Claims
8.0
As a Participating Provider billing for services with a fee-for-service contract with
MAPMG, please follow the procedures listed below. Participating Providers billing for
services rendered to Flexible Choice members, see Section 15.0 of this manual.
8.1
Billing Procedures for Fee-For-Service Claims
1. All patient services must be billed on a fully completed CMS 1500 or UB04 form,
unless otherwise indicated by contract.
2. All claims/bills requiring authorization to be considered for processing and payment
must have an authorization number reflected on the claim form or a copy of the
referral form may be submitted with the claim.
3. All claims/bills can be mailed to :
Kaiser Permanente
P. O. Box 6233
Rockville, MD 20849-6233
KPMAS also has the ability to receive your claims electronically through the Emdeon
Clearinghouse.
The Kaiser Permanente Mid-Atlantic States payor ID is: 52095
In the event a paper claim (CMS 1500 or UB 04) or a electronic claim has been
rejected, denied and/or requires additional supporting documentation for processing
(i.e. Medicare Summary Notice (MSN), commercial Explanation of Benefits or
Payment (EOB or EOP), operative report, etc), providers may submit the appropriate
documentation electronically via fax to our Claims Department at 301-388-1640.
Provider Fax Transmission Form, (copy of form at the end of chapter 8)
If you have any questions regarding submitting your claims electronically, please
contact Provider Relations at  1 (877) 806-7470. Should you require technical
assistance with Electronic Data Interface (EDI), contact EDI Technical Support at 
(301) 879-5453.
4. Payment is generally made within thirty (30) days of receiving the claim/bill.
Participating Providers may check the status of a claim/bill submitted for payment by
calling  1 (800) 810-4766, select the Claims prompt to speak to a Member
Services representative.
If you have a question regarding a previously submitted claim, billing or utilization,
please contact our Provider Services Center at  1 (800) 810-4766 and select the
Claims prompt to speak to a Member Services representative. If no resolution is
received after thirty (30) days, please feel free to contact Provider Relations Department
at  1 (877) 806-7470.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Timely Filing Requirements
Claims/bills for services provided to non-Medicare members must be received within one
hundred eighty (180) calendar days of the date of service to be considered for
processing and payment.
Claims/bills for services provided to Medicare Plus members must be received within the
following timeline:
 For services rendered between January 1st and September 30th, the claim/bill
must be submitted by December 31st of the following year.
 For services rendered between October 1st and December 31st, the claim/bill
must be submitted by December 31st of the second year following the service.
8.2
Clean Claim
KPMAS considers a claim ‘clean’ when submitted on the appropriate CMS form (1500 or
UB04), using current coding standards to complete form fields, and including the
attachments that provide information necessary in the processing the claim.
Note: Dentists should use a J512 Form and the most recent instructions provided by the
American Dental Association.
Note: Pharmacies should use the Universal Prescription Drug Claim Form or its
electronic equivalent.
Definition: A “Clean claim” is a claim/bill for reimbursement submitted to KPMAS by a
health care practitioner, pharmacy (or pharmacist), hospital or vendors entitled to
reimbursement that contains:
1.) Current industry standard data coding;
2.) Attachments appropriate for submission and procedural circumstance;
3.) Completed data element fields required for the CMS 1500 or the CMS form UB04
A claim is not considered to be “Clean” or payable if one or more of the following
conditions exists, due to a good faith determination or dispute regarding:







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
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Requirements For Clean Claim Submission
Correct Form – KPMAS requires claims for professional services to be submitted using
the CMS form 1500 and claims for hospital services (or appropriate ancillary services)
should be submitted using the CMS form UB04.
Standard Coding – All fields should be completed using industry standard coding as
outlined below.
Applicable Attachments – Attachments should be included in your submission when
circumstances require additional information.
Completed Field Elements for CMS Form 1500 Or CMS Form UB04– All applicable
data elements of CMS forms should be completed.
Forms
Participating Physicians will submit CMS 1500 or UB04 forms for all services rendered to
members, according to jurisdictional requirements.

Professional Services – KPMAS requires claims for professional services to
be submitted using the CMS form 1500.

Facility And Hospital Services – KPMAS requires claims for hospital
services (or the appropriate ancillary services) to be submitted using the CMS
form UB04.
Clean claims for covered benefits will be processed according to jurisdictional
regulations and paid, unless covered under a capitation agreement. Inaccurate coding
may result in claim processing and payment delays. As many factors are considered in
the processing of a claim, it is important to realize that a pre-authorized referral does not
guarantee payment, except under very limited conditions.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Coding Standards

Coding – All fields should be completed using industry standard coding
as outlined below.
