CLAIMS. Providers must submit itemized claims for covered services provided to members on an appropriate billing form, as follows:

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1 SECTION 10 CLAIMS 10.1 INTRODUCTION The applicable payer identified in the Provider Agreement is responsible for payment of authorized services and emergency services in accordance with the Provider Agreement and applicable law. It is the provider s responsibility to submit itemized claims for those services provided to members in a complete and timely manner in accordance with their Provider Agreement, this Provider Manual and applicable law. The terms bill, claim and invoice are used interchangeably in this section, and should not be interpreted to differ in meaning BILLING REQUIREMENTS Providers must submit itemized claims for covered services provided to members on an appropriate billing form, as follows: Professional Charges Professional charges must be submitted on a CMS or UB04 form (or successor form) with current ICD-9 diagnostic and CPT-4 procedure coding (or successor coding accepted commonly in the industry). Should a provider also be required under their Provider Agreement and/or applicable law to submit certain encounter data for covered services provided to members, it must be provided on the applicable billing form. Supporting Documentation In general, the provider must submit, in addition to the applicable billing form, all supporting documentation that is reasonably relevant information and that is information necessary to determine Kaiser Permanente s payment. At a minimum, the supporting documentation that may be reasonably relevant includes the following, to the extent applicable to the services provided: Treatment notes as reasonably relevant and necessary to determine payer payment to the provider, including a provider report relating to any claim under which a provider is billing a CPT-4 code with a modifier, demonstrating the need for the modifier. 41

2 If additional documentation is deemed to be reasonably relevant information and/or information necessary to determine payment, Kaiser Permanente will notify the provider in writing. Standard Billing Codes Standard codes, including the following, must be used on all billing forms: REVENUE CODE: Code used to identify specific accommodation, ancillary service or billing calculation CPT 4: Physicians Current Procedural Terminology HCPCS: Health Care Procedure Coding System ICD-9-CM: Medical Index, for medical diagnostic coding 10.3 FORM CMS 1500 REQUIRED FIELDS Field Number (SEE APPENDIX #4 FOR SAMPLE FORM) Field Name 1 Type of Claim, i.e. Medicare, Medicaid Required Fields For Claim Submissions Not Required Instructions/Examples Check the type of health insurance coverage applicable to this claim by checking the appropriate box 1a Insured s I.D. Number Required Enter the subscriber s plan identification number 2 Patient s Name Required Enter the patient s name. When submitting newborn claims, enter the newborn s first and last name 3 Patient s Birth Date and Sex Required Enter the patient s date of birth and gender. The date of birth must include the month, day and FOUR DIGITS for the year (MM/DD/YYYY) 42

3 Required Fields Field Field Name For Claim Number Submissions Instructions/Examples 4 Insured s Name Required Enter the name of the insured (Last Name, First Name, and Middle Initial), unless the insured and the patient are the same then the word SAME may be entered 5 Patient s Address Required Enter the patient s mailing address and telephone number. On the first line, enter the STREET ADDRESS; the second line is for the CITY and STATE; the third line is for the ZIP CODE 6 Patient s Relationship to Insured 7 Insured s Address 8 Patient Status 9 Other Insured s Name 9a Other Insured s Policy or Group Number and PHONE NUMBER Check the appropriate box for the patient s relationship to the insured Enter the insured s address (STREET ADDRESS, CITY, STATE, and ZIP CODE) Check the appropriate box for the patient s MARITAL STATUS, and check whether the patient is EMPLOYED or is a STUDENT When additional insurance coverage exists, enter the last name, first name and middle initial of the insured Enter the policy and/or group number of the insured individual name in Field 9 (Other Insured s Name) above. NOTE: For each entry in Field 9a, there must be a corresponding entry in Field 9d) 43

4 Field Number 9b 9c 9d 10a-c Required Fields Field Name For Claim Instructions/Examples Submissions Other Insured s Date of Birth/Sex Employer s Name or School Name Insurance Plan Name or Program Name Is Patient s Condition Related To 10d Reserved For Local Use 11 Insured s Policy Number or FECA Number 11a 11b 11c Insured s Date of Birth Employer s Name or School Name Insurance Plan or Program Name Required Not Required Not Required Not Required Not Required Not Required Enter the other insured s date of birth and sex. The date of birth must include the month, day and FOUR DIGITS for year (MM/DD/YYYY) Enter the name of the other insured s EMPLOYER or SCHOOL NAME (if a student) Enter the name of the other insured s INSURANCE PLAN or program Check Yes or No to indicate other employment, auto liability, or other accident involvement applies to one or more of the services described in Field 24 NOTE: If Yes there must be a corresponding entry in Field 14 (Date of Current Illness/Injury) Place (State) enter the State postal code If there is insurance primary to Medicare, enter the insured s policy or group number If insured s date of birth and sex are different from Field 3, then it must be entered here If applicable, enter the name of the employer or school (if student) If available enter the insurance plan or program name 44

