Provider Manual. Billing and Payment

Transcription

1 Provider Manual Billing and Payment

2 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 Provider Inquiry Department by calling or

3 Table of Contents INTRODUCTION... 6 SECTION 5: BILLING AND PAYMENT WHOM TO CONTACT WITH QUESTIONS METHODS OF CLAIMS FILING PAPER CLAIM FORMS RECORD AUTHORIZATION NUMBER ONE MEMBER/ PROVIDER PER CLAIM FORM NO FAULT/ WORKERS COMPENSATION/OTHER ACCIDENT ENTERING DATES MULTIPLE DATES OF SERVICES AND PLACE OF SERVICES SURGICAL AND/OR OBSTETRICAL PROCEDURES BILLING INPATIENT CLAIMS THAT SPAN DIFFERENT YEARS SUPPORTING DOCUMENTATION FOR PAPER CLAIMS (REQUIRED) WHERE TO MAIL/FAX PAPER CLAIMS ELECTRONIC DATA INTERCHANGE (EDI) ELECTRONIC CLAIMS FORMS SUPPORTING DOCUMENTATION FOR EDI CLAIMS (REQUIRED) TO INITIATE ELECTRONIC CLAIMS SUBMISSIONS ELECTRONIC SUBMISSION PROCESS KP Contracted Clearinghouses HIPAA REQUIREMENTS CLEAN CLAIMS

4 5.21 CLAIMS SUBMISSION TIMEFRAMES (REQUIRED) CLAIMS PROCESSING TURN AROUND TIME (REQUIRED) Appeal of Timely Claims Submission 5.24 PROOF OF TIMELY CLAIMS SUBMISSION (REQUIRED) Claim Adjustments/Corrections Incorrect Claims Payments (Required) REJECTED CLAIMS DUE TO EDI CLAIMS ERROR (REQUIRED) FEDERAL TAX ID NUMBER (REQUIRED) CHANGES IN FEDERAL TAX ID NUMBER (REQUIRED) NATIONAL PROVIDER IDENTIFICATION (NPI) (REQUIRED) Member Cost Share Member Claims Inquiries Visiting Members (Required) Coding for Claims (Required) Coding Standards Modifiers in CPT and HCPCS (Required) Modifier Review CODING & BILLING VALIDATION (REQUIRED) Coding Edit Rules (Required) Medical Claims Review (Required)...30 Major Categories of Claim Coding Errors/Inconsistencies...30 Incidental Procedures...31 Mutually Exclusive Procedures...31 Age and Gender (Sex) Conflicts...32 Obsolete/Deleted Codes...32 Multiple/ Duplicate Component Billing

5 5.41 Other Party Liability (OPL) Workers Compensation PROVIDER CLAIMS APPEALS (REQUIRED) CMS 1500 (08/05) FIELD DESCRIPTIONS CMS 1450 (UB 04) FIELD DESCRIPTIONS BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES Evaluation Management (E/M) Services Emergency Rooms Durable Medical Equipment Injection/ Immunizations Newborn Services Expanded Care 5.47 Anesthesia COORDINATION OF BENEFITS (COB) How to Determine the Primary Payor Description of COB Payment Methodologies COB Claims Submission Requirements and Procedures Members Enrolled in Two Kaiser Permanente Plans COB Claims Submission Timeframes COB FIELDS ON THE UB 92 and UB 04 CLAIM FORM COB FIELDS ON THE CMS 1500 (HCFA 1500) CLAIM FORM EXPLANATION OF PAYMENT (EOP) (REQUIRED)

6 Introduction At the heart of Kaiser Permanente s claim processing operation is the set of policies and procedures followed in determining the appropriate handling and reimbursement of claims received. Kaiser Permanente uses code editing software from third party vendors to assist in determining the appropriate handling and reimbursement of claims. Currently, Kaiser Permanente has selected IntelliClaim, which in turn uses software from McKesson and Claims Edit System (CES) Knowledgebase. From time to time, Kaiser Permanente may change this coding editor or the specific rules that it uses in analyzing claims submissions. Kaiser Permanente s goal is to help ensure the accuracy of claims payments. IntelliClaim is a code editor software application designed to evaluate professional claims data including HCPCS and CPT codes as well as associated modifiers. IntelliClaim is a rule-based application; some of these rules have been chosen to meet Kaiser Permanente s goals of increased accuracy in claims payment. IntelliClaim assists Kaiser Permanente in identifying various categories of claims coding and possible inconsistencies. Claims with coding errors/inconsistencies are pended to the Medical Claim Review staff for manual review. Each claim is validated against Kaiser Permanente s payment criteria, and then is subsequently released for processing. This process has a goal of improving the accuracy of coding and consistency in claims payment procedures. In order to help illustrate how this process works, examples have been provided where appropriate. If you have questions about the application of these rules, please contact our Claims Inquiry Unit. It is your responsibility to submit itemized claims for services provided to Members in a complete and timely manner 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 5.1 Whom to Contact with Questions If you have any questions relating to the submission of claims to Kaiser Permanente for processing, please refer to the table below for the correct department/number to call: PLEASE CALL: IF YOU HAVE QUESTIONS ABOUT: TELEPHONE NUMBER(S): CLAIMS ADMINISTRATION Coordination of Benefits (COB Third Party Liability (TPL) COB Local Telephone #: (503) COB Toll-Free Telephone #: (888) TPL Local Telephone #: (503) TPL Toll-Free Telephone #: (866)

7 PLEASE CALL: IF YOU HAVE QUESTIONS ABOUT: TELEPHONE NUMBER(S): Fax #: (503) Address: Kaiser Permanente Claims Administration Department 500 NE Multnomah Street, Suite 100 Portland, OR CLAIMS INQUIRY Benefits/Co-Pay Information Claim Payment Inquiries * Claim Status * Claim Submission Explanation of Payment (EOP) Medical Policy Questions Member Eligibility Referral Questions Local Telephone #: (503) Toll-Free Telephone #: (866) Address: Kaiser Permanente Claims Inquiry Unit 500 NE Multnomah Street, Suite 100 Portland, OR For Questions regarding Refunds and Refund Requests Local Telephone #: (503) Toll-Free Telephone #: (800) Address: Kaiser Permanente Claims Inquiry Unit 500 NE Multnomah Street, Suite 100 Portland, OR PROVIDER CONTRACTING & RELATIONS Contracts Credentialing Fee Schedule Participation Request Participation Status Practice Demographic Updates Provider Appeals Referral Policy Orientation Local Telephone #: (503) Fax #: (503) Address: Kaiser Permanente Provider Contracting & Relations 500 NE Multnomah Street, Suite 100 Portland, OR

8 5.2 Methods of Claims Filing Kaiser Permanente of the Northwest accepts all claims submitted by mail or electronically. 5.3 Paper Claim Forms CMS-1500 (8/05) must be used for all professional services and suppliers. UB-04 (CMS-1450) must be used by all facilities (e.g., hospitals). Any professional services (for example, services rendered by radiologists, ER physicians, etc.) should be billed on CMS-1500 claim forms, unless you are contracted under a GLOBAL rate, in which case professional services should not be billed separately. Please use standard claim forms formatted with RED ink to ensure maximum compatibility with Kaiser Permanente s optical scanning equipment. Claim forms formatted with black or blue lines will not scan as efficiently as those formatted with RED. 5.4 Record Authorization Number 5.5 One Member/ Provider per Claim Form 5.6 No Fault/ Workers Compensation/ Other Accident 5.7 Entering Dates Services that require prior authorization must have an authorization number reflected on the claim form. CMS 1500(8/05) Form If applicable, enter the Authorization Number (Field 23) and the Name of the Referring Provider (Field 17) on the claim form, to ensure efficient claims processing and handling. One Member per Claim Form/One Provider per claim Do not bill for different Members on the same claim form Do not bill for different Providers on the same claim form. Separate claim forms must be completed for each Member and for each Provider Be sure to indicate on the CMS-1500 (HCFA-1500) Claim Form in the Is Patient s Condition Related To fields (Fields 10a -10c), whenever No Fault, Workers Compensation, or Other Accident situations apply. All dates (dates of birth, dates of service, etc.) must be reported in the following format: month, day, and FOUR DIGITS for the year (MM/DD/YYYY)

9 Example: 01/05/2008 CONSECUTIVE DATES OF SERVICE Consecutive dates of service can be billed on one claim line as long as the units entered in Field 24g equal the total number of days billed. Example: Correct Way to Bill CPT/HCPCS DATE OF SERVICE UNITS /05/ /07/ /09/ /13/ Incorrect Way to Bill CPT/HCPCS DATE OF SERVICE UNITS /05/ /13/