Code Set
Standard
CPT- 4
(Current Procedure Terminology)
Maintained and distributed by the American Medical
Association, including its codes and modifiers, and codes
for anesthesia services
CDT- 1
(The Code on Dental Procedures and
Nomenclature)
Maintained and distributed by the American Dental
Association
ICD-9 CM
(International Classification of
Diseases, Clinical Modification)
Maintained and distributed by the U.S. Department of
Health and Human Services
HCPCS and Modifiers
(CMS Common Procedure Coding
System)
Maintained and distributed by the U.S. Department of
Health and Human Services
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)
Revenue Code
For psychiatric services, codes distributed by the American
Psychiatric Association
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
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Attachments To Include In Claims Submission

Attachments – The following attachments should be included in your
submission when the circumstances below apply. You may elect to submit any
additional attachments that may assist in receiving prompt payment.
ATTACHMENT WHEN SHOULD IT BE USED? A REFERRAL For Specialty Services – when you have received a consultant treatment plan or referral from a member’s PCP, another Participating Provider or a MAPMG provider. AN EXPLANATION OF BENEFITS STATEMENT FROM A PRIMARY CARRIER MEDICARE REMITTANCE NOTICE (EOMB) For members with other primary coverage – when you have received reimbursement or denial from a member’s primary carrier. For member’s with Medicare primary coverage – when you have received reimbursement or denial from Medicare MEDICAL RECORD AND DESCRIPTION OF PROCEDURES When the service rendered has no corresponding Current Procedural Terminology (CPT) or HCPCS code OPERATIVE NOTES For multiple surgeries – when using modifiers 22, 58, 62, 66 ,78, 80, 81, or 82 ANESTHESIA RECORDS For report on service and time spent – when using modifiers P4 or P5 INVOICES AND OTHER ATTACHMENTS For global contracts – when you have agreed to submit an attachment and/or invoice to describe services, supplies or pricing AMBULANCE TRIP REPORT For Maryland ambulance companies licensed by the Maryland Institute for Emergency Medical Services System OFFICE NOTES For prolonged and unusual services – when using modifier 21 or 22 or when our audit has determined patterns of improper billing Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
PHYSICIAN NOTES For professional services – when the services provided are outside the time and scope of the authorization obtained from KPMAS ADMITTING NOTES For inpatient services – when the services provided are outside the time and scope of the authorization obtained from KPMAS ITEMIZED BILLS For inpatient service – when there is no prior authorization or the admission is inconsistent with KPMAS concurrent review Fields of the CMS 1500 To Complete

APPROPRIATE DATA ELEMENTS COMPLETED (CMS FORM 1500) – The
following are field data elements required for clean claim submission
Field Location
Field 1a
Field 2
Field 3
Field 4
Field 5
Field 6
Field 7
Field 8
Field 10
Field 11
Field 11a
Field 11c
Field 11d
Field 12
Field 13
Field 14
Field 15
Field 17
Field 18
Field 21
Field 24a
Essential Data Elements Required
Subscriber’s plan ID number
The patient’s name
The patient’s date of birth and gender
The subscriber’s name
The patient’s address (state or P.O. Box, city, and zip code)
The patient’s relationship to the subscriber
The subscriber’s address (state or P.O. Box, city, and zip code)
Patient status
Whether the patient’s condition is related to employment, an auto accident, or
other accident
The subscriber’s policy number
The subscriber’s birth date and gender
Name of the third-party payor
Disclosure of any health benefit plans
The patient’s or authorized person’s signature or notation that the signature is
on file with the health care practitioner
The subscriber’s or authorized person’s signature or notation that the signature
is on file with the health care practitioner or person entitled to reimbursement,
if applicable
The date of current illness, injury, or pregnancy
Except in the case of a health care practitioner for emergency services,
whether the patient has had the same or a similar illness
Except in the case of a health care practitioner for emergency services, the
name of the referring physician
The hospitalization dates related to current services, if applicable
The diagnosis codes or nature of the illness or injury
The date of service
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Field 24b
Field 24c
Field 24d
Field 24e
Field 24f
Field 24g
Field 24i
Field 25
Field 26
Field 28
Field 31
Field 31
Field 32
Field Location
Field 33
The place of service code
The type of service code, if applicable
The procedure code
The diagnosis code by specific service
The charge for each listed service
The number of days, the time (minutes), the start and stop time or units
NPI number
The health care practitioner’s or person entitled to reimbursement’s federal tax
ID number
The patient’s account number
The total charge
For claims submitted electronically, a computer printed name as the
signature of the health care practitioner or person entitled to reimbursement.
