2015 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc.
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1 2015 Northern California HMO Provider Manual Kaiser Foundation Health Plan, Inc.
2 Welcome from Kaiser Permanente It is our pleasure to welcome you as a contracted provider (Provider) participating under HMO plans offered by the Kaiser Permanente Medical Care Program Affiliated Payors. We want this relationship to work well for you, your medical support staff, and our Members. This Provider Manual was created to help guide you and your staff in working with Kaiser Permanente s various systems and procedures applicable to our HMO products in Northern California. It is an important part of your relationship with Kaiser Permanente, but this Provider Manual does not cover all aspects of your relationship with us. Please continue to consult your Provider agreement with Kaiser Permanente. During the term of such agreement, Providers are responsible for (i) maintaining copies of the Provider Manual and its updates as provided by Kaiser Permanente, (ii) providing copies of the Provider Manual to its subcontractors and (iii) ensuring that Provider and its practitioners and subcontractors comply with all applicable provisions. The Provider Manual, including but not limited to all updates, shall remain the property of Kaiser Permanente and shall be returned to Kaiser Permanente or destroyed upon termination of the obligations under such agreement. If you have questions or concerns about the information contained in this HMO Provider Manual, you can reach our Medical Services Contracting Department by calling (510) Additional resources can also be found on our Community Provider Portal website at:
3 Table of Contents INTRODUCTION... X 1. KAISER PERMANENTE MEDICAL CARE PROGRAM (KPMCP) HISTORY ORGANIZATIONAL STRUCTURE KPNC SERVICE AREA INTEGRATION NONDISCRIMINATION PREVENTATIVE HEALTH CARE OTHER PRODUCTS Exclusive Provider Organization (EPO) Point of Service (POS) Two-Tier Point of Service (POS) Three-Tier Out of Area Preferred Provider Organization (PPO) IDENTIFICATION CARDS AND MEDICAL RECORD NUMBER (MRN) KEY CONTACTS NORTHERN CALIFORNIA REGION KEY CONTACTS MEMBER SERVICES INTERACTIVE VOICE RESPONSE SYSTEM (IVR) KP OUTSIDE SERVICES KP FACILITY LISTING ELIGIBILITY AND BENEFITS DETERMINATION ELIGIBILITY AND BENEFIT VERIFICATION After Hours Eligibility Requests Benefit Coverage Determination MEMBERSHIP TYPES BENEFIT EXCLUSIONS AND LIMITATIONS DRUG BENEFITS UTILIZATION MANAGEMENT/RESOURCE STEWARDSHIP (UM) OVERVIEW OF UTILIZATION MANAGEMENT/RESOURCE STEWARDSHIP PROGRAM i
4 4.1.1 Data Collection and Surveys MEDICAL APPROPRIATENESS REFERRAL AND AUTHORIZATION GENERAL INFORMATION AUTHORIZATION OF SERVICES Hospital Admissions Other Than Emergency Services Admission to Skilled Nursing Facility (SNF) Home Health/Hospice Services Home Health Only Hospice Only Durable Medical Equipment (DME)/ Prosthetics and Orthotics (P&O) Psychiatric Hospital Services Non-Emergent Transportation Non-Emergency Medical Transport (Gurney Van/Wheelchair Van) Non-Emergency Ambulance Transportation Authorization for KP Emergency Department Visits Required Information for Transfers to KP EMERGENCY ADMISSIONS AND SERVICES; HOSPITAL REPATRIATION POLICY Emergency Prospective Review Program (EPRP) Post-Stabilization Care CONCURRENT REVIEW CASE MANAGEMENT HUB CONTACT INFORMATION DENIALS AND PROVIDER APPEALS DISCHARGE PLANNING UM INFORMATION CASE MANAGEMENT CLINICAL PRACTICE GUIDELINES (CPGS) PHARMACY SERVICES / DRUG FORMULARY Pharmacy Benefits Filling Prescriptions Prescribing Non-Formulary Drugs Pharmacies ii