5 Field Number 11d Required Fields Field Name For Claim Instructions/Examples Submissions Is There Another Health Benefit Plan? 12 Patient s or Authorized Person s Signature 13 Insured s or Authorized Person s Signature 14 Date of Current Illness, Injury, Pregnancy 15 If Patient Has Had Same or Similar Illness 16 Dates Patient Unable to Work in Current Occupation 17 Name of Referring Physician or Other Source Required Not Required Check Yes or No to indicate if there is another health benefit plan. For example, the patient may be covered under insurance held by a spouse, parent, or some other person If Yes then Fields 9 and 9a-d must be completed This field is not required only if the signature is on file. If the patient s representative signs, then the relationship to the patient must be indicated Not Required Same as Field 12 Not Required Enter the date of the current illness or injury. If pregnancy, enter the date of the patient s last menstrual period. See 9b for date format example Enter the previous date the patient had a similar illness. See 9b for dating format example Enter the from and to dates that the patient is unable to work See 9b for date format example Enter FIRST and LAST NAME of the referring or ordering physician 17a Other ID # Not Required If Field 17 is required enter the Identification Number of said physician 17b NPI Number Required In the non-shaded area enter the NPI number of the referring provider 18 Hospitalization Dates Related to Current Services Not Required Complete this block when a medical service is furnished as a result of, or subsequent to, a related hospitalization. 45

6 Field Number Required Fields Field Name For Claim Instructions/Examples Submissions 19 Reserved for Local Use 20 Outside Lab Not Required 21 Diagnosis or Nature of Illness or Injury 22 Medicaid Resubmission 23 Priority Authorization Number 24a-g Supplemental Information Required Not Required Required Not Required If you are covering for another provider, enter the name of the provider in this field Enter the diagnosis/condition of the patient, indicated by an ICD-9-CM code number. Enter up to 4 diagnostic codes, in PRIORITY order Enter the prior authorization number for all devices/services Supplemental information can only be entered with a corresponding, completed service line The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service 24a Dates of Service Required Enter the month, day, and year (MM/DD/YYYY) for each procedure, service or supply. Services must 46

7 Required Fields Field Field Name For Claim Number Submissions Instructions/Examples be entered chronologically (starting with the oldest date first) For each service date listed/billed, the following fields must also be entered: Units, Charges/Amounts, Place of Service, Procedure Code and corresponding Diagnosis Code IMPORTANT: Do not submit a claim with a future date of service. Claims can only be submitted once the service has been rendered 24b Place of Service Required Enter the place of service code for each item used or service performed 24c EMG Not Required 24e Diagnosis Pointer Required Enter the diagnosis code reference number (pointer) as it relates to the date of service and the procedures shown in Field 21. When multiple services are performed, the primary reference number for each service should be listed first, and other applicable services should follow. The reference number(s) should be a 1 or a 2 or a 3 or a 4; or multiple numbers as explained IMPORTANT: ICD-9-CM diagnosis codes must be entered in Field 21 only. Do not enter them in 24e 24f $ Charges Required Enter the FULL CHARGE for each listed service. 47

8 Required Fields Field Field Name For Claim Number Submissions Instructions/Examples Any necessary payment reductions will be made during claims adjudication Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number 24g Days or Units Required Enter the number of days or units in this block. (For example: unit of supplies) When entering the NDC units in addition to the HCPCS units, enter the applicable NDC units qualifier and related units in the shaded line. The following qualifiers are to be used: F2 International Unit ML Milliliter GR Gram UN Unit 24h EPSDT Family Plan Not Required 48

9 Required Fields Field Field Name For Claim Number Submissions Instructions/Examples 24i ID QUAL Required Enter in the shaded areas the qualifier identifying if the number is a non-npi. The Other ID# of the rendering provider is reported in Filed 24j in the shaded area. The NUCC defines the following qualifiers: 0B State License Number 1B Blue Shield Provider 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number EI Employer s Identification Number LU Location Number N5 Provider Plan Network Identification Number SY Social Security Number (this may not be used for Medicare) X5 State Industrial Accident Provider Number ZZ 24j Rendering Provider ID# Required Provider Taxonomy Enter the non-npi ID number in the shaded area of the field. Enter the NPI number in the non-shaded area of the field Report the ID number in Fields 24i and 24J only when different from data recorded in Fields 33a and 33b 49