For claims not submitted electronically, the signature of the health care
practitioner who provided the service, or notation that the signature is on file
with KPMAS
The name and address of the facility where services were rendered (if other
than home or office)
Essential Data Elements Required
The health care practitioner’s or person entitled to reimbursement’s billing
name, address, zip code, and phone number
Field Applicable to Any other field or essential data element necessary to comply with the
specific
Applicable Standard Code Set
circumstances
Field 9
Field 9a
Field 9b
Field 9c
Field 9d
Field 10d
Field 11b
Field 19
Field 23
Field 24d
Field 24d
Field 24d
Field 27
Field 29
Field 30
in applicable circumstances - other insured’s or enrollee’s name
in applicable circumstances - the other insured’s or enrollee’s policy/group
number
in applicable circumstances - the other insured’s or enrollee’s date of birth
in applicable circumstances - the other insured’s or enrollee’s plan name
(employer, school, etc.)
in applicable circumstances - the other insured’s or enrollee’s HMO or
insurer name
in applicable circumstances - the word “amended” or “corrected”
in applicable circumstances - the subscriber’s plan name
in applicable circumstances - a description of the presenting symptoms
in applicable circumstances - the prior authorization number
in applicable circumstances - codes pursuant to a global contract
in applicable circumstances - codes established by the Medicaid Program, if
applicable
in applicable circumstances - the modifier code is applicable when a modifier
code is used to explain unusual circumstances, if applicable
in applicable circumstances - whether an assignment was accepted
in applicable circumstances - the amount paid
in applicable circumstances - the balance due
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Fields of the CMS UB-04 To Complete

APPROPRIATE DATA ELEMENTS COMPLETED (CMS FORM UB-04) – The
following are field data elements required for clean claim submission
Field Location
Essential Data Elements Required
Field 1
Field 3
Field 4
Field 5
Field 6
Field 12
Field 13
Field 14
Field 15
Field 16
Field 17
Field 18
Field 19
Field 20
Field 22
Field 23
Field 37
Field 38
Field 39-41
Field 42
Field 43
Field 45
Field 46
Field 47
Field 48
Field 50
Field 51
Field 52
Field 53
Field 55
Field 58
Field 59
Field 60
The hospital’s name and address and telephone number
The patient’s control number
The type of bill code
The hospital’s federal tax ID number
The beginning and ending date of claim period
The patient’s name
The patient’s address
The patient’s date of birth
The patient’s gender
The patient’s marital status
The date of admission
The admission hour
The type of admission (e.g. emergency, urgent, elective, newborn)
The source of admission code
The patient status at discharge code
The medical record number
The internal control number
The responsible party name and address
The value code and amounts
The applicable revenue code
The revenue description
The service date
The units of service
The total charge
Non-covered charges
The name of third-party payor
The provider number
Release of information
Assignment of benefits
The estimated amount due
The subscriber’s name
The patient’s relationship to the subscriber
The patient’s/subscriber’s certificate number, health claim number and ID
number
The treatment authorization code
The principal diagnosis code
The admitting diagnosis
The attending physician ID
Other physician ID
The signature of the provider representative or notation that the signature is
on file with the third party payor
The date the bill was submitted
Any other field or essential data element necessary to comply with the
Applicable Standard Code Set
Field 63
Field 67
Field 76
Field 82
Field 83
Field 85
Field 86
Field Applicable
to specific
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
circumstances
UB-04 (third party payor)
Field
Location
Essential Data Elements Required for Specific Circumstances
Field 7
Covered days is applicable if Medicare is primary or secondary payor
Field 8
Field 9
Field 10
Non-covered days is applicable if Medicare is primary or secondary payor
Coinsurance days is applicable if Medicare is primary or secondary payor
Lifetime reserve days is applicable if Medicare is primary or secondary payor
and the patient was an inpatient
Field 21
The discharge hour is applicable if the patient was an inpatient or was
admitted for outpatient observation
The condition codes are applicable if the UB-92 manual contains a condition
code appropriate to the patient’s condition
The occurrence span code and from and through dates are applicable if the
UB-92 manual contains an occurrence code appropriate to the patient’s
condition
The occurrence span code and from and through dates are applicable if the
UB-92 manual contains an occurrence span code appropriate to the patient’s
condition
HCPCS/Rates are applicable if there is a primary or secondary payor
A code pursuant to a global contract is applicable if the claim is between
parties to a global contract
Prior payments are applicable if payments have been made to the hospital by
the patient or another payor
Field 24-30
Field 32-36
Field 36
Field 44
Field 44
Field 54
Field 64
Field 65
Field 66
Fields 68-75
Fields 68-75
Field 79
Field 80
The employment status code
The employer name
The employer location
Diagnosis codes other than the principal diagnosis code are applicable if there
are diagnoses other than the principal diagnosis
Diagnosis codes describing the patient’s presenting symptoms are applicable
for services provided in a hospital emergency department
The procedure coding methods used appropriate to the patient’s condition
The principal procedure code applicable if the patient has undergone an
inpatient or outpatient surgical procedure
Field 81
Other procedure codes are applicable as an extension of subsection (17) of
this section if additional surgical procedures were performed
Field 84
A description of the presenting symptoms is applicable if the claim is for
emergency services needed
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.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
8.3
Multiple Procedure Reimbursement Policy*
Multiple procedures performed in the same operative session will be reimbursed at
100% of the rate indicated for the first procedure from the highest payment group. All
other procedures will be paid at 50% of respective rates.
