLING VALIDATION ............................................................................................................. 23 5.40 Coding Edit Rules ................................................................................................................................... 25 5.41 Medical Claims Review ......................................................................................................................... 29 5.42 Third Party Liability (TPL) .................................................................................................................... 29 5.43 Workers’ Compensation ........................................................................................................................ 29 5.44 Third Party Administrator (TPA) ....................................................................................................... 29 5.45 PROVIDER CLAIMS APPEALS .................................................................................................................... 29 5.46 CMS-1500 (08/05) FIELD DESCRIPTIONS ......................................................................................... 30 Kaiser Permanente Provider Manual Section 5: Billing and Payment 8/31/2011 4 KAISER PERMANENTE 5.47 CMS-1450 (UB-04) FIELD DESCRIPTIONS ........................................................................................ 39 5.48 BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES ..................................................... 44 5.48. 1 Capitation Payments ....................................................................................................................... 44 5.48.2 Evaluation Management (E/M) Services ........................................................................................... 44 5.48.3 Emergency Rooms ................................................................................................................................ 45 5.48.4 Critical Care Services ......................................................................................................................... 46 5.48.5 Observation Services ............................................................................................................................ 46 5.48.6 Injection/ Immunizations .................................................................................................................... 46 5.48.7 Obstetrical Services .............................................................................................................................. 46 5.48.8 Newborn Services ................................................................................................................................ 47 5.48.9 Surgery ................................................................................................................................................. 49 5.48.10 Laboratory Procedures ...................................................................................................................... 53 5.48.11 Radiology Services ............................................................................................................................. 54 5.49 COORDINATION OF BENEFITS (COB) ....................................................................................................... 56 5.49.1 How to Determine the Primary Payor............................................................................................. 56 5.49.2 Description of COB Payment Methodologies ................................................................................ 57 5.49.3 COB Claims