10 Field Number 25 Federal Tax ID Number Required Fields Field Name For Claim Instructions/Examples Submissions Required Enter the provider federal tax I.D. number or Social Security Number. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked 26 Patient s Account Number Required 27 Accept Assignment Not Required IMPORTANT: The Federal Tax ID Number in this field must match the information on file with the IRS Enter the Member s account number assigned by the provider s accounting system IMPORTANT: This Field aids in patient identification by the provider 28 Total Charge Required Enter the total charges for the services rendered (total of all charges listed in Field 24f) 29 Amount Paid 30 Balance Due Not Required Enter the amount paid (i.e. Member copayments or other insurance payments) to date in this Field for the services billed 31 Signature of Physician or Supplier Including Degrees or Credentials Required Enter the signature of the provider or his/her representative and the date the form was signed For claims submitted electronically, include a computer printed name as the signature of the health care provider or person entitled to reimbursement 50

11 Field Number Required Fields Field Name For Claim Instructions/Examples Submissions 32 Service Facility Location Information The name and address of the facility where services were rendered (if other than patient s home or provider s office) Do not use commas, periods, or other punctuation in the address. Enter a space between town name and state code; do not include a comma. When entering a 9 digit zip code, include the hyphen 32a NPI# Required Enter the NPI number of the service facility 32b Other ID# Required Enter the two digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number 33 Billing Provider Info & Phone Number Required Enter the name, address and phone number of the billing entity 33a NPI # Required Enter the NPI number of the service facility location in Field 32a 33b Other ID# Required Enter the two digit qualifier identifying the non-npi number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number If available, please enter your provider or unique vendor number 51

12 10.4 FORM UB04 REQUIRED FIELDS (SEE APPENDIX #5 FOR SAMPLE FORM) Field Number Field Name Required Fields For Claim Submissions Instructions/Examples 1 Provider Name & Address 2 Pay-To Name, Address, City/State, ID# Required Required Enter the name and address of the hospital or person who rendered the services being billed. Enter the name and address of the hospital or person to receive the reimbursement 3a Patient Control Number Required Enter the member s control number IMPORTANT: This Field aids in patient identification by the provider 3b Medical Record Number Not Required Enter the number assigned to the patient s medical/health record by the provider 4 Type of Bill Required Enter the appropriate code to identify the specific type of bill being submitted. This code is required for the correct identification of inpatient vs. outpatient claims, voids, etc. 5 Federal Tax Number Required Enter the federal tax ID of the hospital or person entitled to reimbursement 6 Statement Covers Period Required Enter the beginning and ending date of service included in the claim 7 Blank 8 Patient Name Required Enter the member s name 9 Patient Address Required Enter the member s address 10 Patient Birth Date Required Enter member s birth date 11 Patient Sex Required Enter member s sex 12 Admission Date Required For inpatient claims only, enter the date of admissions 52

13 13 Admission Hour Required For either inpatient or outpatient care, enter the 2- digit code for the hour during which the member was admitted or seen 14 Admission Type Required Indicate the type of admission 15 Admission Source Required Enter the source of the admission type code 16 Discharge Hour Enter the 2-digit code for the hour during which the member was discharged 17 Patient s Status Required Enter the discharge status Condition Codes code Enter any applicable codes which identify conditions relating to the claim that may affect claims processing 29 Accident (ACDT) State Not Required Enter the two-character code indicating the state in which the accident occurred which necessitated medical treatment 30 Blank Occurrence Codes and Dates Occurrence Span Dates and Codes Enter the code and associated date defining a significant event relating to this bill that may affect claims processing Enter the occurrence span code and associated dates defining a significant event relating to this bill that may affect claims processing 37 Blank 38 Responsible Party Not Required Enter the responsible party s name and address Value Codes and Amount Enter the code and related amount/value which is necessary to process the claim 42 Revenue Code Required Identify the specific accommodation, ancillary service, or billing calculation, by assigning an appropriate revenue code 53

14 43 Revenue Description Not Required Enter the revenue description 44 Procedure Code and Modifier Required For all outpatient claims, enter both a revenue code in Field 42 and the corresponding CPT/HCPCS procedure code in this Field 45 Service Date Required Outpatient Series Bills: A service date must be entered for all outpatient series bills whenever the from and through dates in Field 6 are not the same. Submissions that are received without the required service date(s) will be rejected with a request for itemization. Multiple/Different Dates of Service: Multiple/different dates of service can be listed on one claim form. List each date on a separate line on the form, along with the corresponding revenue code (Field 42), procedure code (Field 44) and total charges (Field 47) 46 Units of Service Required Enter the units of service 47 Total Charges Required Indicate the total charges pertaining to the related revenue code for the current billing period, as listed in Field 6 48 Non Covered Charges Not Required Enter any non-covered charges 49 Blank 50 Payer Name Required Enter (in appropriate order on lines A, B, and C) the name and number of each payer organization from whom you are expecting payment towards the claim 51 Health Plan ID Required Enter the provider number 52 Release of Information (RLS Info) Not Required Enter the release of information certification number 54