*This policy applies to the professional service component only
8.4
Same Service/Same Code Billed by Multiple Providers
In accordance with CMS Medicare guidelines for payment of claims, Kaiser Permanente
will only pay for an “interpretation and report” of an x-ray or an EKG procedure and not a
“review” of the same procedures. As defined in the Medicare claims manual, an
interpretation and report should address the findings, relevant clinical issues, and
comparative data (when available). A professional component billing based on a
“review” of the findings of the procedure, without a complete, written report similar to that
which would be prepared by a specialist in the field, does not meet the conditions for a
separate payment.
Exceptions to this policy will only be made under unusual circumstances for which
documentation is provided justifying a second interpretation. The studies subject to this
policy are:



8.5
EKG, echocardiograms
Neurological testing such as EEG
X-rays, plain films, ultrasound, MRI, CT, PET, and fluoroscopy studies
Description and Justification of Processing and Adjudication Edits
Kaiser Permanente continuously makes enhancements to our claim processing system
to ensure accurate and timely payment of claims for health care services provided to our
members. Kaiser Permanente utilizes the Intelliclaim claim editing software to evaluate
the accuracy and adherence of (professional) medical claims to accepted CPT/HCPCS
coding practices. The coding and billing practices are defined by the Center for
Medicare and Medicaid Services (CMS) Correct Coding Initiative (CCI).
The purpose of these processing edits is to make reimbursement guidelines and policies
more readily available to our Participating Providers, and to respond to the increasingly
complex developments in medical technology and procedure coding used to process
reimbursement to practitioners. Kaiser Permanente continually evaluates its claim
processing policies and payment methodologies including how reimbursement is
determined for specific procedures and code sets to confirm adherence with generally
accepted guidelines (e.g., AMA CPT Code Book, CMS/CMS Correct coding Initiative).
Intelliclaim Processing Edits and Explanation of Payment Codes
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Reason
Code
X0002
EOP
EX Code
TB
Reason
Type
NC
X0003
TC
NC
X0004
X0005
X0006
TD
TE
TF
NC
NC
NC
X0007
TG
NC
X0008
X0009
X0010
TH
TI
TJ
NC
NC
NC
X0011
TK
NC
X0012
TL
NC
X0013
TM
NC
X0014
X0015
X0016
X0017
TN
TO
TP
TQ
NC
NC
NC
NC
X0019
TS
NC
X0020
X0021
X0022
X0023
X0024
X0025
TT
TU
TV
TW
TX
TY
NC
NC
NC
NC
NC
NC
Reason Description
Deny, outpatient consult billed w/DOS
<6mos
Deny, confirmatory consult billed w/DOS
<6mos
Deny, initial consult billed>max time period
Deny, Consult billed by PCP
Deny, new patient code billed within past 3
years
Deny, E&M billed within procedure follow-up
period not payable
Deny, supplies billed same day as surgery
Deny, procedure identified as unbundled
Deny, anesthesia code billed by a nonanesthesiologist
Deny, not billed on Sunday/Federal holiday
or after hours
Deny, procedure code not consistent with
gender
Deny, procedure code not generally
covered
Deny, unlisted CPT code
Deny, duplicate claim /service
Deny, modifier required
Deny, procedure billed does not require
service of assistant surgeon
Deny, deleted or expired HCPCS or CPT
code
Deny, add-on billed w/o primary procedure
Deny, bilateral billed inappropriately
Deny, incorrect bilateral modifier
Deny, base code billed with Quantity>1
Deny, diagnosis not consistent with gender
Deny, always bundled
Claim Adjudication Edits, Policy Concepts and Descriptions
Supplies on the same day as surgery - Identifies supplies on the same day as a
surgery
CMS has established that certain supplies should be denied when billed on the same
day as surgical procedures for which the concept of the global surgical package applies.
Bundled Service – Identifies procedures indicated by CMS as always bundled when
billed with any other procedure
According to CMS, certain codes are always bundled when billed with other services on
the same date of service.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Deleted Supply and Procedure Codes – Identifies deleted service and procedure
codes that were in past editions of the CPT and HCPCS books.