5 Telephone and Internet Refill Lines Mail Order Restricted Use Drugs Emergency Situations BILLING AND PAYMENT WHOM TO CONTACT WITH QUESTIONS METHODS OF CLAIMS SUBMISSION CLAIMS FILING REQUIREMENTS Record Authorization Number One Member and One Provider per Claim Form Submission of Multiple Page Claim (CMS-1500 Form and UB-04 Form) Billing Inpatient Claims That Span Different Years Interim Inpatient Bills Bills from Dialysis Providers for Non-Dialysis Services Psychiatric and Recovery Services Provided to MediCal Members Services Provided to Medicare Cost Members PAPER CLAIMS Submission of Paper Claims Calling KP Regarding Referred Services Claims Submission of Paper Claims Emergency Services Calling KP Regarding Emergency Claims Supporting Documentation for Paper Claims Ambulance Services SUBMISSION OF ELECTRONIC CLAIMS Electronic Data Interchange (EDI) Where to Submit Electronic Claims EDI Claims Acknowledgement Supporting Documentation for Electronic Claims HIPAA Requirements COMPLETE CLAIM CLAIMS SUBMISSION TIMEFRAMES iii
6 5.8 PROOF OF TIMELY CLAIMS SUBMISSION CLAIMS RECEIPT VERIFICATION AND STATUS CLAIM CORRECTIONS INCORRECT CLAIMS PAYMENTS Underpayments Overpayments Overpayment Identified by Provider Overpayment Identified by KP Contested Notice No Contest Offset to Payments Inconsistent Payments MEMBER COST SHARE BILLING FOR SERVICE PROVIDED TO VISITING MEMBERS CODING FOR CLAIMS CODING STANDARDS MODIFIERS USED IN CONJUNCTION WITH CPT AND HCPCS CODES MODIFIER REVIEW CLAIMS ADJUSTMENTS, CODING & BILLING VALIDATION Claims Review Code Review Coding Edit Rules Clinical Review Compensation Methodologies Do Not Bill Events (DNBE) Claims for Do Not Bill Events CMS-1500 (02/12) FIELD DESCRIPTIONS UB-04 (CMS-1450) FIELD DESCRIPTIONS COORDINATION OF BENEFITS (COB) How to Determine the Primary Payor Description of COB Payment Methodology COB Claims Submission Requirements and Procedures iv
7 Direct Patient Billing THIRD PARTY LIABILITY (TPL) Third Party Liability Guidelines WORKERS COMPENSATION PROHIBITED BILLING PRACTICES EXPLANATION OF BENEFITS AND REMITTANCE ADVICE INVOICES Other Contracted Functions Related to Professional Services Other Contracted Functions Related to Services Delivered at KFH (Non- Professional) Tax Documents PROVIDER DISPUTE RESOLUTION PROCESS TYPES OF DISPUTES SUBMITTING PAYMENT DISPUTES Directions for Delivery and Mailing of Payment Disputes Payment Disputes Related to Referred Service Claims Payment Disputes Related to Emergency Services Claims Required Information for Provider Payment Dispute Notices Time Period for Submission of Provider Dispute Notices Timeframes for Acknowledgement of Receipt and Determination of Provider Dispute Notices Instructions for Filing Substantially Similar Payment Disputes RESPONDING TO REQUESTS FOR OVERPAYMENT REIMBURSEMENTS OTHER DISPUTES MEMBER RIGHTS AND RESPONSIBILITIES MEMBER RIGHTS AND RESPONSIBILITIES STATEMENT NON-COMPLIANCE WITH MEMBER RIGHTS AND RESPONSIBILITIES Members Providers HEALTH CARE DECISION-MAKING ADVANCE DIRECTIVES Physician Orders for Life Sustaining Treatment (POLST) v
8 7.5 MEMBER COMPLAINT AND GRIEVANCE PROCESS Provider Participation in Member Complaint Resolution Member Complaint and Grievance Resolution Procedure Medicare Process for Grievances and Complaints Grievances Organization Determination Quality of Care Complaint Reconsideration Coverage Determinations Redeterminations Expedited Review Non-Medicare Process for Initial Claims, Grievances, Complaints and Appeals Quality of Care Complaints Expedited Review Instructions for Filing a Grievance Department of Managed Health Care Complaint Process Non-Medicare Independent Medical Review Program Availability Non- Medicare Demand for Arbitration PROVIDER RIGHTS AND RESPONSIBILITIES PROVIDERS RIGHTS AND RESPONSIBILITIES COMPLAINT AND PATIENT CARE PROBLEMS Administrative and Patient Related Issues Claim Issues REQUIRED NOTICES Provider Changes That Must Be Reported Provider Illness or Disability Practice Relocations Adding/Deleting New Practice Site or Location Adding/Deleting Practitioners to/from the Practice vi