10 5.8 Multiple Dates of Services and Place of Services DIFFERENT PLACES OF SERVICE When services are rendered in DIFFERENT places of service (locations), a separate claim form must be submitted for EACH different place of service. SAME PLACES OF SERVICE Whenever services are provided in the SAME place of service, on DIFFERENT dates, these services may be reported and listed as separate lines on ONE claim form, along with the corresponding date, diagnosis code(s), procedure code(s), and charges. 5.9 Surgical and/or Obstetrical procedures 5.10 Billing Inpatient Claims That Span Different Years 5.11 Supporting Documentation for Paper Claims If any surgical and/or obstetrical procedures were performed, record the ICD-9-CM principal procedure and date in Field 80 (Principal Procedure Code and Date) and enter any additional ICD-9-CM procedure codes and corresponding dates in Field 81A-E (Other Procedure Codes and Dates). When submitting the UB-04, use Field 74a-e (Principal Procedure Code and Date) When an inpatient claim spans different years (for example, the patient was admitted in December and was discharged in January of the following year), it is NOT necessary to submit two claims for these services. Bill all services for this inpatient stay on one claim form (if possible), reflecting the correct date of admission and the correct date of discharge. Kaiser Permanente will apply the appropriate/applicable payment methodologies when processing these claims. To expedite claims processing and adjudication, a Practitioner/Provider should submit supporting written documentation (for example, copies of pertinent medical records) with certain types of claims. Supporting Documentation Submitted WITH a Claim: When supporting documentation is submitted WITH the corresponding paper claim form, attach/secure the documentation to the paper claim with a paper clip (do not staple) and mail to Kaiser Permanente s mailing address. Supporting Documentation Submitted SEPARATELY From a Claim: When sending supporting documentation SEPARATELY from the claim (for example, when sending in requested medical information for a pended claim)

11 5.12 Where to Mail Paper Claims Kaiser Permanente Claims Administration 500 NE Multnomah Street, Suite 100 Portland, OR Note: Faxed Claims are not acceptable 5.13 Electronic Data Interchange (EDI) Electronic Claim Submissions: Kaiser Permanente encourages electronic submission of claims. EDI is an electronic exchange of 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 (for example, claims data elements) are entered into the computer only ONCE - typically at the Provider s office, or at another location where services were rendered. Benefits of EDI Submission 1 Reduced Overhead Expenses: Administrative overhead expenses are reduced, because the need for handling paper claims is eliminated. 2 Improved Data Accuracy: Because the claims data submitted by the Provider is sent electronically to Kaiser Permanente via the Clearinghouse, data accuracy is improved, as there is no need for re-keying or re-entry of data. 3 Low Error Rate: Additionally, up-front edits applied to the claims data while information is being entered at the Provider s office, and additional payer-specific edits applied to the data by the Clearinghouse before the data is transmitted to the appropriate payer for processing, increase the percentage of clean claim submissions. 4 Bypass US Mail Delivery: The usage of envelopes and stamps is eliminated. Providers save time by bypassing the U.S. mail delivery system. 5 Standardized Transaction Formats: Industry-accepted standardized medical claim formats may reduce the number of exceptions currently required by multiple payers. NOTICE TO ALL PROVIDERS: Even though you may be reimbursed under a capitated arrangement, periodic interim payments (PIP), or other reimbursement methodology, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500/08/05 or UB-04), and to follow all claims completion instructions set forth in this Manual

12 5.14 Electronic Claims Forms 5.15 Supporting Documentation for EDI Claims Currently, Kaiser Permanente receives and sends the following electronically via the current 4010A1 version through our contracted Clearinghouses 837P must be used for all professional services and suppliers. 837I must be used by all facilities (e.g., hospitals).below To expedite claims processing and adjudication, a Practitioner/Provider should submit supporting written documentation (for example, copies of pertinent medical records) with certain types of claims. Supporting Documentation Submitted SEPARATELY From a Claim: When sending supporting documentation SEPARATELY from the claim (for example, when sending in requested medical information for a pended claim) 1) Complete a Supporting Documentation Cover Sheet for each Member for whom you are submitting paper documentation. 2) Attach the cover sheet to each Member s paper documentation with a paper clip. 3) Mail the supporting documentation as per the instructions on the form To Initiate Electronic Claims Submissions A Practitioner/Provider may be contacted by Kaiser Permanente and encouraged to submit claims electronically. 1) Written Request/Call Alternately, a Practitioner/Provider may initiate the call (or may submit a written request) to our Provider Contracting & Relations Department, asking that they be set up to transmit claims electronically to Kaiser Permanente. This information will be relayed to the Regional EDI Coordinator. 2) Verifying Connection Is Established Upon receipt of the EDI request from the Practitioner/Provider, the Regional EDI Coordinator from Kaiser Permanente will contact the Practitioner/Provider to confirm that they have established a connection with a Clearinghouse that Kaiser Permanente contracts

13 with. If not, Kaiser Permanente will assist in informing the Practitioner/Provider in the steps to take. 3) EDI Set-Up Once the Practitioner s/provider s billing information and verification processes are complete, a representative from either the selected Clearinghouse and/or Kaiser Permanente s Regional EDI Coordinator will contact the Practitioner/Provider to work through the technical components of electronic claim testing and submissions

14 5.17 Electronic Submission Process 1) Practitioners /Providers EDI Responsibilities: Once a Practitioner/Provider has entered all of the required data elements (i.e., all of the required data for a particular claim) into a computer system, the Practitioner/Provider then electronically sends all of this information to a Clearinghouse for further data sorting and distribution. 2) Clearinghouse s EDI Responsibilities: The Clearinghouse receives information electronically from a variety of Practitioners and Providers, who have chosen that particular Clearinghouse as their data sorter and distributor. The Clearinghouse batches all of the information it has received from the various Practitioners and Providers, sorts the information, and then electronically sends the information to the correct payer for processing. Data content required by HIPAA Transaction Implementation Guides is the responsibility of the Practitioner/Provider and the Clearinghouse. The Clearinghouse should ensure HIPAA Transaction Set Format compliance with HIPAA rules. In addition, Clearinghouses: Frequently supply the required PC software to enable direct data entry in the Practitioner s/provider s office. Edit the data which is electronically submitted to the Clearinghouse by the Practitioner s/provider s office, so that the data submission will be accepted by the appropriate payer for processing. Transmit the data to the correct payer in a format easily understood by the payer s computer system. Transmit electronic claim status reports from payers to Practitioners/Providers. 3) Kaiser Permanente s EDI Responsibilities: Kaiser Permanente receives EDI information after the Practitioner/Provider sends it to the Clearinghouse for distribution. The data is loaded into Kaiser Permanente s computer electronically and is prepared for further processing

15 On the same business day that Kaiser Permanente receives the EDI claims, Kaiser Permanente EDI Transaction Solution (KPEDITS) prepares a 997 electronic acknowledgement which is transmitted back to the Clearinghouse. NOTE: If you do not receive Kaiser Permanente s 997 electronic claim acknowledgements from the Clearinghouse, contact your billing service or the Clearinghouse and request that this be routinely forwarded to you. Additionally, Kaiser Permanente provides a Kaiser Permanente EDI Transaction Solutions (KP EDITS) Reject Detail Report for those claims which were rejected by KP EDITS because of fatal front-end errors. Any rejected claims may be re-submitted electronically once the claims have been corrected by the Practitioner/Provider. NOTE: See the Claims Status Category and Reason Codes at for a list of common Insurance Business Process Application error codes that prevent a claim from being accepted by Kaiser Permanente

16 5.18 KP Contracted Clearinghouses Clearinghouse Payer IDs as of 11/07/2006 Clearing House Payer IDs as of 11/07/2006 Cortex EDI Emdeon (WebMD, Envoy) Gateway EDI KS007 (837P) MedAvant (ProxyMed) KS007 (837P) or (837I) Medisoft KS007 (837P) NDCHealth (837P) or (837I) Office Ally Payer Connection KS007 (837P) Per Se (837P) RelayHealth RH002 (837I and 837P) THIN (Thinedi) KS007 (837P) or (837I) Zirmed Z1059 Providers should access their Clearinghouses to identify the Payer Id for Kaiser Foundation NW HIPAA Requirements PLEASE NOTE: Payer IDs are for both 837I (UB) and 837P (HCFA) transactions unless otherwise noted. Also, these Payer IDs are only for Kaiser Foundation Health Plan of the Northwest. If you wish to submit EDI claims to another Kaiser Permanente region, you must obtain the appropriate Payer ID from your Clearinghouse or the appropriate region. All electronic claim submissions must adhere to all HIPAA requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at (301) 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 Form 1500(8/05) and all facility claims (or appropriate ancillary services) to be submitted using the CMS Form CMS 1450 (UB04). Standard Coding All fields should be completed using industry standard coding. Applicable Attachments Attachments should be included in your submission when circumstances require additional information

17 Completed Field Elements for CMS Form 1500 (08/05 ) Or CMS 1450 (UB- 04) All applicable data elements of CMS 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 standards or format used in the completion or submission of the claim The eligibility of a person for coverage The responsibility of another payor for all or part of the claim The amount of the claim or the amount currently due under the claim The benefits covered The manner in which services were accessed or provided The claim was submitted fraudulently 5.21 Claims Submission Timeframes 5.22 Claims Processing Turn-Around Time Note: Failure to include all information will result in a delay in claim processing and payment and it will be returned for any missing information. A claim missing any of the required information will not be considered a clean claim. New Claims: 365 Days from Date of Service(DOS) COB Claims: 365 Days from date of Primary EOP Self Funded Claims: 120 Days from DOS Clean Claims: Please allow 30 days for Kaiser Permanente to process and adjudicate your claim(s). Claims requiring additional supporting documentation and/or coordination of benefits may take longer to process. NOTE: While Kaiser Permanente may require the submission of specific supporting documentation necessary for benefit determination (including medical and/or coordination of benefits information), Kaiser Permanente may have to make a decision on the claim before such information is received. A "complete or clean" claim is defined as a claim that has no defect or impropriety, including lack of required substantiating documentation from providers, suppliers, or Members or particular circumstances requiring special treatment that prevents timely payments from being made on the claim Appeal of Timely Claims Submission Resubmitted claims along with proof of initial timely filing received within 365 days of the original date of denial or explanation of payment, will be allowed for reconsideration of claim processing and payment. Any claim