CMS does not permit reimbursement of AMA deleted codes when they are submitted
after the deletion date and beyond the permitted submission period.
Inappropriate Procedure for Gender – Identifies procedures that are inconsistent with
the member’s gender
Certain procedure and diagnosis codes are exclusive to either the male or female
gender.
Duplicate Line Items – Identifies duplicate line items. Duplicate line items are
determined based on matches on certain key fields. The fields used for matching are
customizable by the payor.
Duplicate claim lines are those claim lines that match previously submitted claim lines.
Global Surgical Package – Identifies Evaluation & Management (E&M) codes and
supplies billed within the global period.
Procedure codes have a time frame associated with them which includes services and
supplies associated with the procedure. The time frames are set by both CMS and
broadly accepted industry sources.
Procedure Code Not Covered, or Not Generally Covered – Identifies procedure
codes that are not typically covered. The procedure codes that are not covered may be
based on CMS regulations, industry standards, or may be specific to Kaiser Permanente
guidelines and/or policy.
CMS guidelines or industry accepted standards establish that certain procedures are not
covered.
Modifier Validation – Identifies situations where a modifier 26, denoting professional
component, should have been reported for the procedure performed at the noted place
of service.
According to CMS or industry accepted standards, the professional component modifier
should have been reported for services rendered in this place of service.
New Patient Code for Established Patient – Identifies new patient visits that are billed
for established patients.
The AMA has established that a provider practice can only bill a patient code as new
once every three years.
Procedure Maximum Frequency Per Day – Identifies a service that is billed with a
frequency exceeding a given norm in a 24hr period.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Procedure codes have maximum quantities allowed within a 24 hr period. These
quantities have been derived by broadly accepted industry sources.
Consult (Inpatient Initial) Maximum Frequency – Identifies situations where more
than one Initial Inpatient Consult is being paid per hospital admission. This rule
identifies claims with Initial Inpatient Consultations that are not truly initial.
The AMA has established that only one initial consultation should be reported per
inpatient admission.
Consult (Confirmatory) Maximum Frequency – Identifies Confirmatory Consultations
that should have been billed at the appropriate level of office visit, established patient, or
subsequent hospital care.
The AMA has established that only one initial consultation should be reported per patient
per episode of care.
Consult (Outpatient) Maximum Frequency – Identifies inappropriate billing of
Outpatient Consultation codes. Outpatient Consultations should be performed only upon
provider request and follow-up visits in the consultant’s office that are initiated by the
physician consultant should be reported using office visit codes for established patients.
The AMA has established that follow-up visits in the consultant’s office or other
outpatient facility that are initiated by the physician consultant are to be reported using
office visit codes for established patients.
Consults by PCP – Identifies consultation codes that are billed by the member’s
primary care physician (PCP).
Primary Care Providers cannot bill for consultations performed on his/her own primary
care patients.
Deny Base Code with quantity greater than (1) one – This rule identifies situations
where the provider is billing a base code with quantity, rather than the appropriate add
on code(s).
According to AMA, add-on procedures are to be listed in addition to the primary (base
code) procedure). Primary (base code) procedures are typically billed with a quantity of
one. When a provider is billing a primary (base code) procedure with quantity of (1) one,
those additional services beyond the primary (base code) procedure should be billed as
add-on codes.
Consult (Inpatient Initial) Maximum Frequency – Identifies situations where more
than (1) one Initial Inpatient Consult is being paid per hospital admission. This rule
identifies claims with Initial Consultations that are not truly initial.
The AMA has established that only (1) one initial consultation should be reported per
inpatient admission.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Consult (Confirmatory) Maximum Frequency – Identified Confirmatory Consultations
that should have been billed at the appropriate level of office visit, established patient, or
subsequent hospital care.
The AMA has established that only (1) one initial consultation should be reported per
patient per episode of care.
Consult (Outpatient) Maximum Frequency – Identifies inappropriate billing of
outpatient consultation codes. Outpatient consultations should be performed only upon
Provider request. Follow-up visits in the consultant’s office that are initiated by the
physician consultant’s office should be reported using office visit codes for established
patients.
The AMA has established that follow-up visits in the consultant’s office or other
outpatient facility that are initiated by the physician consultant are to be reported using
office visit codes for established patients.
Date of service not billed on Sunday/Federal Holiday – Identifies procedure codes
that are only allowed to be billed on holidays or Sundays, but have been billed on other
days of the week.
The AMA has designated CPT code 99054 to be reimbursed on holidays and Sundays.
Inappropriate Diagnosis for Gender – Identifies diagnosis codes that are inconsistent
with the member’s gender.
Certain procedure and diagnosis codes are exclusive to either the male or female
gender.
