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Claims

New Update: As of 9/1/2020, Claim Status can only be obtained through one of our self-service tools.

Sign-on or Register to access KP Online Affiliate, or view claim status as a guest user.

 

Corrected Claim submission process:

If the claim is normally submitted via EDI, the corrected claim can be submitted via EDI as long the claim is identified as a corrected claim, and includes the original claim # in the EDI transaction. If the original claim number is not included, the claim will be rejected before it gets to the claims processing system, as the original claim # is a required data element in the EDI transaction.

If claim is submitted via paper CMS 1500-- corrected claims need to be submitted on preprinted red claim forms, in box 22 the resubmission code is 7 (replacement claim) and the original reference # would be the original claim # that this claim is replacing. Do not stamp or note “Corrected Claim” on the form as it interferes with the OCR process causing delays in processing.

If claim is submitted via paper UB 04-- corrected claims need to be submitted on preprinted red claim forms the right most number in the type of bill field needs to be a 7 (example: 137). Please note the original claim # in box 64 of the corresponding line (A,B,or C) to which Kaiser Permanente is identified as the payor in block 50. Example Kaiser Permanente is identified as the payor in box 50A. The original claim number would be provided in box 64A. Do not stamp or note "Corrected Claim" on the form as it interferes with OCR process causing delays in processing.


Disputes and appeals

If you or a member disagree with the handling of a claim, learn how to file a dispute or appeal a denial of payment or authorization.

Effective May 4, 2020 dispute and appeals will be submitted per below:

Initial criteria:

  • Full denial = Appeal (All LOBs)
  • Partial denial = disputes (excluding Non-Con Medicare); For Non-Con Medicare a dispute will be handled as an appeal.
  • EDC Analyzer and House Bill 1174 Claims (regardless of dispute or appeal, for all LOBs should go to Provider Services; Claim Services.

Exceptions grid (after the above criteria is identified and uncertain where to distribute)

  • Scenario
    Transaction Type
    Dispute
    Appeal
    1
    Rate/Fee Dispute - dispute request for a claim that was paid or denied at an incorrect fee
    X
    2
    Coding Edit Denials - request for a claim that was denied or adjusted for CCI edit or bundling
    X
    3
    Medical Necessity/Utilization Management Decision - request for a claim that was denied on initial medical necessity review
    X
    4
    Benefit Coverage - request for a claim that was denied based on covered benefit available to the member
    X
    5
    Denials Due to Incomplete or Invalid Billing Information - claims resubmitted due to rejection denials for invalid codes, rejected by pricing software (APC edits), or claim missing standard coding (DX, modifier, etc.)
    X
    6
    Local or National Coverage Issue - request to reconsider disagreements with coverage determination related to CMS (local or national) policy and coverage guidelines
    X
    7
    Request for Information - request to process claims where medical records, reports, COB, EOP, initially pended and closed/denied for no response
    X
    8
    Duplicate Denial - request to review denials for duplicate payment (corrections, tracer, interim claims)
    X
    9
    Denial for No Authorization - request to scope of authorization when processed within the scope of the authorized service(s) but paid less than billed
    X
    10
    Credentialing Issue - provider is listed as non-contracted but linked to the contract in Tapestry
    X
    X

The links below have information for utilizing Affiliate link (Online Affiliate) for submitting Disputes/Appeals/Request for Information (RFI):

View claim status as a guest user

Contracted and non-contracted providers can view their claim status as a guest user without registering. You will be asked to provide key information about a claim in question. In return, you will be able to view claim status information, including the current processing status, and, if paid, the vender and specific payment information. If your claim is not found in the Guest User system, call the phone number listed on the member’s ID card.

Claims procedures

Find out how to submit your claims electronically and obtain claims status and claim payment information.

Claims tools (NEW)

Learn more about our Claims tools and partnership.

Electronic Enrollment/Disenrollment of Electronic Funds or Electronic Remits

Kaiser Permanente Electronic Payment and Remittance Advice Centralized Enrollment Processing

Kaiser Permanente has partnered with CAQH to process Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERAs) enrollments. With this partnership, Kaiser Permanente is moving to a National EFT/ERA enrollment platform. We request that all providers pursuing EFT/ERA enrollments utilize the CAQH web portal for these activities. The portal is available 24 hours a day/seven days a week for first time enrollment or changes.

Enrolling in EFT/ERA will provide the following benefits: Receive claims payments and remittance data faster and more efficiently, reduce processing costs, and improve office workflow.

It is easy to get started now:

Visit https://solutions.caqh.org* for information and to create your secure account.

Or, speak with the CAQH EnrollHub Helpline at
1-844-815-9763. Representatives are available
7 AM - 9 PM EST Monday - Thursday and 7 AM - 7 PM EST Friday.


Kaiser Permanente contracted Clearing Houses and Electronic Data Interchange information

If you are already enrolled in ERA & EFT with other insurers, you still must enroll with Kaiser Permanente and select the correct region to receive ERA & EFT.

Important Note: If you are a provider retrieving ERAs from a clearinghouse, you must remember to also complete the ERA set up with your clearinghouse as well as with Kaiser via the CAQH EnrollHub.

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