15 53 Assignment of Benefits (ASG BEN) Enter the assignment of benefits certification number 54a-c Prior Payments If payment has already been received toward the claim by one of the payers listed in Field 50 prior to the billing date, enter the amounts here 55 Estimated Amount Due Not Required Enter the estimated amount due 56 National Provider Identifier (NPI) Required Enter the service provider s National Provider Identifier 57 Other Provider ID Required Enter the service provider s Kaiser Permanente-assigned provider ID 58 Insured s Name Required Enter the subscriber s name 59 Patient s Relation to Insured Enter the member s relationship to the subscriber 60 Insured s Unique IP Required Enter the insured person s unique individual member identification number (medical/health record number), as assigned by Kaiser Permanente 61 Insured s Group Name Enter the insured s group name 62 Insured s Group Number Enter the insured s group number as shown on the identification card. For prepaid services claims 63 Treatment Authorization Code 64 Document Control Number Not Required enter PPS For all patient and outpatient claims, enter the referral number Enter the document control number related to the member or the claim 65 Employer Name Enter the employer s name 66 DX Version Qualifier Not Required Indicate the type of diagnosis cods being reported NOTE: At the time of printing Kaiser Permanente only accepts ICD-9-CM diagnosis codes on the UB-04 55

16 67 Principal Diagnosis Code Required 67 a-q Other Diagnosis Codes Enter the principal diagnosis code, on all inpatient and outpatient claims Enter other diagnosis codes corresponding to additional conditions. Diagnosis codes must be carried to their highest degree of detail 68 Blank 69 Admitting Diagnosis Required Enter the admitting diagnosis code on all inpatient claims 70a-c Reason For Visit Not Required Enter the diagnosis codes indicating the patient s reason for outpatient visit at the time of registration 71 PPS Code 72 External Cause of Injury Code (ECI) 73 Blank 74 Principal Procedure Code and Date 74 a-e Other Procedure Codes and Dates 75 Blank Enter the DRG number which the procedures group, even if you are being reimbursed under a different payment methodology Enter an ICD-9-CM E code in this Field Enter the ICD-9-CM procedure code(s) and date(s) on all inpatient and outpatient claims (in fields A through E for any additional surgical and/or obstetrical procedures which were performed Enter other ICD-9-CM procedure code(s) and date(s) on all inpatient and outpatient claims (in fields A through E for any additional surgical and/or obstetrical procedures which were performed 56

17 76 Attending Physician/NPI/Qual/ID 77 Operating Physician/NPI/Qual/ID Required Enter the NPI and the name of the attending physician for inpatient bills or the physician that requested outpatient services Inpatient Claims Attending Physician: Enter the full name of the physician who is responsible for the care of the patient Outpatient Claims Referring Physician For all outpatient claims, enter the full name of the physician who referred the member for outpatient services billed on the claim Enter the NPI and the name of the lead surgeon who performed the surgical procedure Enter the NPI and name of any other physicians Other Physician/NPI/Qual/ID 80 Remarks Not Required Special annotations may be entered in this Field 81 Code-Code Not Required Enter the code qualifier and additional code, such as marital status, taxonomy, or ethnicity codes, as may be appropriate Note: Fields must be completed in accordance with the National Uniform Billing Committee (NUBC) requirements for mandatory data fields, and as required by federal and state statutes and regulations. 57

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19 10.5 CLAIM SUBMISSION REQUIREMENTS Authorized or Emergency Services Bills for authorized or emergency services should be mailed to the address located on the authorization document(s). Timeliness of Submission: The provider is required to submit initial claims within: Colorado: 90 Days Georgia: 90 Days Hawaii: 365 Days Northern California: 365 Days Mid-Atlantic States: 180 Days Northwest: 365 Days Ohio: 365 Days Southern California: 365 Days after the date of service as a condition for payment, unless the Provider Agreement provides for a longer timeframe and except as otherwise required or permitted by any state or federal law or regulation. Resubmission of Claims: Resubmitting claims for correction purposes must be received within: Colorado: 12 Months for commercial members 24 Months for Medicare/Medicaid members (If within the last 3 months of the year, for Medicare/Medicaid members the provider has 27 months) Hawaii: Contact Contracting Office at Georgia: 6 months Mid-Atlantic States: 6 Months Northern California: 6 Months Northwest: 6 Months Ohio: 6 Months Southern California: 6 Months of the date of Kaiser Permanente s notification to provider unless the Provider Agreement provides for a longer timeframe and except as otherwise required or permitted by any state or federal law or regulation. 59