Procedure Not Covered with Diagnosis – Identifies procedure codes that are not
typically covered unless billed with specific ICD-9 codes. The procedure codes that are
not covered may be based on CMS regulations, industry standard, and/or Kaiser
Permanente policy.
CMS guidelines or industry accepted standards establish that coverage for certain
procedures is dependent on an appropriate diagnosis.
Inappropriate CPT to Modifier Combination – This rule denies inappropriate CPT to
Modifier combinations.
Certain procedure codes and modifier combinations are not appropriate.
8.6
Reimbursement Policy for Comprehensive and Component Codes
When (2) two or more related procedures are performed on a patient during a single
session or visit, there are instances when a claim is submitted with multiple codes
instead of one comprehensive code that fully describes the entire service. Kaiser
Permanente will reimburse for the comprehensive procedure code.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
The specific procedure code relationships in this Reimbursement Policy are modeled
after The Correct Coding Initiative (CCI) administered through the Centers for Medicare
and Medicaid Services (CMS), AMA Current Procedural Terminology (CPT) and other
general industry-accepted guidelines.
8.7
Evaluation and Management on Same Day as Surgery
When a Kaiser Permanente Participating Provider performs an established evaluation
and management (E&M) or inpatient/outpatient consult procedure on the same day a
surgical procedure is performed, the E&M procedure is included in the fee for the
surgical procedure. The fee for certain supplies associated with the procedure is also
included in the reimbursement for the surgical procedure. In some cases, an
appropriate modifier will override this adjustment.
8.8
Global Surgical Package (GSP)
A global period for surgical procedures is a long-established concept under which a
“single fee” is billed and paid for all services rendered by a surgeon before, during, and
after the procedure. According to CMS, the services included in the global surgical
package may be furnished in any setting. (i.e. hospital, ambulatory surgery center,
physician’s office)
Kaiser Permanente’s GSP policy follows CMS guidelines with respect to the timeframes
assigned to each global surgical procedure. All procedures with an entry of 10 or 90
days in the Medicare Fee Schedule Database (MFSDB) are subject to Kaiser
Permanente’s GSP Policy.
Under the GSP Policy, the fee for any evaluation and management procedure performed
within the follow-up period is included in the reimbursement for the surgical procedure.
The fee for the certain supplies associated with the procedure is also included in the
reimbursement for the global surgical procedure if used within the follow-up period. If a
Kaiser Permanente Participating Provider bills for such services and supplies separately,
Kaiser Permanente will indicate on the claim that reimbursement for such services is
included in the payment of the global surgical code.
8.9
Do No Bill Event Policy (DNBE)
Kaiser Permanente adheres to guidelines and policies established by the Centers for
Medicare and Medicaid Services (CMS).
The Health Plan’s “Do Not Bill Event” policy is based on payment rules that waive fees
for all or part of health care services directly related to the occurrence of certain adverse
events as defined by the CMS National Coverage Determinations for surgical errors and
the published listing of CMS Hospital Acquired Conditions. The “Do Not Bill Event”
policy will apply to all claims for Health Plan Members enrolled in the Kaiser Permanente
Medicare Plus™ plan as well as those claims for Members enrolled in Commercial
Health Plan products such as the Kaiser Permanente Signature™ and Select™ plans.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Surgical “Do Not Bill Events” include an event in any care setting related to:
 Wrong surgical or invasive procedure(s) performed on a patient;
 Surgical or other invasive procedure(s) performed on the wrong part of the body;
 Surgical or other invasive procedure(s) performed on the wrong patient; and
 Unintended retention of a foreign object after surgery or procedure.
Hospital Acquired Conditions include a condition or event that occurs in a general
hospital or acute care setting such as:
 Intravascular air embolism that occurs while being cared for in a health care facility;
 Hemolytic reaction due to the administration of ABO/HLA-incompatible blood or
blood products;
 Stage 3 or 4 pressure ulcers acquired after admission to a health care facility;
 Falls and Trauma (fractures, dislocations, intracranial injuries, crushing injuries,
burns, electric shock);
 Manifestations of poor glycemic control: diabetic ketoacidosis, nonketotic
hypersmolar coma, hyperglycemic coma, secondary diabetes with ketoacidosis,
secondary diabetes with hypersomality;
 Surgical site infections following certain elective procedures;
 Deep vein thrombosis;
 Vascular-catheter associated infection;
 Catheter associated urinary tract infection; and
 Mediastinitis after coronary artery bypass grafting.
Notification of Adverse Event to Kaiser Permanente
Participating Providers should notify the Health Plan when an adverse “Do Not Bill
Event” or condition impacting a Member is discovered by contacting the Utilization
Management Operations Center (UMOC) at 1-800-810-4766 or Provider Relations at 1877-806-7470.