18 resubmissions received for timely filing reconsideration beyond 365 days 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 situations: Proof or Documentation Examples System generated claim copies, account print-outs, or reports that indicate the original date that claim was submitted, and to which insurance carrier. *Hand-written or typed documentation is not acceptable proof of timely filing. Account ledger posting that includes multiple patient submissions Individual Patient ledger CMS UB04 or 1500(8/05) with a system generated date or submission. EDI Transmission report Reports from a Provider Clearinghouse (i.e. WebMD) Lack of member insurance information. Proof of follow-up with member for lack of insurance or incorrect insurance information. *Members are responsible for providing current and appropriate insurance information each time services are rendered by a provider. Copies of dated letters requesting information, or requesting correct information from the member. Original hospital admission sheet or face sheet with incomplete, absent, or incorrect insurance information. Any type of demographic sheet collected by the provider from the member with incomplete, absent, or incorrect insurance information Claim Adjustments/ Corrections CMS-1500 (08/05) Claim Forms: NOTE: Kaiser Permanente prefers corrections to 837P claims which were already accepted by Kaiser Permanente to be submitted on paper claim forms. Corrections submitted electronically may inadvertently be denied as a duplicate claim. Refer to page Error! Bookmark not defined. within this GUIDE for further information/instructions. When submitting a corrected CMS-1500 (08/05) paper claim to Kaiser Permanente for processing:

19 1) Write CORRECTED CLAIM in the top (blank) portion of the standard claim form. 2) Attach a copy of the corresponding page of Kaiser Permanente s Explanation of Payment (EOP) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip. 3) Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address (see page Error! Bookmark not defined. in this section). UB-04 Claim Forms (837I): NOTE: 837I corrections may be submitted electronically. When submitting a corrected UB-04 claim to Kaiser Permanente for processing: Electronic Include the appropriate Type of Bill code when electronically submitting a corrected UB-04/837I claim to Kaiser Permanente for processing. Paper When submitting a corrected or UB-04 paper claim to Kaiser Permanente for processing: 1) Include the appropriate Type of Bill code in Field 4. 2) Attach a copy of the corresponding page of Kaiser Permanente s Explanation of Payment (EOP) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip. 3) Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address (see page Error! Bookmark not defined. in this section)

20 5.26 Incorrect Claims Payments If you receive an incorrect payment (i.e., either an overpayment or an underpayment), please do one of the following: Option 1: Do not cash or deposit the incorrect payment check. Mail the incorrect payment check back to Kaiser Permanente, along with a copy of the Explanation of Payment (EOP) and a brief note explaining the payment error to: Kaiser Permanente Claims Administration 500 Multnomah St, Suite 100 Portland, OR NOTE: If Kaiser Permanente s EOP is not available, please record the Member s Health Record Number and/or Claim Number on the payment check you are returning. Kaiser Permanente will re-issue and mail you a new, corrected payment check within 30 days. Option 2: Deposit the incorrect Kaiser Permanente payment check in your account. For an Underpayment Error: Write or call our Claims Inquiry Unit and explain the error. Upon verification of the error, appropriate corrections will be made to Kaiser Permanente s accounting system and the underpayment amount owed will be reflected in a Kaiser Permanente reimbursement check within 30 days. For an Overpayment Error: Please do the following: 1) Write a refund check to Kaiser Permanente for the excess amount paid to you by Kaiser Permanente. Attach a copy of Kaiser Permanente s Explanation of Payment to your refund check, as well as a brief note explaining the error. Attach with a paper clip. NOTE: If Kaiser Permanente s EOP is not available, please record the Member s Health Record Number on the payment check you are returning

21 2) Mail your refund check (and brief note) to: Kaiser Permanente Claims Administration, Recoveries Unit 500 NE Multnomah St, Suite 100 Portland, OR

22 5.27 Rejected Claims Due to EDI Claims Error Electronic Claim Acknowledgement: Kaiser Permanente sends an electronic claim acknowledgement to the Clearinghouse. This claims acknowledgement will be forwarded to you as confirmation of all claims received by Kaiser Permanente. NOTE: If you are not receiving Kaiser Permanente s electronic claim receipt from the Clearinghouse, contact the Clearinghouse and request that this be routinely forwarded to you Federal Tax ID Number The Federal Tax ID Number as reported on any and all claim form(s) must match the information filed with the Internal Revenue Service (IRS). 1 When completing IRS Form W-9, please note the following: Name: This should be the equivalent of your entity name, which you use to file your tax forms with the IRS. Sole Provider/Proprietor: List your name, as registered with the IRS. Group Practice/Facility: List your group or facility name, as registered with the IRS. 2 Business Name: Leave this field blank, unless you have registered with the IRS as a Doing Business As (DBA) entity. If you are doing business under a different name, enter that name on the IRS Form W-9. 3 Address/City, State, Zip Code: Enter the address where Kaiser Permanente should mail your IRS Form Taxpayer Identification Number (TIN): The number reported in this field (either the social security number or the employer identification number) MUST be used on all claims submitted to Kaiser Permanente. Sole Provider/Proprietor: Enter your taxpayer identification number, which will usually be your social security number (SSN), unless you have been assigned a unique employer identification number (because you are doing business as an entity under a different name). Group Practice/Facility: Enter your taxpayer identification number, which will usually be your unique employer identification number (EIN). If you have any questions regarding the proper completion of IRS Form W

23 9, or the correct reporting of your Federal Taxpayer ID Number on your claim forms, please contact the IRS help line in your area or refer to the following website: Completed IRS Form W-9 should be mailed to the following address: Kaiser Permanente <Provider Contracting and Relations 500 NE Multnomah Ste 100 Portland, OR 97232> 5.29 Changes in Federal Tax ID Number If your Federal Tax ID Number should change, please notify us immediately, so that appropriate corrections can be made to Kaiser Permanente s files National Provider Identification (NPI) The Health Insurance Portability and Accountability Act of 1996 (HIPPA) mandates that all providers use a standard unique identifier on all electronic transactions. Your National Provider Identifier (NPI) must be used on all HIPPA-standard electronic transactions by May 23, For additional information regarding the National Provider Identifier (NPI), how to apply and report please contact the Center for Medicare & Medicaid Services (CMS) or refer to the following website: Member Cost Share Depending on the benefit plan, Kaiser Permanente Members may be responsible to share some cost of the services provided. Copayment, coinsurance and deductible (collectively, Member Cost Share ) are the fees a Member is responsible to pay a Provider for certain covered services. This information varies by plan and all Providers are responsible for collecting Member Cost Share in accordance with Kaiser Permanente Member s benefits unless explicitly stated otherwise in your Agreement. Please verify applicable Member Cost Share at the time of service. Member Cost Share information can be obtained from: Member Services at or

24 5.32 Member Claims Inquiries 5.33 Visiting Members 5.34 Coding for Claims 5.35 Coding Standards Please direct Member to call Member Services at or For Visiting Member Claims: All non Medicare claims and claims from Medicare Choice Members should be submitted directly to Kaiser Permanente for processing, as per the claims submission instructions set forth in this Manual. For Medicare claims from Medicare FFS and Medicare Cost Members, please refer to the section of this Manual that discusses Coordination of Benefits (COB) Reimbursement Rates: Providers will be reimbursed for visiting members at the same rates negotiated for all other Kaiser Permanente Members. It is the Provider s responsibility to ensure that billing codes used on claims forms are current and accurate, that codes reflect the services provided and they are in compliant with Kaiser Permanente s coding standards. Incorrect and invalid coding may result in delays in payment or denial of payment. Coding All fields should be completed using industry standard coding as outlined below. ICD-9 To code diagnoses and hospital procedures on inpatient claims, use the International Classification of Diseases- 9th Revision-Clinical Modification (ICD-9-CM) developed by the Commission on Professional and Hospital Activities. ICD-9-CM Volumes 1 & 2 codes appear as three-, four- or fivedigit codes, depending on the specific disease or injury being described. Volume 3 hospital inpatient procedure codes appear as two-digit codes and require a third and/or fourth digit for coding specificity. CPT-4 The Physicians' Current Procedural Terminology, Fourth Edition (CPT) code set is a systematic listing and coding of procedures and services performed by Participating Providers. CPT codes are developed by the American Medical Association (AMA). Each procedure code or service is identified with a five-digit code. If you would like to request a new code or suggest deleting or revising an existing code, obtain and complete a form from the AMA's Web site at or submit your request and supporting documentation to:

25 CPT Editorial Research and Development American Medical Association 515 North State Street Chicago IL HCPCS The Healthcare Common Procedure Coding System (HCPCS) Level 2 identifies services and supplies. HCPCS Level 2 begin with letters A V and are used to bill services such as, home medical equipment, ambulance, orthotics and prosthetics, drug codes and injections. Revenue Code Approved by the Health Services Cost Review Commission for a hospital located in the State of Maryland, or of the national or state uniform billing data elements specifications for a hospital not located in that State. NDC (National Drug Codes) Prescribed drugs, maintained and distributed by the U.S. Department of Health and Human Services ASA (American Society of Anesthesiologists) Anesthesia services, the codes maintained and distributed by the American Society of Anesthesiologists DSM-IV (American Psychiatric Services) For psychiatric services, codes distributed by the American Psychiatric Association 5.36 Modifiers in CPT and HCPCS Modifiers submitted with an appropriate procedure code further define and/or explain a service provided. Valid modifiers and their descriptions can be found in the most current CPT or HCPCS coding book. Note CMS-1500 Submitters: Kaiser Permanente processes up to four modifiers per claim line. When submitting claims, use modifiers to: Identify distinct or independent services performed on the same day Reflect services provided and documented in a patient's medical record Modifiers for Professional and Technical Services Most commonly used modifiers are:

26 Modifier -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-e/m services, see modifier 59. Modifier -26 Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier '-26' to the usual procedure number. Modifier -TC Technical Component - The modifier TC is submitted with a CPT procedure code to bill for equipment and facility charges, to indicate the technical component. Use with diagnostic tests; e.g. radiation therapy, radiology, and pulmonary function tests. Indicates the Provider performed only the technical component portion of the service.] Modifier 50 Bilateral Procedure: Add Modifier 50 to the service line of a unilateral 5- digit CPT procedure code to indicate that a bilateral procedure was performed. Modifier 50 may be used to bill surgical procedures at the same operative session, or to bill diagnostic and therapeutic procedures that were performed bilaterally on the same day

27 Modifier 51 Multiple Procedures: Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or provision of supplies (eg, vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated "add-on" codes. Modifier 52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier '-52', signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers '-73' and '-74' (see modifiers approved for ASC hospital outpatient use). Modifier 57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding the modifier '-57' to the appropriate level of E/M service. Modifier 59 Distinct Procedural Service: Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see

28 modifier 25. Modifier 62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding the modifier '-62' to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with the modifier '-62' added. Note: If a cosurgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier '-80' or modifier '-82' added, as appropriate. Modifier 76 Repeat Procedure or Service by Same Physician: Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service Modifier 78 Return to the Operating Room for a Related Procedure During the Postoperative Period: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.) This list is not all-inclusive. Durable Medical Equipment (DME) Modifiers NU= new equipment RP= replacement and repair RR= Rental of DME equipment

29 5.37 Modifier Review 5.38 Coding & Billing Validation Kaiser Permanente reserves the right to review use of modifiers to ensure accuracy and appropriateness, to include review of supporting documentation. Improper use of modifiers may cause claims to pend and/or be returned for correction. Documentation may be requested from various units within the claims department. Kaiser Permanente uses code editing software from third party vendors to assist in determining the appropriate handling and reimbursement of claims. Currently, Kaiser Permanente has selected IntelliClaim as our claim editing source, which in turn uses software from McKesson and McKesson Knowledgebase. From time to time, Kaiser Permanente may change this coding editor or the specific rules that it uses in analyzing claims submissions. Kaiser Permanente s goal is to help ensure the accuracy of claims payments. IntelliClaim is a code editor software application designed to evaluate professional claims data including HCPCS and CPT codes as well as associated modifiers. IntelliClaim is a rule-based application; some of these rules have been chosen to meet Kaiser Permanente s goals of increased accuracy in claims payment. IntelliClaim assists Kaiser Permanente in identifying various categories of claims coding and possible inconsistencies. Claims with coding errors/inconsistencies are pended to the Claim Review staff for manual review. Each claim is validated against Kaiser Permanente s payment criteria, and then is subsequently released for processing. This process has a goal of improving the accuracy of coding and consistency in claims payment procedures. In order to help illustrate how this process works, examples have been provided where appropriate. If you have questions about the application of these rules, please contact our Claims Inquiry Unit Coding Edit Rules An example of the Coding Edit Rules is provided below. Please see Appendix A for entire listing of Rules

30 5.40 Medical Claims Review Major Categories of Claim Coding Errors/Inconsistencies Procedure Unbundling Definition: 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

31 [Example 1: Laboratory unbundling occurs when certain laboratory tests are billed separately when a pre-defined panel exists that contains all of the individual tests billed. These tests should NOT be billed separately, but should be billed using ONE panel code. Example 2: Billing the following 2 codes together is considered unbundling Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. When and are performed on the same day the appropriate comprehensive procedure code would be ] Incidental Procedures Definition: An incidental procedure is typically performed at the same time as a more complex primary procedure. However, the incidental procedure requires little additional physician resources, and/or is clinically integral to the performance of the primary procedure. Therefore, incidental procedures are NOT reimbursed separately. Appendectomy with other abdominal procedures is not billable when the appendix was removed solely for incidental reasons, in other words, since the surgeon was in the abdominal cavity he removed the appendix. Separate Procedures Definition: 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 do 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. Tracheotomy performed in an emergent situation is warranted for separate reimbursement. Yet, tracheotomy performed to create a permanent tracheostomy is part of the larger procedure. Mutually Exclusive Procedures Definition: Mutually exclusive procedures are two or more procedures that

32 are usually NOT performed at the same operative session on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedure(s), for which the physician should be submitting only ONE of the procedure codes. An example of a mutually exclusive situation is when the repair of an organ can be performed by two different methods. One repair method must be chosen to repair the organ and must be reported. A second example is the reporting of an initial service and a subsequent service. It is contradictory for a service to be classified as an initial and a subsequent service at the same time. CPT codes that are mutually exclusive of one another based either on the CPT definition or the medical impossibility/improbability that the procedures could be performed at the same session can be identified as code pairs. Age and Gender (Sex) Conflicts Definition: An age conflict occurs when the Provider bills an age-specific procedure code for a patient outside of the designated age range. Similarly, a gender conflict occurs when a gender-specific procedure is assigned to a patient of the opposite gender. [Example 1: The Provider assigns the code for surgical opening of the stomach, for newborns (43831), to a 45-year-old patient. Example 2: Code Total abdominal hysterectomy is submitted for a male patient. Exception: Initial Newborn Care (99431, 99432, 99435) are payable under the mother s contract and are excluded from the age processing rules. The following age categories are examined for conflicts: Newborn (age less than 1 year old) Pediatric (age 1-17 years old) Maternity (age years old) Adult (age over 14 years old)] Obsolete/Deleted Codes Claims submitted with obsolete or deleted codes may be denied. Obsolete or deleted codes are updated each calendar year and will be end dated as specified by CMS. Kaiser Permanente does not pay against deleted codes following the end date

33 Example: An old code is deleted effective 12/31/2007 and a replacement code is in effect on 01/01/2008. If the provider bills with the deleted code in 2008, that procedure will be denied. Multiple/ Duplicate Component Billing When procedures are billable for professional and technical components (i.e. with modifiers 26 and TC), Kaiser Permanente monitors that the total amount paid for the service does not exceed what would have been paid if the procedure had been billed without the modifier(s). Kaiser Permanente reserves the right to adjust claims that are paid in excess of the total. Example: (Interpretation and report of chest x-ray) billed by provider A and billed by provider B for the same patient same day. Since encompasses both the technical and the professional component of the chest x-ray, claim from provider A could be denied as a partial duplicate unless supported by documentation or another supporting modifier

34 5.41 Other Party Liability (OPL) Other Party Liability (OPL) is a way of determining the order in which benefits are paid and the amounts which are payable when a claimant is covered under more than one plan (individual or group). It is intended to prevent duplication of benefits when an individual is covered by multiple plans or payers providing benefits or services for medical, dental or other care and treatment. Other Party Liability includes Coordination of Benefits (COB), Third Party Liability (TPL), Worker s Compensation (WC), TRICARE (also known as Champus), Medicare Primary and dual coverage. Kaiser Permanente follows the National Association of Insurance Commissioners (NAIC) model regulations for coordinating benefits, except in those instances where the NAIC model regulations differ from Oregon or Washington state law, state law supersedes the NAIC model regulations. If you have any questions relating to the coordination of benefits, please call the appropriate number listed below for assistance. COB Local Telephone #: (503) COB Toll-Free Telephone #: (888) TPL Local Telephone #: (503) TPL Toll-Free Telephone #: (866) Worker s Compensation, TRICARE & Medicare Primary Local Telephone #: (503) Worker s Compensation, TRICARE & Medicare Primary Toll-Free Telephone #: (866) Workers Compensation 5.43 Provider Claims Appeals If you have questions, please call or If your office/facility has questions or concerns about the way a particular claim was processed by Kaiser Permanente, please contact our Claims Inquiry Unit at Many questions and issues regarding claim payments, coding, and submission policies can be resolved quickly over the phone or via fax. If your issue cannot be resolved through this initial contact, you will be instructed as follows:

35 Provider Claim Payment Appeals Process: If your concern is determined to be a claim payment appeals issue, you will be advised to submit your concern in writing to: Kaiser Permanente Provider Appeals Provider Contracting and Relations 500 NE Multnomah Blvd Ste 100 Portland, OR Fax Please note that all claim payment appeal requests must be filed within 365 days of the date the claim was originally processed or denied, in order to be considered for payment by Kaiser Permanente

36 5.44 CMS-1500 (08/05) FIELD DESCRIPTIONS The fields identified in the table below as Required must be completed when submitting a CMS-1500 (08/05) claim form to Kaiser Permanente for processing: Note: The required fields for submission shown below are required by Kaiser Permanente but not necessarily required by CMS or other payers. For Medicare Members, please refer to Medicare Billing Requirements for appropriate field requirements and instructions/examples. Note: The new CMS-1500 (08/05) form is revised to accommodate National Provider Identifiers (NPI). Kaiser currently accepts both forms. FIELD NUMBER FIELD NAME 1 MEDICARE/ MEDICAID/ TRICARE CHAMPUS/ CHAMPVA/ GROUP HEALTH PLAN/FECA BLK LUNG/OTHER 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). Example: 01/05/ 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 and PHONE NUMBER. 6 PATIENT'S RELATIONSHIP TO INSURED Required if Applicable 7 INSURED'S ADDRESS Required if Applicable 8 PATIENT STATUS Required if Applicable Check the appropriate box for the patient s relationship to the insured. Enter the insured s address (STREET ADDRESS, CITY, STATE, and ZIP CODE) and telephone number. When the address is the same as the patient s the word SAME may be entered. Check the appropriate box for the patient s MARITAL STATUS, and check whether the patient is EMPLOYED or is a STUDENT

37 FIELD NUMBER REQUIRED FIELDS FIELD NAME FOR CLAIM INSTRUCTIONS/EXAMPLES SUBMISSIONS 9 OTHER INSURED'S NAME Required if Applicable 9a 9b OTHER INSURED S POLICY OR GROUP NUMBER OTHER INSURED S DATE OF BIRTH/SEX Required if Applicable Required if Applicable 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 named in Field 9 (Other Insured s Name) above. NOTE: For each entry in Field 9A, there must be a corresponding entry in Field 9d. 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). Example: 01/05/2008 9c EMPLOYER S NAME OR SCHOOL NAME Required if Applicable Enter the name of the other insured s EMPLOYER or SCHOOL NAME (if a student). 9d 10a-c INSURANCE PLAN NAME OR PROGRAM NAME IS PATIENT CONDITION RELATED TO Required if Applicable Required Enter the name of the other insured s INSURANCE PLAN or program. Check Yes or No to indicate whether 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. 10d RESERVED FOR LOCAL USE Not Required Leave blank. 11 INSURED S POLICY NUMBER OR FECA NUMBER Not Required If there is insurance primary to Medicare, enter the insured s policy or group number. 11a INSURED S DATE OF BIRTH Not Required Enter the insured s date of birth and sex, if different from Field 3. The date of birth must include the month, day, and FOUR digits for the year (MM/DD/YYYY). Example: 01/05/ b EMPLOYER S NAME OR SCHOOL NAME Not Required Enter the name of the employer or school (if a student), if applicable. 11c INSURANCE PLAN OR PROGRAM NAME Not Required Enter the insurance plan or program name. 11d IS THERE ANOTHER HEALTH BENEFIT PLAN? Required Check yes or no to indicate if there is another health benefit plan. For example,

38 FIELD NUMBER REQUIRED FIELDS FIELD NAME FOR CLAIM INSTRUCTIONS/EXAMPLES SUBMISSIONS the patient may be covered under insurance held by a spouse, parent, or some other person. 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 Not Required Not Required Required if Applicable Not Required Not Required If yes then fields 9 and 9a-d must be completed. Have the patient or an authorized representative SIGN and DATE this block, unless the signature is on file. If the patient s representative signs, then the relationship to the patient must be indicated. Have the patient or an authorized representative SIGN this block, unless the signature is on file. Enter the date of the current illness or injury. If pregnancy, enter the date of the patient s last menstrual period. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2008 Enter the previous date the patient had a similar illness, if applicable. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2008 Enter the from and to dates that the patient is unable to work. The dates must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/ NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Required if Applicable Enter the FIRST and LAST NAME of the referring or ordering physician. 17a OTHER ID # Not Required In the shaded area, enter the non-npi ID number of the physician whose name is listed in Field 17. Enter the qualifier identifying the number in the field to the right of 17a. The NUCC defines the following qualifiers: 0B - State License Number 1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number

39 FIELD NUMBER REQUIRED FIELDS FIELD NAME FOR CLAIM INSTRUCTIONS/EXAMPLES SUBMISSIONS 1H - CHAMPUS Identification Number EI - Employer s Identification Number G2 - Provider Commercial Number LU - Location Number N5 - Provider Plan Network Identification Number SY - Social Security Number X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy 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. 19 RESERVED FOR LOCAL USE Required if Applicable If you are covering for another physician, enter the name of the physician (for whom you are covering) in this field. If a non-contracting Provider/Provider will be covering for you in your absence, please notify that individual of this requirement. 20 OUTSIDE LAB CHARGES Not Required Required 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Enter the diagnosis/condition of the patient, indicated by an ICD-9-CM code number. Enter up to 4 diagnostic codes, in PRIORITY order (primary, secondary condition). 22 MEDICAID RESUBMISSION Not Required 23 PRIOR AUTHORIZATION NUMBER Required if Applicable Enter the prior authorization number for those procedures requiring prior approval. 24a-g SUPPLEMENTAL INFORMATION Required Supplemental information can only be entered with a corresponding, completed service line. SUPPLEMENTAL INFORMATION, con t. 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. When reporting additional anesthesia services information (e.g., begin and end times), narrative description of an unspecified code, NDC, VP HIBCC codes, OZ GTIN codes or contract rate, enter the applicable qualifier and number/code/information starting with the first space in the shaded line of this field. Do not

40 FIELD NUMBER REQUIRED FIELDS FIELD NAME FOR CLAIM INSTRUCTIONS/EXAMPLES SUBMISSIONS enter a space, hyphen, or other separator between the qualifier and the number/code/information. The following qualifiers are to be used when reporting these services. 7 - Anesthesia information ZZ - Narrative description of unspecified code N4 - National Drug Codes (NDC) VP - Vendor Product Number Health Industry Business Communications Council (HIBCC) Labeling Standard OZ - Product Number Health Care Uniform Code Council Global Trade Item Number (GTIN) CTR - Contract rate 24a DATE(S) OF SERVICE Required Enter the month, day, and year (MM/DD/YY) for each procedure, service, or supply. Services must be entered chronologically (starting with the oldest date first). For each service date listed/billed, the following fields must also be entered: Units, Charges/Amount/Fee, 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 (for example: durable medical equipment). 24b PLACE OF SERVICE Required Enter the place of service code for each item used or service performed. 24c EMG Not Required Enter Y for "YES" or leave blank if "NO" to indicate an EMERGENCY as defined in the electronic 837 Professional 4010A1 implementation guide. 24d PROCEDURES, SERVICES, OR SUPPLIES: CPT/HCPCS, MODIFIER Required Enter the CPT/HCPCS codes and MODIFIERS (if applicable) reflecting the procedures performed, services rendered, or supplies used. IMPORTANT: Enter the anesthesia time, reported as the beginning and end times of anesthesia in military time above the appropriate procedure code

41 FIELD NUMBER REQUIRED FIELDS FIELD NAME FOR CLAIM INSTRUCTIONS/EXAMPLES SUBMISSIONS 24e DIAGNOSIS POINTER Required Enter the diagnosis code reference number (pointer) as it relates 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 Item Number 21 only. Do not enter them in 24E.) 24f $ CHARGES Required Enter the FULL CHARGE for each listed service. Any necessary payment reductions will be made during claims adjudication (for example, multiple surgery reductions, maximum allowable limitations, co-pays etc). 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: units of supplies, etc.) 24h EPSDT FAMILY PLAN Not Required 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 24i ID. QUAL Required Enter in the shaded area of 24I the qualifier identifying if the number is a non-npi. The Other ID# of the rendering provider is reported in 24J in the shaded area. The NUCC defines the following qualifiers: 0B - State License Number 1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number 1H - CHAMPUS Identification Number EI - Employer s Identification Number G2 - Provider Commercial Number LU - Location Number N5 - Provider Plan Network Identification Number SY - Social Security Number (The social security number may not be used for Medicare.) X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy

42 REQUIRED FIELDS FIELD FIELD NAME FOR CLAIM INSTRUCTIONS/EXAMPLES NUMBER SUBMISSIONS 24j RENDERING PROVIDER ID # Required 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 Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b. 25 FEDERAL TAX ID NUMBER Required Enter the physician/supplier 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. IMPORTANT: The Federal Tax ID Number in this field must match the information on file with the IRS. 26 PATIENT'S ACCOUNT NO. Required Enter the Members account number assigned by the Provider s/provider s accounting system. 27 ACCEPT ASSIGNMENT Not Required IMPORTANT: This field aids in patient identification by the Provider/Provider. 28 TOTAL CHARGE Required Enter the total charges for the services rendered (total of all the charges listed in Field 24f). 29 AMOUNT PAID Required if Applicable Enter the amount paid (i.e., Member copayments or other insurance payments) to date in this field for the services billed. 30 BALANCE DUE Not Required Enter the balance due (total charges less amount paid). 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 32 SERVICE FACILITY LOCATION INFORMATION Required Required if Applicable Enter the signature of the physician/supplier 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. The name and address of the facility where services were rendered (if other than patient s home or physician s office). Enter the name and address information in the following format: 1st Line Name 2nd Line Address 3rd Line City, State and Zip Code Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N

43 FIELD NUMBER REQUIRED FIELDS FIELD NAME FOR CLAIM INSTRUCTIONS/EXAMPLES SUBMISSIONS Main Street, #101 ). 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. Required 33 BILLING PROVIDER INFO & PH # Enter the name, address and phone number of the billing entity. 33a NPI # Required Enter the NPI number of the service facility location in 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

44

45 5.45 CMS-1450 (UB-04) FIELD DESCRIPTIONS The fields identified in the table below as Required must be completed when submitting a CMS-1450 (UB-04) claim form to Kaiser Permanente for processing: Please Note: The fields required for submission below are required by Kaiser Permanente but not necessarily by CMS or other payers. For Medicare members, please refer to Medicare s billing requirements for appropriate field requirements and instructions or examples. FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 1 PROVIDER NAME and 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/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 Not Required Leave 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 the member s birth date. 11 PATIENT SEX Required Enter the member s gender. 12 ADMISSION DATE Required For inpatient claims only, enter the date of admission. 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

46 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 14 ADMISSION TYPE Required Indicate the type of admission (e.g. emergency, urgent, elective, and newborn). 15 ADMISSION SOURCE Required Enter the source of the admission type code. 16 DISCHARGE HOUR (DHR) Required if Applicable Enter the two-digit code for the hour during which the member was discharged. 17 PATIENT STATUS Required Enter the discharge status code CONDITION CODES Required if Applicable 29 ACCIDENT (ACDT) STATE Not Required 30 BLANK Not Required Leave blank OCCURRENCE CODES AND DATES OCCURRENCE SPAN CODES AND DATES Required if Applicable Required if Applicable 37 BLANK Not Required Leave blank. Enter any applicable codes which identify conditions relating to the claim that may affect claims processing. Enter the two-character code indicating the state in which the accident occurred which necessitated medical treatment. Enter the code and the 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. 38 RESPONSIBLE PARTY Not Required Enter the responsible party name and address VALUE CODES and AMOUNT Required if Applicable 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. 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 (Rev. CD.), and the corresponding CPT/HCPCS procedure code in this field

47 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 45 SERVICE DATE Required Outpatient Series Bills: 46 UNITS OF SERVICE Required The units of service. A service date must be entered for all outpatient series bills whenever the from and through dates in Field 6 (Statement Covers Period: From/Through) 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). 47 TOTAL CHARGES Required Indicate the total charges pertaining to the related revenue code for the current billing period, as listed in Field BLANK Not Required Leave blank. 48 NON COVERED CHARGES Not Required Enter any non-covered charges. 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) 53 ASSIGNMENT OF BENEFITS (ASG BEN) Not Required Required if Applicable Enter the release of information certification number Enter the assignment of benefits certification number. 54a-c PRIOR PAYMENTS Required if Applicable 55 ESTIMATED AMOUNT DUE Not Required If payment has already been received toward the claim by one of the payers listed in Field 50 (Payer) prior to the billing date, enter the amounts here. Enter the estimated amount due.

48 FIELD NUMBER FIELD NAME 56 NATIONAL PROVIDER IDENTIFIER (NPI) REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required INSTRUCTIONS/EXAMPLES Enter the service provider s National Provider Identifier (NPI). 57 OTHER PROVIDER ID Required Enter the service provider s Kaiser-assigned provider ID. 58 INSURED S NAME Required Enter the subscriber s name. 59 PATIENT S RELATION TO INSURED Required if Applicable Enter the member s relationship to the subscriber. 60 INSURED S UNIQUE ID Required Enter the insured person s unique individual member identification number (medical/health record number), as assigned by Kaiser. 61 INSURED S GROUP NAME 62 INSURED S GROUP NUMBER 63 TREATMENT AUTHORIZATION CODE 64 DOCUMENT CONTROL NUMBER Required if Applicable Required if Applicable Required if Applicable Not Required 65 EMPLOYER NAME Required if Applicable 66 DX VERSION QUALIFIER 67 PRINCIPAL DIAGNOSIS CODE 67 A-Q OTHER DIAGNOSES CODES Not Required Required Required if Applicable 68 BLANK Not Required Leave blank. Enter the insured s group name. Enter the insured s group number as shown on the identification card. For Prepaid Services claims enter "PPS". For ALL inpatient and outpatient claims, enter the referral number. Enter the document control number related to the member or the claim. Enter the employer s name. Indicate the type of diagnosis codes being reported. Note: At the time of printing, Kaiser only accepts ICD-9-CM diagnosis codes on the UB-04. Enter the principal diagnosis code, on all inpatient and outpatient claims. Enter other diagnoses codes corresponding to additional conditions. Diagnosis codes must be carried to their highest degree of detail. 69 ADMITTING DIAGNOSIS Required Enter the admitting diagnosis code on all inpatient claims. 70 (a-c) REASON FOR VISIT (PATIENT REASON DX) Not Required 71 PPS CODE Required if Applicable Enter the diagnosis codes indicating the patient s reason for outpatient visit at the time of registration. Enter the DRG number which the procedures group, even if you are being reimbursed under a different payment methodology

49 FIELD NUMBER FIELD NAME 72 EXTERNAL CAUSE OF INJURY CODE (ECI) REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required if Applicable 73 BLANK Not required Leave blank. 74 PRINCIPAL PROCEDURE CODE AND DATE 74 (a e) OTHER PROCEDURE CODES AND DATES Required if Applicable Required if Applicable 75 BLANK Not required Leave blank. INSTRUCTIONS/EXAMPLES Enter an ICD-9-CM E-code in this field (if applicable). Enter the ICD-9-CM procedure CODE and DATE on all inpatient AND outpatient claims for the principal surgical and/or obstetrical procedure which was performed (if applicable). 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 (if applicable). 76 ATTENDING PHYSICIAN / NPI / QUAL / ID Required Enter the National Provider Identifier (NPI) and the name of the attending physician for inpatient bills or the physician that requested the outpatient services. Inpatient Claims Attending Physician Enter the full name (first and last name) of the physician who is responsible for the care of the patient. 77 OPERATING PHYSICIAN / NPI/ QUAL/ ID OTHER PHYSICIAN/ NPI/ QUAL/ ID Required If Applicable Required if Applicable Outpatient Claims Referring Physician For ALL outpatient claims, enter the full name (first and last name) of the physician who referred the Member for the outpatient services billed on the claim. Enter the National Provider Identifier (NPI) and the name of the lead surgeon who performed the surgical procedure. Enter the National Provider Identifier (NPI) and name of any other physicians. 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 martial status, taxonomy, or ethnicity codes, as may be appropriate

50

51 5.46 Billing Requirements and Instruction for Specific Services Evaluation Management (E/M) Services CMS-1500 (8/05) Field 19 When covering for another physician, enter the name of the physician you are covering for. NOTE: If a non-participating Practitioner/Provider will be covering for you in your absence, please notify that individual of this requirement. Inpatient E/M Services: If a patient is admitted for observation following the performance of a major/minor surgical package procedure, do not report hospital observation service codes, because all postoperative E/M services are included as part of the global surgical package. Consultations: Kaiser Permanente will reimburse for initial consultations when billed with any surgical procedure done on the same day of service. For office/outpatient: If the consultant assumes patient management responsibilities following the initial consultation, office E/M (established patient) visit codes should be used for all subsequent patient encounters, NOT office consultation codes. For inpatient: If the consultant assumes patient management responsibilities, use subsequent hospital care codes (NOT follow-up inpatient consultation codes) to report all additional E/M encounters with the patient. Surgery and E/M Services: Reimbursement will generally NOT be made for a pre- or post-operative E/M visit provided on the same day as major/minor surgery, or an endoscopic procedure, unless Kaiser Permanente agrees that there was a significant, separately identifiable E/M service provided in addition to the procedure. In these instances, the provider must bill for the E/M visit using the appropriate modifier. If E/M services are performed during the post-operative period for a reason unrelated to the original procedure (such as for other disease or injuries), you may bill for these services using modifier 24 (Unrelated E/M service by the same physician during a post-operative period), and you must list a corresponding diagnosis code which reflects that the E/M services were for a problem other than the surgical diagnosis. Urgent or Emergency Services Provided in the Office: For urgent or emergency services provided in the office setting, use code Office services provided on an emergency basis in addition to the appropriate E/M office visit code. Non-Surgical Procedure that Include E/M Services: There are certain instances where Kaiser Permanente will deny medical visits when billed with certain non-surgical procedures, because the codes for these procedures include admission to the hospital and/or daily visits. The non-surgical procedures which fall into this category include:

52 Clinical brachytherapy End stage renal disease services Allergy immunotherapy services Preventive Medicine Services: Preventive medicine codes -- NOT office evaluation/management codes -- should be used to report the routine evaluation and management of adults and children, in the absence of patient complaints. For example, preventive medicine codes should be used for: Well-baby check ups Routine pediatric visits Camp or school physicals Routine, annual gynecological exams Emergency Rooms UB-04 Field 15 (UB-04) Enter the code indicating the source of the admission or outpatient registration Field 44 The emergency department E/M visit codes should ONLY be used if the patient is seen in the emergency department. Emergency department E/M visit codes should be used for E/M services provided in the emergency department, even if these were non-emergency services. The only requirement for using emergency department codes is that the patient must be registered in the emergency department. Office visit E/M codes should be used if the patient is seen in the ER as a convenience to the physician and/or patient, but the patient is not registered in the emergency department. NOTE: If both an emergency department physician and an attending physician are involved in admitting a patient from the ER, the ER physician should bill for services utilizing the emergency department E/M codes, and the attending physician should bill for services using the initial hospital visit codes. The two physicians cannot each bill for both the ER services rendered and the hospital admission Durable Medical Equipment Description: Durable Medical Equipment is medically necessary equipment that is: Appropriate for use at home Primarily and customarily used to service a medical purpose Not useful to a person in absence of an illness Able to withstand repeated use CMS-1500 Field 24d CPT codes are required for all professional services. Use HCPCS Level II codes to define DME. Use modifiers, if applicable. UB-92 or UB-04 Field 42 Enter the appropriate revenue code Field 44 HCPCS/Rates required Field 46 Number of rental months

53 Field 54 DME cost sharing amounts collected from the Member are reported in this field. Field 84 (UB-92) or Field 80 (UB-04) For DME billing, rental rate costs and anticipated months of usage should be inserted in this field Injection/ Immunizations CPT codes are required for all professional services. Use HCPCS Level II codes to define Injections/ Immunizations. NOTE: If there was no identifiable E/M service rendered by the nurse or the provider, and the patient received only an injection during the encounter, it is permissible to report an injection administration code in lieu of the E/M visit code and the appropriate HCPCS code (specifying the drug administered). Unlike injections, immunization procedures include the supply of materials. Additionally, injection administration fees are not eligible for reimbursement when billed with immunization codes Newborn Services CMS-1500 (8/05) Field 2 Enter the first and last name of the newborn Field 3 Enter the newborn s date of birth UB-04 Field 8 (UB-04) Enter the first and last name of the newborn Field 10 (UB-04) Enter the newborn s date of birth NOTE: If the Health Record Number is not established, contact the Membership Services Department at or (503) Expanded Care CMS-1500 (8/05) Field 21 Diagnosis code V66.9 should always be used when billing expanded care services Field 24 d Enter the appropriate procedure codes per your Provider Contract UB-04 Field 67 Diagnosis code V66.9 should always be used when billing expanded care services Field 42 Enter the appropriate procedure codes per your Provider Contract Field 44 Enter the appropriate HCPC and/or CPT code NOTE: Services provided for Expanded care, hospice and home health should be billed on a separate CMS-1500 (8/05) or UB04 claim forms. The claim may inadvertently be denied if these services are submitted on one claim form

54 5.47 Anesthesia GLOBAL ANESTHESIA PACKAGE OFFICE-BASED SURGICAL PROCEDURES ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT The global anesthesia package includes: The performance of a pre-anesthetic examination and evaluation (even if the exam is done on a date different from the date of surgery) The administration of the anesthetic The administration of fluids and/or blood incidental to the delivery of anesthesia (or the procedure being performed) The usual monitoring services (ECG, blood pressure, etc.) The provision of post-operative anesthesia care (postoperative visit) When an office-based surgical procedure is performed, reimbursement for the procedure includes reimbursement for anesthesia services as part of the global surgical fee, because it is expected that appropriate anesthesia will be administered with the office-based procedure. Kaiser Permanente reimburses participating providers for anesthesia services based on nationally recognized criteria for reporting of anesthesia services, including: The American Medical Association (AMA) CPT codes ( ) American Society of Anesthesiologists (ASA) Relative Value Guide (RVG) Medicare Guidelines BASE UNITS: Providers are NOT to indicate the ASA base unit values in the Days/Units field (Item 24, Box G). Base units are determined as defined by the American Society of Anesthesiologists Relative Value Guide. The base units assigned to a procedure are intended to demonstrate the relative complexity of a specific procedure and include the value of all anesthesia services, except the value of the actual time spent administering the anesthesia. Kaiser Permanente stores the base unit value within our claims system and will calculate the anesthesia payment of the base units according to the information provided on the claim. ANESTHESIA

55 REPORTING REQUIREMENTS & REIMBURSEMENT Con t. REPORTING OF ANESTHESIA TIME: Anesthesia time begins when the anesthesiologist starts to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area. Anesthesia time ends when the anesthesiologist is no longer in personal attendance, which is when the patient may be safely placed under postoperative supervision. Time units are calculated by allowing 1 unit for each 15 minute interval or remaining fraction thereof. Providers are to show time as total number of minutes in the Units field (Item 24, Box G). REIMBURSEMENT: Payment for most anesthesia services is based on: The base unit value Plus anesthesia time units Multiplied by the fee schedule conversion factor, as appropriate. Other services are reimbursed based upon the CPT code. EXCEPTIONS TO BILLING ANESTHESIA CODES MULTIPLE SURGICAL PROCEDURES: When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex procedure is reported. The time reported is the combined total of all procedures reported on the primary procedure. Anesthesiologists should bill using anesthesia codes only, unless one or more of the following services was performed by the anesthesiologist (in which case the appropriate non-anesthesia CPT code(s) may be reported and billed in accordance with CMS guidelines): Evaluation and management services Hospital inpatient services Consultations Critical care services Pain management Nerve blocks Destruction by neurolytic agents Services not included in the global anesthesia fee Other miscellaneous services QUALIFYING CIRCUMSTANCES: CPT codes 99100, 99116, and represent various patient conditions that may impact the anesthesia service provided. Such codes may be billed in addition to the anesthesia being billed

56 Charges for these codes are to be shown on the same line as the CPT Qualifying Circumstances Code in Item 24, Box F. PATIENT-CONTROLLED ANALGESIA (PCA): Benefits may be available for the administration of patientcontrolled analgesia (PCA) following a surgical procedure. PCA billed by a surgeon is covered as part of the global surgical package and is not separately reimbursable. PCA reimbursements are limited to anesthesiologists only. EXCEPTIONS TO BILLING ANESTHESIA CODES Con t. An anesthesiologist s services for PCA should be submitted as a single line on the claim form as follows: Span the dates to include the entire care for the PCA (reimbursement will be made as a global allowance, and will include the entire course of PCA). Any hospital care provided by the anesthesiologist subsequent to the initial day of PCA will be considered covered under the global PCA fee. Use CPT code when billing for PCA services. CONSCIOUS SEDATION: Sedation with or without analgesia (conscious sedation), intravenous, intramuscular or inhalation (CPT code ) are considered eligible for reimbursement when billed by an anesthesiologist, pain management or certified registered nurse anesthetist. ANESTHESIA MODIFIERS Personally Performed or Medically-Directed/Supervised Anesthesia Services: Use an appropriate HCPCS anesthesia modifier to denote whether the anesthesia services were personally performed, medically directed, or medically supervised: AA - Anesthesia service performed personally by the Anesthesiologist AD - Medical supervision by a physician of more than four concurrent procedures QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals QX - CRNA service with medical direction by a physician QY - Medical direction of one CRNA by the

57 QZ - CRNA service without medical direction by a physician QS - Monitored anesthesia care service (can be billed by a CRNA or a physician) Physical Status Modifiers: As indicated in the CPT book, the following physical status modifiers should be appended to the CPT anesthesia code to distinguish between the various levels of complexity of the anesthesia service(s) provided: P1 - A normal healthy patient P2 - A patient with mild systemic disease P3 - A patient with severe systemic disease P4 - A patient with severe systemic disease that is a constant threat to life P5 - A moribund patient who is not expected to survive without the operation P6 - A declared brain-dead patient whose organs are being removed for donor purposes DO NOT enter additional minutes for the Physical Status modifier. If eligible for reimbursement, the additional unit(s) will be calculated by our claims system. The patient cannot be billed for Physical Status modifiers not allowed by Kaiser Permanente. Other CPT Modifiers/Qualifying Circumstances Codes: Other modifiers and qualifying circumstances codes may be used as appropriate. Follow the instructions in the CPT/HCPCS books when reporting these additional modifiers and/or codes