20 Coordination of Benefits (COB) Claims: COB information must be received within: Colorado: Georgia: Hawaii: Mid-Atlantic States: Northern California: Northwest: Ohio: Southern California: 12 Months 12 Months 12 Months 6 Months 12 Months 12 Months 12 Months 12 Months of request of information unless the Provider Agreement provides for a longer timeframe and except as otherwise required or permitted by any state or federal law or regulation. Claims Appeals: The submission of appeals must be received within: Colorado: Georgia: Hawaii: Mid-Atlantic States: Northern California: Northwest: Ohio: Southern California: 180 Days 365 Days for commercial 24 Months for Medicare/Medicaid (If within the last 3 months of the year Medicare/Medicare is 27 months) 180 Days 180 Days 180 Days 365 Days 180 days for commercial members 60 days for Medicare members 180 days for Federal Employee members 180 Days of the original date of denial or explanation of payment unless the Provider Agreement provides for a longer timeframe and except as otherwise required or permitted by any state or federal law or regulation. 60

21 10.6 APPEAL OF TIMELY CLAIMS SUBMISSION Resubmitted claims along with proof of initial timely filing received within: Colorado: Georgia: Hawaii: Mid-Atlantic States: Northern California: Northwest: Ohio: Southern California: 180 Days 180 Days 180 Days 180 Days 180 Days 365 Days 180 Days 180 Days of the original date of denial or explanation of payment will be allowed for reconsideration of claim processing and payment unless the Provider Agreement provides for a longer timeframe and except as otherwise required or permitted by any state or federal law or regulation. Any claim resubmissions received for timely filing consideration beyond the above-noted timeframes of the original date of denial or explanation of payment will be denied as untimely submitted. Proof of Timely Claims Submission Claims submitted for consideration or reconsideration of timely filing must be reviewed with information that indicates the claim was initially submitted within the appropriate time frames. Acceptable proof of timely filing may include the following documentation and/or situation: System-generated claim copies, account printouts, or reports that indicate the original date that claim was submitted and to which insurance company. EDI transmission reports (reports from a clearinghouse, i.e. Emdeon) Remit notices Denial notices Handwritten or typed documentation is not acceptable proof of timely filing. 61

22 10.7 ELECTRONIC DATA INTERCHANGE Kaiser Permanente encourages (and the Agreement may require) electronic submission of claims and encounter data. Electronic Data Interchange (EDI) is an electronic exchange of claims information in a standardized format that adheres to all Health Insurance Portability and Accountability Act (HIPAA) requirements. EDI transactions replace the submission of paper claims. Required data elements are entered into the computer system only once typically at the provider s office or at another location where services were rendered. Advantages of EDI: Complete end-to-end claim turnaround tracking Improved data accuracy Bypass U.S. mail delivery Standardized transaction formats Upfront editing Front-end acknowledgement report Reduced Provider expenses Kaiser Permanente has two submission options. They are: Direct Submission This is the preferred method for 837 and 835 Explanation of Payment HIPAA transactions. Clearinghouse Kaiser Permanente has the following major clearinghouses (these may vary by region) They are: Emdeon HDX RelayHealth The SSI Group, Inc. MedAvant For the provider number for each region please call the Claims Department at the number listed in the Key Contacts section of this Provider Manual. It is not necessary to notify Kaiser Permanente when you wish to submit claims electronically. Work with your clearinghouse or billing partner in setting up EDI. It is the provider s responsibility to initiate EDI and to select a vendor for processing electronic claims. 62

23 Clearinghouse Reciprocal Arrangements: If a provider uses a different clearinghouse than the Kaiser Permanente affiliated clearinghouse, the supplier should follow up with their clearinghouse to determine if a connectivity can be made with EDI. Often clearinghouses have mutual provider Agreements with other clearinghouses that would allow for electronic transactions. Providers should check with their clearinghouse to see if this is an option and, what if any, additional transaction fees may apply. If the provider has further questions about electronic submission of bills and encounter data, please contact the local Kaiser Permanente EDI Helpline at the telephone number listed in the Key Contact section of this Provider Manual. Exclusions to EDI Claims Submission: Claims with more than 99 lines Professional claims with line units greater than 999 COB claims (permissible if you include not that EOB/MEOB is being sent via paper copy) HIPAA Requirements: All electronic claim submissions must adhere to all HIPAA requirements. The following web sites include additional information on HIPAA and electronic loops and segments. If you do not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company at