Claims Submission and Adjustments Related to a “Do Not Bill Event”
Participating Hospital/Facility must include “Present on Admission” indicators on all
Member claims. Participating Providers should ensure that their billing staff are aware
when a “Do Not Bill Event” involving a Member’s care has occurred prior to submitting
the claim to Kaiser Permanente for processing.
When a “Do Not Bill Event” is recognized prior to claim submission, the UB-04 or CMS1500 form should include:
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The applicable International Classification of Diseases (ICD) codes
All applicable standard modifiers (including CMS National Coverage
Determination (“NCD”) modifiers for surgical errors)
Additionally, the UB-04 or CMS 1500 form should reflect all service provided including
those related to a “Do Not Bill Event” with an adjustment in fee to reflect the waiver of
fees directly related to the event(s).
Any Member Cost Share related to a “Do Not Bill Event” should be waived or reimbursed
to the Member. An impacted Member may not be balanced billed for any services
related to a “Do Not Bill Event”.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
DNBE Policy Exception for Maryland Hospitals
Participating Maryland Hospitals are required to adopt the Health Services Cost Review
Commission (HSCRC) Payment Policy for Preventable Hospital Acquired Conditions.
8.10
Billing Procedures for Medicare Members
Members who are Medicare beneficiaries and are enrolled with Kaiser Permanente will
be covered by Medicare Plus (a Medicare cost product). To determine coverage, you
can either check the member identification card or you can call  1 (800) 777-7902 for
verification.
For members covered under the Medicare Cost program, you must first bill CMS for
Medicare covered services provided. After CMS has reviewed the bill, send the
Medicare Summary Notice (MSN), formerly known as Explanation of Medicare Benefits
(EOMB) and a copy of the original bill to Kaiser Permanente to the Claims address
stated on the first page of this section.
*Note: It is important that we receive an exact copy of the CMS 1500 form submitted to
the Centers for Medicaid and Medicare Services (CMS).
For dates of service prior to January 1, 2003 if a member was covered under the
Medicare+ Choice/ Senior Advantage program, please follow the procedures for Fee-For
Service billing. Claims with dates of service October 1st through December 31st 2002,
may be billed under the Senior Advantage program until December 31st 2004.
8.11
Provider Payment Dispute Process
Providers who disagree with a decision not to pay a claim in full or in part may file a
payment dispute request. Payment disputes must be filed within one hundred eight
(180) days of the date of the denial and/or Explanation of Payment. The dispute process
applies only to clean claims as outlined in Section 8.2 – Clean Claims.
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A summary of the dispute
Claim number(s) at issue
Specific payment and/or adjustment information
Necessary supporting documentation to review the request
(i.e. pertinent medical records, proof of timely filing, other insurance carrier
explanation of payment, and/or Medicare Summary Notice (MSN)).
All payment dispute requests must be received in writing and sent to:
Kaiser Permanente
Attention: Provider Relations – Provider Dispute Resolution Unit
2101 East Jefferson Street
Rockville, Maryland 20852
Timely Filing Requirements and Appeal of Timely Filing
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
All claims must be received within the timeframes included in Section 8.1.
Resubmitted claims along with proof of initial timely filing received within six (6) months
of the original date of denial or explanation of payment, will be allowed for
reconsideration of claim processing and payment. Any claim resubmissions received
for timely filing reconsideration beyond six (6) months of the original date of denial or
explanation of payment will be denied as untimely submitted.
Proof of Timely Filing
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 outlined in Section 8.1. Acceptable proof of timely filing may include the
following documentation and/or situations:
Proof or Documentation
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.
EDI Transmission report
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.
8.12
Examples
 Account ledger posting that
includes multiple patient
submissions
 Individual Patient ledger
 CMS UB04 or 1500 with a system
generated date or submission.
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Reports from a Provider
Clearinghouse (i.e. WebMD)
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 Overpayment
In the case of an overpayment of a claim, Kaiser Permanente will provide the
Participating Provider with a written notice of explanation. The Participating Provider
should send the appropriate refund to Kaiser Permanente within thirty (30) days of
receiving the overpayment notice, or when the Participating Provider confirms that
he/she is not entitled to the payment, whichever is earlier.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
If for some reason the Participating Provider’s refund is not received within thirty (30)
days of receiving the overpayment notice, Kaiser Permanente may deduct the refund
amount from future payments.
8.13
Coordination of Benefits
There are many instances in which a member’s episode of care may be covered by
more than one insurance carrier. Kaiser Permanente Participating 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) submission.
For assistance in determining the primary payor, review the guidelines listed below or
call your Provider Relations Department for assistance at  1 (877) 806-7470.
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.