9 Changes in Telephone Numbers Federal Tax ID Number and Name Changes Mergers and Other Changes in Legal Structure Contractor Initiated Termination (Voluntary) Other Required Notices CALL COVERAGE PROVIDERS HEALTH INFORMATION TECHNOLOGY QUALITY ASSURANCE AND IMPROVEMENT (QA & I) NORTHERN CALIFORNIA QUALITY PROGRAM AND PATIENT SAFETY PROGRAM QUALITY ASSURANCE AND IMPROVEMENT (QA & I) PROGRAM OVERVIEW PROVIDER CREDENTIALING AND RECREDENTIALING Practitioners Practitioner Office Site Quality Practitioner Rights Practitioner Right to Correct Erroneous or Discrepant Information Practitioner Rights to Review Information Practitioner Right To Be Informed of the Status of the Credentialing Application Practitioner Right to Credentialing and Privileging Policies Organizational Providers (OPs) Corrective Action Plan or Increased Monitoring Status for OPs MONITORING QUALITY Compliance with Legal, Regulatory and Accrediting Body Standards Member Complaints Infection Control Practitioner Quality Assurance and Improvement Programs QUALITY OVERSIGHT Quality Review OPs Quality Assurance & Improvement Programs (QA & I) Sentinel Events / Reportable Occurrences for OPs (Applicable to Acute Hospitals, Chronic Dialysis Centers, Ambulatory Surgery Centers, vii
10 Psychiatric Hospitals, SNFs and Transitional Residential Recovery Services Providers) Definitions: Sentinel Events and Reportable Occurrences Notification Timeframes Sentinel Event/Reportable Occurrences Home Health & Hospice Agency Providers Report Within 24 Hours Report Within 72 Hours DNBEs / Reportable Occurrences for Providers QA & I REPORTING REQUIREMENTS FOR HOME HEALTH & HOSPICE PROVIDERS Annual Reporting Site Visits and/or Chart Review Personnel Records QA & I REPORTING REQUIREMENTS FOR SNFS Quarterly Reporting Medical Record Documentation QA & I REPORTING REQUIREMENTS FOR CHRONIC DIALYSIS PROVIDERS Reporting Requirements Vascular Access Monitoring (VAM) Surveillance Procedure for an Established Access Performance Target Goals/Clinical Indicators Chronic Dialysis Patients MEDICAL RECORD REVIEW AND STANDARDS ACCESS AND AVAILABILITY GUIDELINES COMPLIANCE COMPLIANCE WITH LAW KP PRINCIPLES OF RESPONSIBILITY AND COMPLIANCE HOTLINE GIFTS AND BUSINESS COURTESIES CONFLICTS OF INTEREST FRAUD, WASTE AND ABUSE PROVIDERS INELIGIBLE FOR PARTICIPATION IN GOVERNMENT HEALTH CARE PROGRAMS VISITATION POLICY viii
11 10.8 COMPLIANCE TRAINING CONFIDENTIALITY AND SECURITY OF PATIENT INFORMATION HIPAA and Privacy and Security Rules Confidentiality of Alcohol and Drug Abuse Patient Records PROVIDER RESOURCES ADDITIONAL INFORMATION AFFILIATED PAYORS SUBCONTRACTORS AND PARTICIPATING PRACTITIONERS Regulatory Compliance Licensure, Certification and Credentialing Billing and Payment Encounter Data Identification of Subcontractors KP'S HEALTH EDUCATION PROGRAMS Health Education Program Focused Health Education Efforts Preventive Health and Clinical Practice Guidelines (CPGs) Telephonic Wellness Coaching Service KP S LANGUAGE ASSISTANCE PROGRAM Using Qualified Bilingual Staff When Qualified Bilingual Staff Is Not Available Telephone Interpretation American Sign Language Support Documentation Family Members as Interpreters ADDITIONAL SERVICE SPECIFIC INFORMATION LABORATORY SERVICES ORDERING FOR SNFS PSYCHIATRIC CARE SETTINGS KP CHEMICAL DEPENDENCY SERVICES PROGRAM SPECIAL NEEDS PLAN (SNP) AUTISM SPECTRUM DISORDER (ASD) SERVICES ix
12 Introduction This Northern California HMO Provider Manual applies to you as a Provider for HMO products offered by Kaiser Permanente Medical Care Program Affiliated Payors, as referenced in your Agreement with a Kaiser Permanente entity. To the extent provided in your Agreement, if there is a conflict between this Provider Manual and your Agreement, the terms of the Agreement will control. The term "Member" as used in this Provider Manual refers to currently eligible enrollees of HMO plans offered by Kaiser Permanente Medical Care Program Affiliated Payors, including Kaiser Foundation Health Plan, and their beneficiaries. The term Provider as used in this Provider Manual refers to the practitioner, facility, hospital, or contractor subject to the terms of the Agreement. Additionally, you or your in the Provider Manual refers to the practitioner, facility, hospital, or contractor subject to the terms of the Agreement and we or our in the Provider Manual refers to Kaiser Permanente. Operational instructions in this Provider Manual specifically relate to the HMO product. Capitalized terms used in this Provider Manual may be defined within the Provider Manual or if not defined herein, will have the meanings given to them in your Agreement. x
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