24 10.8 PROHIBITED BILLING PRACTICES Balance billing members for services covered by Kaiser Permanente is prohibited by federal, Knox-Keene Act and/or local laws and under the Provider Agreement. Except for applicable co-payments, coinsurance and deductibles, and as otherwise expressly permitted in the Provider Agreement and under applicable law, providers must look solely to Kaiser Permanente or other responsible payer (e.g., Medicare) for compensation of covered services provided to members. In the event a member is unable to pay applicable charges, Kaiser Permanente has a member financial assistance program. Please contact the Member Services department for further details. Their telephone number is listed in the Key Contacts section of this Provider Manual CLAIM PROCESSING GUIDELINES Kaiser Permanente will follow the applicable Knox-Keene Act or Medicare requirements for invoice processing. All invoices for services provided to Kaiser Permanente members must be submitted within the timelines noted in Section 10.5 (or any longer period specified in your Provider Agreement or required by law) after the date of service. To the extent required by law, claims that are denied because they are filed beyond the applicable claims filing deadline shall, upon a provider s submission of a provider s appeal of timely claims submission and the demonstration of good cause for the delay, be accepted and adjudicated in accordance with the applicable claims adjudication process CLAIMS PAYMENT POLICY Except for emergency services, the member s eligibility and benefits coverage must have been verified prior to the time of service, in accordance with the Agreement and applicable law. All non-emergency services must be authorized, and the authorization number must be included on field 23 of the form CMS 1500 or line 63 of the UB04. In most cases, bills for non-emergency services will be denied for payment if an authorization was not obtained in accordance with the requirements of the Provider Agreement. Invoices for emergency services are subject to retrospective review for medical necessity, using the prudent layperson standard, in accordance with the Provider Agreement and applicable law. 64

25 Contracted providers will be compensated for covered services based on the compensation arrangement set forth in the Provider Agreement. Clean claims for commercial members will be paid within: Colorado Georgia Hawaii: Mid-Atlantic States Northern California Northwest Ohio Southern California 30 Days 30 Days 45 Days 30 Days 45 Days 30 Days 30 Days 45 Days Clean claims for Medicare members will be paid within 60 calendar days from the Kaiser Permanente claim receipt date CLEAN CLAIMS Kaiser Permanente considers a claim clean when the following requirements are met: Correct Form -Kaiser Permanente requires all professional claims to be submitted using the CMS-1500 and all facility claims (or appropriate ancillary services) to be submitted using the UB04. Standard Coding All fields should be completed using industry-standard coding. Attachments Attachments should be included in the provider s submission when circumstances require additional information. Completed Field Elements for CMS-1500 or UB04 All applicable data elements of the above-noted forms should be completed. A claim is not considered to be clean or payable if one or more of the following are missing or are in dispute: The format used in the completion or submission of the claim is missing required fields or codes are not active. 65

26 The eligibility of a member cannot be verified. The responsibility of another payer for all or part of the claim is not included or sent with the claim. Other coverage has not been verified. Additional information is required for processing such as COB information or medical notes. (These will be requested upon denial or pending of a claim.) The claim was submitted fraudulently. Or as otherwise defined by applicable state law. Failure to include all information will result in a delay in claim processing and payment and will be returned for any missing information CLAIMS ADJUSTMENTS Kaiser Permanente reviews codes and adjusts claims in accordance with the Provider Agreement and the provisions below, and in accordance with applicable law. Claims adjustments are made in connection with claims review, as described in more detail below and as otherwise set forth in the Provider Agreement. If you believe Kaiser Permanente has made an incorrect adjustment to a claim that has been paid, please refer to the Provider Appeals Process section of this Provider Manual for information on how to dispute such adjustment. When submitting the dispute resolution documentation, please clearly state the reason(s) you believe the claim adjustment was incorrect CLAIMS REVIEW Billed items will be reviewed and/or corrected as described in the Agreement and as permitted by applicable law. Final payment will be based on such reviewed (and, if necessary, corrected) information. Code Review 66

27 The terms of the Provider Agreement govern the amount of payment for services provided under the Provider Agreement. The following general rules apply to Kaiser Permanente s payment policies. Kaiser Permanente s claims policies for provider services follow industry standards as defined by the AMA and CMS. Routinely updated code editing software from a leading national vendor is used for processing all relevant bills in a manner consistent with the Medicare Correct Coding Initiative and CPT guidelines. Our claims adjudication systems accept and identify all active CPT and HCPCS codes as well as all coding modifiers. Payment for services such as multiple procedures, bilateral procedures, requiring modifiers are paid in accordance with Medicare guidelines. When applicable, we request supportive documentation for unlisted procedure codes. Kaiser Permanente does not allow code unbundling for procedures for which Medicare requires all-inclusive codes and we will re-bundle the procedures and pay according to Medicare s all-inclusive codes. If the Provider Agreement so provides, Kaiser Permanente uses reasonable and customary rates to pay for those services that are not subject to contracted rates. Reasonable and Customary rates are determined using a statistically credible database updated at least annually. Coding and Billing Validation Kaiser Permanente performs code editing to enforce both the Kaiser Permanente and nationally-accepted coding and payment rules and to verify the codes providers submit are consistent, based on the services rendered. Each claim a provider submits will be subjected to McKesson code editing software program. This software assists the claims examiner and Utilization Management staff in evaluating the accuracy of the coding and procedure(s) not their clinical necessity. It provides consistent and objective claim review by accurately applying coding criteria for all areas of treatment. The program may change and edit your claim, perhaps substantially, as a result of these code editing rules. When a change is made to your submitted code(s) Kaiser Permanente will provide an explanation of the reason for the change. Possible outcomes include: Accepting the code(s) as submitted 67