58 5.48 Coordination of Benefits (COB) Coordination of Benefits (COB) is a method for determining the order in which benefits are paid and the amounts which are payable when a Member is covered under more than one plan. It is intended to prevent duplication of benefits when an individual is covered by multiple plans providing benefits or services for medical or other care and treatment. Kaiser Permanente Providers are responsible for determining the primary payor and for billing the appropriate party. If Kaiser Permanente is not the primary carrier, an EOB is required with the claim CMS 1500 (HCFA 1500) submission How to Determine the Primary Payor 1 The benefits of the plan that covers an individual as an employee, Member or subscriber other than as a dependent are determined before those of a plan that covers the individual as a dependent. 2 When both parents cover a child, the birthday rule applies the payor for the parent whose birthday falls earlier in the calendar year (month and day) is the primary payor. When determining the primary payor for a child of separated or divorced parents, inquire about the court agreement or decree. In the absence of a divorce decree/court order stipulating parental healthcare responsibilities for a dependent child, insurance benefits for that child are applied according to the following order: Insurance carried by the 1 Natural parent with custody pays first 2 Step-parent with custody pays next 3 Natural parent without custody pays next 4 Step-parent without custody pays last If the parents have joint custody of the dependent child, then benefits are applied according to the birthday rule referenced above. If this does not apply, call the Member Services Department at or Kaiser Permanente is generally primary for working Medicare-eligible Members when the CMS Working Aged regulation applies

59 2 3 Medicare is generally primary for retired Medicare Members over age 65, and for employee group health plan (EGHP) Members with End Stage Renal Disease (ESRD) for the first thirty (30) months of dialysis treatment. This does not apply to direct pay Members. In cases of work-related injuries, Workers Compensation is primary unless coverage for the injury has been denied Description of COB Payment Methodologies COB Claims Submission Requirements and Procedures 4 In cases of services for injuries sustained in vehicle accidents or other types of accidents, primary payor status is determined on a jurisdictional basis. If the auto insurance is primary, claims will require an EOB.] Kaiser Permanente Coordination of Benefits allows benefits from multiple carriers to be added on top of each other so that the Member receives the full benefits from their primary carrier and the secondary carrier pays their entire benefit up to 100% of allowed charges. When Kaiser Permanente has been determined as the secondary payor, Kaiser Permanente pays the difference between the payment by the primary payor and the amount which would be have been paid if Kaiser Permanente was primary, less any amount for which the Member has financial responsibility. Benefit carve-out calculations are based on whether or not the Provider accepts Medicare assignment for the provider contract corresponding to the claim. Medicare assignment means the provider has agreed to accept the Medicare allowed amount as payment. Whenever Kaiser Permanente is the SECONDARY payer, claims can be submitted EITHER electronically or on one of the standard paper claim forms: 1 Electronic Claims: If Kaiser Permanente is the secondary payer, send the completed electronic claim with the payment fields from the primary insurance carrier entered as follows: 837P claim transaction Enter Amount Paid 837I claim transaction Enter Prior Payments 2 Paper Claims

60 Members Enrolled in Two Kaiser Permanente Plans COB Claims Submission Timeframes If Kaiser Permanente is the secondary payer, send the completed claim form with a copy of the corresponding Explanation of Benefit (EOB) or Explanation of Medicare Benefits (EOMB)/Medicare Summary Notice (MSN) from the primary insurance carrier attached to the paper claim to ensure efficient claims processing/adjudication. Kaiser Permanente cannot process a claim without an EOB or EOMB/MSN from the primary insurance carrier. CMS-1500 claim form: Complete Field 29 (Amount Paid) CMS-1450 claim form: Complete Field 54 (Prior Payments) Some Members may be enrolled under two separate plans offered through Kaiser Permanente (dual coverage). In these situations, Providers need only submit ONE claim under the primary plan to Kaiser Permanente for processing. If Kaiser Permanente is the secondary payer, any Coordination of Benefits (COB) claims must be submitted for processing within 45 days of the date of the Explanation of Benefits (EOB) or EOMB/MSN.] COB FIELDS ON THE UB-04 CLAIM FORM The following fields should be completed on the CMS-1450 (UB-04) claim form to ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB information in these fields may cause claims to be denied or pended and reimbursements delayed. For additional information, refer to the current UB-04 National Uniform Billing Data Element Specifications Manual. Claims submitted electronically must meet the same data requirements as paper claims. For electronic claim submissions, refer to a HIPAA website for additional information on electronic loops and segments

61 837I FIELD LOOP # NUMBER 2300 H (UB-92) KAISER PERMANENTE (UB-04) FIELD NAME OCCURRENCE CODE/DATE INSTRUCTIONS/EXAMPLES Enter the appropriate occurrence code and date defining the specific event(s) relating to the claim billing period. NOTE: If the injuries are a result of an accident, please complete Field 77 (E-Code) 2330B NM 2320 AMT 50 PAYER (Payer Identification) 54 PRIOR PAYMENTS (Payers and Patient) Enter the name and number (if known) for each payer organization from whom the provider expects (or has received) payment towards the bill. List payers in the following order on the claim form: A = primary payer B = secondary payer C = tertiary payer Enter the amount(s), if any, that the provider has received toward payment of the bill PRIOR to the billing date, by the indicated payer(s). List prior payments in the following order on the claim form: A = primary payer B = secondary payer C = tertiary payer 2330A NM 58 INSURED S NAME Enter the name (Last Name, First Name) of the individual in whose name insurance is being carried. List entries in the following order on the claim form: 2320 SBR 59 Patient s Relationship To Insured A = primary payer B = secondary payer C = tertiary payernote: For each entry in Field 58, there MUST be corresponding entries in Fields 59 through 62 (UB- 92 and UB-04) AND 64 through 65 (Field 65 only on the UB- 04). Enter the code indicating the relationship of the patient to the insured individual(s) listed in Field 58 (Insured s Name). List entries in the following order: A = primary payer B = secondary payer C = tertiary payer 837I LOOP # 2330A NM 2320 SBR FIELD FIELD NAME NUMBER 60 CERT. SSN HIC ID NO. (Certificate/Social Security Number/Health Insurance Claim/Identification Number) 61 GROUP NAME (Insured Group Name) INSTRUCTIONS/EXAMPLES Enter the insured person s (listed in Field 58) unique individual Member identification number (medical/health record number), as assigned by the payer organization. List entries in the following order: A = primary payer B = secondary payer C = tertiary paper Enter the name of the group or plan through which the insurance is being provided to the insured individual (listed in Field 58). Record entries in the following order: A = primary payer B = secondary payer C = tertiary paper 2320 SBR 62 INSURANCE GROUP NO. Enter the identification number, control number, or code assigned by the carrier or administrator to identify the GROUP under which the individual (listed in Field 58) is covered. List entries in the following order: A = primary payer B = secondary payer C = tertiary paper 2320 SBR 64 ESC (Employment Status Code of Enter the code used to define the employment status of the insured individual (listed in Field 58). Record entries in the

62 COB FIELDS ON THE CMS-1500 (HCFA-1500 (8/05) ) CLAIM FORM The following fields should be completed on the CMS-1500 (HCFA-1500) (8/05) claim form, to ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB information in these fields may cause claims to be denied or pended and reimbursements delayed. Claims submitted electronically must meet the same data requirements as paper claims. For electronic claim submissions, refer to a HIPAA website for additional information on electronic loops and segments 837P LOOP # FIELD NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES 2330A NM 9 OTHER INSURED S NAME When additional insurance coverage exists (through a spouse, parent, etc.) enter the LAST NAME, FIRST NAME, and MIDDLE INITIAL of the insured. NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). 2330A NM 9a OTHER INSURED S POLICY OR GROUP NUMBER Enter the policy and/or group number of the insured individual named in Field 9. If you do not know the policy number, enter the Social Security number of the insured individual. NOTE: Field 9a must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). NOTE: For each entry in this field, there must be a corresponding Entry in 9d (Insurance Plan Name or Program Name) DMG 9b OTHER INSURED S DATE OF BIRTH/SEX Enter date of birth and sex, of the insured named in Field 9. The date of birth must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/1971 NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). N/A 9c EMPLOYER S NAME or SCHOOL NAME Enter the name of the employer or school name (if a student), of the insured named in Field NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health

63 837P LOOP # FIELD NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES Benefit Plan?). 2330B NM 9d INSURANCE PLAN NAME or PROGRAM NAME Enter the name of the insurance plan or program, of the insured individual named in Field 9. NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?) CLM 10 IS PATIENT S CONDITION RELATED TO: a. Employment? b. Auto Accident? c. Other Accident? Check yes or no to indicate whether 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) and in Field 21 (Diagnosis). PLACE (State) N/A 11d IS THERE ANOTHER HEALTH BENEFIT PLAN? PLACE (State) Enter the state the Auto Accident occurred in. 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). NOTE: If yes, then Field Items 9 and 9a-d must be completed DTP 14 DATE OF CURRENT --Illness (First symptom) --Injury (Accident) --Pregnancy (LMP) 2300 H1 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Enter the date of the current illness or injury. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2008 Enter the diagnosis and if applicable, enter the Supplementary Classification of External Cause of Injury and Poisoning Code. NOTE: This field must be completed when there is an entry in Field 10 (Is The Patient s Condition Related To) AMT 29 AMOUNT PAID Enter the amount paid by the primary insurance carrier in Field

64 5.49 Explanation of Payment

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