3. When determining the primary payor for a child of separated or divorced parents,
inquire about the court agreement or decree. If this does not apply, call the Provider
Relations staff at  1 (877) 806-7470 for assistance.
4. Kaiser Permanente is generally primary for working Medicare-eligible members when
the CMS Working Aged regulation applies.
5. 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.
6. In cases of work-related injuries, Workers Compensation is primary unless coverage
for the injury has been denied.
7. 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, KPMAS will require an EOB.
When KPMAS has been determined as the secondary payor, KPMAS pays the
difference between the payment by the primary payor and the amount which would be
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
have been paid if KPMAS was primary, less any amount for which the member has
financial responsibility.
8.14
Primary Care Capitation Payment
Kaiser Permanente has established a process for the submission of bills for services
covered by monthly capitation, and utilization information for all patient encounters.
Capitation payments will be made on a monthly basis, on or about the 15th calendar day
of each month. Monthly payments are retrospective and will cover the previous month.
The payment will be based on the age and sex of the members identified on the panel of
each physician in a group practice. This amount will be adjusted for additional payments
for open panel and extended hours provisions.
Each group practice will receive a Capitation Roster Report with their capitation
payment. This report is a retrospective report listing members by name and
identification number. This report will also show by member any payment adjustments
made for retroactive membership (retroactive adjustments are limited to 90 days).
If you have any issues or questions concerning the capitation payments, or the report
accompanying the capitation payment, you may contact the Provider Relations
Department by calling  1 (877) 806-7470.
8.15
Billing for Capitated Specialty Care Providers
Specialty Care Participating Providers with a capitated contract will not need to bill for
services. However, Kaiser Permanente still requires the monthly submission of
encounter data and utilization information. This is used to determine the volume and the
types of services your office provides, and will be used to determine future contract
rates.
Follow the steps below to submit monthly utilization information:
1. Participating Providers will submit a CMS 1500 form, or other format indicated by
contract agreement.
2. All utilization information submitted must include:
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Patient Name
Patient Identification Number/Medical Record Number
Provider’s Name
Tax Identification Number
Date of the Bill
Date(s) of Service
Current CPT-4 Codes
ICD 9 – CM Diagnosis Code
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
 Billed Charges
 Authorization Number
 Narrative description of charges if billing an unlisted code.
Submit all utilization information to:
Kaiser Permanente
Attn: DM/Data Management
2101 East Jefferson Street
P. O. Box 6916
Rockville, Maryland 20849-6916
8.16
Capitation Reports
The following reports are forwarded to Participating PCPs with their capitation checks. If
you have any questions regarding your capitation check or these reports, please feel
free to contact the Provider Relations Department at  1 (877) 806-7470.
Eligibility List for Monthly Capitation Report
This report identifies capitation payments for each member enrolled or “eligible” during
the specified time period. It also contains the member number, name, age, gender, and
allocation amounts. All allocations are distributed to primary care, laboratory, facility, or
specialty service categories. These categories are used for reporting purposes and
demonstrate the type of services covered under the capitation payment agreement.
Eligibility Adjustment List for Monthly Capitation Report
This report identifies retroactive capitation payments for each enrolled or “eligible”
member. In addition to displaying the member number, name, age, gender, and
allocation amounts, the report also indicates the reason for the change in membership
with a code, the explanation of which appears at the end of the report. All allocations
are distributed to primary care, laboratory, facility, or specialty service categories. These
categories are used for reporting purposes and demonstrate the type of services
covered under the capitation payment agreement.
Provider Member- Months by Actuarial Class Report
This report summarizes capitation payments by specific age/gender categories. These
categories are established by the health plan and are used to generate each provider’s
capitation payment. This report also contains the number of member-months and
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
number of individual members accounted for in the report, as well as the allocation
amounts. All allocations are distributed to primary care, laboratory, facility, or specialty
service categories. These categories are used for reporting purposes and demonstrate
the type of services covered under the capitation payment agreement.
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012
Claims Administration - Provider Fax Transmission Form.
**** Faxes should be transmitted in fine mode to fax #301-388-1640
**** Please complete the form by typing in the information
MRN#________________________ Member NAME _________________
TIN#__________________________ Provider Name ________________
Claim was recently submitted electronically?
YES ____ NO ____
If yes, please indicate the date of submission: ____________________
Indicate associated control # if applicable ________________________
Document Type
MED REC/ALL OTHER
MED REC OP/ER
MED REC/DISCHARGE
SUMMARY
ITEMIZED BILL
MSN/EOMB
REFERRAL/AUTH
GLOBAL COVER SHEET
Submitters Name: __________________________ Date: ____________
Submitters Phone Number______________________
Comments: _________________________________________________
Publication Date: 12/20/2007
Last Review and Revised Date: September 2012