28 Changing the submitted code(s) to comply with generally-accepted coding practices that are consistent with CPT, HCPCS and recommendations made by peer specialists Updating outdated or invalid codes Denying line items Bundling or unbundling codes as appropriate Denying code(s) as incidental or inherent part of the more global code billed Adjusting payment Seeking additional information from the provider s office due to inconsistent information on the claim Fraudulent coding will be investigated by Kaiser Permanente. In addition, individual provider evaluation and management coding statistics are routinely trended and compared with national statistics. Aberrant coding statistics may result in contract termination and investigation by federal regulators. Coding Edit Rules Kaiser Permanente applies coding edit rules to all claims submitted. The following descriptions outline some of the major categories of our coding edit rules, some of which the above software program applies automatically as part of coding and billing validation. These rules are subject to change and may be edited from time to time. There may be situations where the provider s Provider Agreement supersedes these rules. Should you have any questions regarding your Provider Agreement and code editing, please contact the National Provider Contracting and Network Management department at the telephone number listed in the Key Contacts section of this Provider Manual. Major Categories of Claim Coding Errors/Inconsistencies: AMA and CMS Guidelines The McKesson software will correct input codes without valid modifiers to more closely correspond to accepted coding practices by eliminating, replacing or flagging potential errors while accepting coding practices judged to be conventional by the AMA and CMS. The CPT and HCPCS manuals explicitly detail and outline many of the rules included in the software. HCPCS Codes Related to CPT Codes 68

29 The software also evaluates the combination of HCPCS codes and CPT codes. These codes are cross walked to identify where a HCPCS code is related to one or many CPT codes and are evaluated based on the existing CPT rules. Unnecessary or disallowed codes are then rejected. HCPCS Codes Not Related to CPT Codes The software also detects situations where HCPCS codes are not related to CPT codes. Rules developed as appropriate that are the result of the review of non-cpt related HCPCS codes are part of the knowledge base supporting the software and do not conflict with the National Correct Coding Policy Initiative. Procedure Unbundling Procedure unbundling occurs when two or more procedure codes are used to describe a procedure performed, when a single more comprehensive procedure code exists that accurately describes the entire procedure performed. Incidental Procedures An incidental procedure is typically performed at the same time as a more complex primary procedure. However, the incidental procedure requires little additional provider resources and/or clinically integral to the performance of the primary procedure. Therefore, incidental procedures are NOT reimbursed separately. Separate Procedures Procedures designated as a separate procedure in the CPT code book are commonly performed as an integral part of a total, larger procedure and normally does NOT warrant separate identification. Therefore these services are typically included as part of the global charges submitted for the related, larger procedure. However, when the procedure is performed as a separate, independent service not in conjunction with any normally-related procedure it may be billed as a separate procedure. If the procedure is performed alone for a specific purpose, it may be eligible for separate reimbursement. Age and Gender (Sex) Conflicts An age conflict occurs when the contracted provider bills an age-specific procedure code for a member outside of the designated age range. Similarly, a gender conflict occurs when a gender-specific procedure is assigned to a member of the opposite gender. 69

30 Obsolete/Deleted Codes If obsolete or deleted codes cannot be cross walked to current or updated codes, claims submitted may be denied. Obsolete or deleted codes are updated each calendar year and are not accepted past the end date specified by CMS. Medicare claims with outdated codes will be subject to denial as per CMS guidelines. For a complete listing of all rules contact your local Claims department at the telephone number listed in the Key Contacts section of this Provider Manual. Clinical Review In addition to code review, invoices may be reviewed by a physician or other appropriate clinician COORDINATION OF BENEFITS (COB) When a member is enrolled in more than one group benefit plan (e.g., a person who has Kaiser Permanente coverage also is covered by another health plan), it is necessary to coordinate the benefits between the two plans so that the provider will receive from both plans no more than 100% of what Kaiser Permanente would have been required to pay if it were the only payer. Determining Primary Coverage Primary coverage is determined using the guidelines established under specific state regulations. In most cases the following rules apply (subject to applicable state law). Between spouses, the plan that covers the member as an employee is the primary plan. The spouse of the employee is a dependent under that plan (and that plan is secondary for that spouse). The provider determines primary coverage for dependent children based on their parents birthdays. The plan of the parent whose birthday occurs earlier in the year (without regard to the year of the parent s birth) is the primary plan. If a provider invoice is submitted to Kaiser Permanente when another carrier is primary, Kaiser Permanente will deny payment of the invoice. 70

