Self-Funded Provider Manual Introduction Section 1 Kaiser Permanente Medical Care Program Section 2 Key Contacts

Transcription

1 Self-Funded Provider Manual Introduction Section 1 Medical Care Program Section 2 Key Contacts Self-Funded Provider Manual 1

2 Welcome to the Self-Funded Program It is our pleasure to welcome you as a Provider for the Self-Funded Program. We want this relationship to work well for you, your medical support staff, and our Members. This Self-Funded Provider Manual is to help guide you and your staff in understanding Insurance Company s policies and procedures for the Self-Funded Program and related administrative procedures. If, at any time, you have a question or concern about the information outlined in this Self-Funded Provider Manual, you can reach our Provider Relations Department by calling the Denver/Boulder service area at (303) and the Southern Colorado service area at (719) Capitalized terms in this Provider Manual which are used in describing the Self-Funded Program are defined in Section 9: Glossary of Terms. Self-Funded Provider Manual 2

3 Table of Contents INTRODUCTION SECTION 1: SELF-FUNDED PROGRAM OVERVIEW KAISER PERMANENTE INSURANCE COMPANY (KPIC) THIRD PARTY ADMINISTRATOR (TPA) SECTION 2: KEY CONTACTS AND TOOLS KEY CONTACTS SELF-FUNDED CUSTOMER SERVICE IVR SYSTEM WEBSITE... 8 Self-Funded Provider Manual 3

4 Introduction This Self-Funded Provider Manual is referenced in your agreement ( Agreement ) with a entity. The information in this Self-Funded Provider Manual is proprietary and may not be used, circulated, reproduced, copied or disclosed in any manner whatsoever, except as permitted by your Agreement, or with prior written permission from Health Plan. This Self-Funded Provider Manual is posted on s website at and The Self-Funded Provider Manual is updated on an ongoing basis by the Provider Relations Representative in collaboration with Contract Managers, other Departments and other local markets. Its intent is to provide providers/vendors with useful information as to how to best access the system and Kaiser Permanente s expectations of providers/vendors. Providers are sent a notification letter annually to reference any relevant changes If there is a conflict between this Self-Funded Provider Manual and your Agreement, the terms of your Provider Manual will control. Capitalized terms that are used in this Self- Funded Provider Manual, but not defined, will have the meanings given to them in your Agreement. Self-Funded Provider Manual 4

5 Section 1: Self-Funded Program Overview 1.1 Insurance Company (KPIC) Insurance Company (KPIC), an affiliate of Kaiser Foundation Health Plan, Inc., will be administering s Self-Funded Program. Each Self- Funded Plan Sponsor (an Other Payor under your Provider Contract) will contract with KPIC to provide administrative services for the Plan Sponsor s Self-Funded plan. KPIC has a dedicated administrative services team to coordinate administration with the Plan Sponsors. KPIC will provide network administration services and certain other administrative functions through an arrangement with Kaiser Foundation Health Plan of Colorado. 1.2 Third Party Administrator (TPA) KPIC has contracted with a Third Party Administrator (TPA), Harrington Health, to provide certain administrative services for s Self-Funded Program, including claims processing, eligibility information, and benefits. Harrington Health administers the Self-Funded Customer Service System, with automated functions as well as access to customer service representatives that allows you to check eligibility, benefit, and claims information for Self-Funded Members. The automated system (interactive voice response or IVR) is available 24 hours a day, 7 days a week. Customer Service Representatives are available Monday - Friday from 7 A.M. to 9 P.M. Eastern Time Zone (ET). Self-Funded Provider Manual 5

6 2 Section 2: Key Contacts and Tools 2.1 Key Contacts Below are key contacts for Self-Funded Member inquiries. Department Contact information Type of Help or Information from this Department Self-Funded Customer Service Provider Contracting & Network Management Department Customer Service Representatives are available Monday through Friday 5 a.m. to 7 p.m. Rocky Mountain Time Self-Service IVR System available: 24 hours / 7 days a week Website available: 24 hours / 7 days a week Available Monday through Friday 8 a.m. to 5 p.m. Rocky Mountain Time Zone Denver/Boulder Service Area Phone: Fax: Southern Colorado Service Area Phone: Fax: Website available: 24 hours / 7 days a week General enrollment questions Eligibility and benefit verification Claims management Billing and payment inquiries EDI questions Appeal and claims dispute questions Co-pay, deductible and coinsurance information Members terminated greater than 90 days Members presenting with no Kaiser Permanente identification number Verifying Member s PCP assignment Send Provider demographic updates such as Tax ID changes, address changes here Send information regarding practitioner additions or terminations from your office here Provider education and training Contract questions Contracted rate payment questions Form requests Issues and problem solving Self-Funded Provider Manual 6

7 Department Contact information Type of Help or Information from this Department Quality Resource Management (QRM) Denver/Boulder Service Area Available Monday through Friday 8:30 a.m. to 4:30 p.m. Rocky Mountain Time Routine Calls: Phone: DME and Home Health Review Phone: Urgent After-Hours calls weekends and holidays Phone: Southern Colorado Service Area Available Monday through Friday 8:00 a.m. to 5:00 p.m. Rocky Mountain Time Routine Calls: Phone: Fax: Urgent After-Hours calls weekends and holidays Obtain pre-certification for services and admissions (if online services are unavailable) DME and Home Health referrals Emergency Department notifications All inpatient admissions Transfers to Skilled Nursing Facilities (SNF) Ambulance Transports Discharge planning, case management 2.2 Self-Funded Customer Service IVR System Self-Funded Customer Service interactive voice response system (IVR) can assist you with a variety of questions. Call to use this service. Please have the following information available when you call into the system to provide authentication: Provider Tax ID or National Provider Index (NPI) Members medical record number (MRN) or Member s health record number (HRN) Member s date of birth For Claims Providers will also need to know the date of service The IVR can assist you to verify eligibility, benefits, authorizations and referrals; check a Member s accumulator (amount applied to deductible); inquire about claims and payments; or speak to a customer service representative. Follow the prompts to access these services. Self-Funded Provider Manual 7

8 2.3 Website Harrington Health has a Web site that allows you and your staff to check eligibility, benefit, and claims information for members enrolled in Self-Funded plans. A formal user guide will be published and provided to you. NOTE: This web site is restricted to information for individuals enrolled in Self-Funded plans administered by KPIC only. Information regarding members enrolled in Kaiser Permanente s fully funded plans (e.g., HMO), cannot be accessed from the Harrington Health site. You will be able to access the Harrington Health Web site from s provider website by clicking on the link that says Sign on here for Self-Funded Plans (see below). This website can also be directly accessed via Benefit and eligibility information for self-funded members can be accessed online from either the Harrington Health website ( ) or KP HealthConnect Online-Affiliate. ( You will then be directed to a log on page. New users to the Harrington Health Web site will be required to self-register to obtain a user ID and password. You have the option to use the same KP Online-Affiliate User ID and password if you wish. Benefits & Eligibility Information Self-funded member benefits and eligibility information can be obtained by searching for the member using their Health Record Number. Below is a sample web page reflecting Self-Funded Provider Manual 8

9 the information available on the Harrington Health Web site. Benefit and eligibility information is also available on KP Online -Affiliate. Claims Information You can also check claims status and verify additional claim information by clicking on the View More link located in the Medical claim status screen. A list of your practice s claims associated with the member will be displayed. Additional information about a specific claim is available by double clicking on one of the rows. NOTE: The bottom portion of the page will populate with the detailed information; however this is not reflected in this example. Self-funded claims information is only available through this link. Self-Funded Provider Manual 9

10 Self-Funded Provider Manual 10