31 The provider will need to submit an invoice to the other (primary) carrier. Within 60 working days (or longer period if required under applicable law or expressly permitted under the Provider Agreement) after the primary carrier has paid its benefit, resubmit the invoice and include the EOB that accompanied payment by the primary carrier to Kaiser Permanente. The invoice will be reviewed and the amount of payment due, if any, will be determined THIRD PARTY LIABILITY (TPL) Unless, and to the extent the Provider Agreement expressly provides to the contrary, Kaiser Permanente has the exclusive right of recovery for third party liability claims. Third party liability (TPL) for health care costs arise from sickness or injury caused or alleged to be caused by a third party. In order to prevent duplicate payments for health care costs that are also paid by another responsible party, contracted providers are required to assist Kaiser Permanente in identifying all potential TPL situations and to provide Kaiser Permanente with information that supports Kaiser Permanente s TPL inquiries. Third Party Liability Guidelines Providers are asked to assist and cooperate with Kaiser Permanente s efforts to identify TPL situations by doing the following: Provide full information in all applicable fields on the CMS 1500 or UB04 billing form. If one or more payers is (are) named, Kaiser Permanente will contact the member for potential TPL information. Enter ICD-9 diagnosis data in field 21 on the CMS 1500 form and fields on the UB04 form. Kaiser Permanente retains the right to investigate TPL recoveries through retrospective review of ICD-9 and CPT-4 codes from billing forms where a possible third party liability is indicated COPAYMENTS, COINSURANCE AND DEDUCTIBLES Contracted providers are responsible for collecting co-payments, coinsurance and deductibles (collectively, co-pays ) in accordance with member benefits unless explicitly stated otherwise in the Provider Agreement. Invoices submitted by providers who are responsible for collecting co-pays will be paid at the applicable rate(s) under the Provider Agreement less the applicable co-pay amount due from the member. 71

32 You must not waive co-pays you are required to collect, except as expressly permitted under applicable law and the Provider Agreement. Please verify applicable co-pays at the time of service by contacting Member Services at the telephone number listed in the Key Contacts section of this Provider Manual. 72

33 10.17 WORKERS COMPENSATION If a member indicates that his or her illness or injury occurred while the member was "on the job", payment for such health care services should be handled as follows: If Kaiser Permanente is specified as the Workers Compensation carrier and the provider has received an authorization to provide such care to the member, they should submit their bill to Kaiser Permanente in the same manner as was submitted other bills for services. The Provider Agreement may specify a different payment rate for these services. If Kaiser Permanente is not specified as the Workers Compensation carrier, the provider should do the following: document that the illness or injury occurred "on the job" on the bill; complete all applicable fields on the CMS 1500 or UB04 form and submit the bill to the member s Workers Compensation carrier. If the member's Workers' Compensation carrier ultimately denies the member s workers compensation claim, the provider should submit the claim for covered services to Kaiser Permanente in the same manner as were other claims submitted for services. Providers must comply with all state and federal laws applicable to Workers Compensation services OVERPAYMENT POLICY If a provider receives an overpayment directly from Kaiser Permanente or as a result of coordination of benefits, they must notify Kaiser Permanente promptly upon discovery and return the overpayment as soon as possible. In addition, they must return any overpayment identified by Kaiser Permanente within 30 working days after receipt from Kaiser Permanente of a notice of overpayment, unless they contest such notice. If a provider contests all or any portion of the overpayment described in the Kaiser Permanente notice, they must send a written notice identifying the contested amount and the basis upon which they believe the claim(s) was (were) not overpaid, within 30 working days after receipt of the notice of overpayment. Such required written notice must be provided to Kaiser Permanente in accord with the terms of the Provider Agreement or as described in the notice of overpayment. If the Provider Agreement so provides, Kaiser Permanente may offset from future claims payments to the provider the 73

34 amount of any uncontested overpayment not paid by them within the 30 working-day repayment period. Please include the following information when returning uncontested overpayments: Name of each Kaiser Permanente member who received care for which an overpayment was received Copy of each applicable explanation of benefits Each applicable member s Kaiser Permanente medical record number (MRN) Authorization number (s) for all applicable non-emergency services DIRECT MEMBER BILLING Kaiser Permanente members may be billed only for co-payments, coinsurance and deductibles where applicable according to member benefit coverage and the Provider Agreement, which payments may be subject to an out of pocket maximum. The circumstances above are the only situations in which a Kaiser Permanente member can be billed for covered services MEMBER CLAIMS INQUIRIES If a provider is presented with a Kaiser Permanente member complaint or inquiry regarding any direct member billing (including any billing for co-pay or other member liability described above) the provider should direct the member to call the Member Services department. Regional telephone numbers are listed in the Key Contact section of this Provider Manual. 74