1. All patient services must be billed on a fully completed CMS 1500 or UB04 form, unless otherwise indicated by contract.

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1 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 KPMAS also has the ability to receive your claims electronically through the Emdeon Clearinghouse. The Kaiser Permanente Mid-Atlantic States payor ID is: 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 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) Should you require technical assistance with Electronic Data Interface (EDI), contact EDI Technical Support at (301) 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) , 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) 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)

2 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 1 st and September 30 th, the claim/bill must be submitted by December 31 st of the following year. For services rendered between October 1 st and December 31 st, the claim/bill must be submitted by December 31 st 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

3 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 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.

4 Coding Standards Coding All fields should be completed using industry standard coding as outlined below. Code Set Standard CPT- 4 (Current Procedure Terminology) CDT- 1 (The Code on Dental Procedures and Nomenclature) ICD-9 CM (International Classification of Diseases, Clinical Modification) HCPCS and Modifiers (CMS Common Procedure Coding System) Maintained and distributed by the American Medical Association, including its codes and modifiers, and codes for anesthesia services Maintained and distributed by the American Dental Association Maintained and distributed by the U.S. Department of Health and Human Services Maintained and distributed by the U.S. Department of Health and Human Services NDC (National Drug Codes) ASA (American Society of Anesthesiologists) DSM-IV (American Psychiatric Services) Revenue Code Prescribed drugs, maintained and distributed by the U.S. Department of Health and Human Services Anesthesia services, the codes maintained and distributed by the American Society of Anesthesiologists 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

5 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 A REFERRAL WHEN SHOULD IT BE USED? 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 For members with other primary coverage when you have received reimbursement or denial from a member s primary carrier. MEDICARE REMITTANCE NOTICE (EOMB) For member s with Medicare primary coverage when you have received reimbursement or denial from Medicare MEDICAL RECORD AND DESCRIPTION OF PROCEDURES OPERATIVE NOTES When the service rendered has no corresponding Current Procedural Terminology (CPT) or HCPCS code 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

6 PHYSICIAN NOTES For professional services when the services provided are outside the time and scope of the authorization obtained from KPMAS ADMITTING NOTES ITEMIZED BILLS For inpatient services when the services provided are outside the time and scope of the authorization obtained from KPMAS 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

7 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 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) Field Location Field 33 Field Applicable to specific circumstances Essential Data Elements Required The health care practitioner s or person entitled to reimbursement s billing name, address, zip code, and phone number Any other field or essential data element necessary to comply with the Applicable Standard Code Set 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

8 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 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 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 Field 63 Field 67 Field 76 Field 82 Field 83 Field 85 Field 86 Field Applicable to specific circumstances Essential Data Elements Required 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

9 UB-04 (third party payor) Field Location Field 7 Field 8 Field 9 Field 10 Field 21 Field Field Field 36 Field 44 Field 44 Field 54 Field 64 Field 65 Field 66 Fields Fields Field 79 Field 80 Field 81 Field 84 Essential Data Elements Required for Specific Circumstances Covered days is applicable if Medicare is primary or secondary payor 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 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 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 Other procedure codes are applicable as an extension of subsection (17) of this section if additional surgical procedures were performed 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.

10 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 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 Reason EOP Reason Reason Description Code EX Code Type X0002 TB NC Deny, outpatient consult billed w/dos <6mos X0003 TC NC Deny, confirmatory consult billed w/dos <6mos X0004 TD NC Deny, initial consult billed>max time period X0005 TE NC Deny, Consult billed by PCP X0006 TF NC Deny, new patient code billed within past 3 years X0007 TG NC Deny, E&M billed within procedure follow-up period not payable X0008 TH NC Deny, supplies billed same day as surgery X0009 TI NC Deny, procedure identified as unbundled X0010 TJ NC Deny, anesthesia code billed by a nonanesthesiologist X0011 TK NC Deny, not billed on Sunday/Federal holiday or after hours X0012 TL NC Deny, procedure code not consistent with gender X0013 TM NC Deny, procedure code not generally covered

11 X0014 TN NC Deny, unlisted CPT code X0015 TO NC Deny, duplicate claim /service X0016 TP NC Deny, modifier required X0017 TQ NC Deny, procedure billed does not require service of assistant surgeon X0019 TS NC Deny, deleted or expired HCPCS or CPT code X0020 TT NC Deny, add-on billed w/o primary procedure X0021 TU NC Deny, bilateral billed inappropriately X0022 TV NC Deny, incorrect bilateral modifier X0023 TW NC Deny, base code billed with Quantity>1 X0024 TX NC Deny, diagnosis not consistent with gender X0025 TY NC 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. 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.

12 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. 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.

13 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. 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 to be reimbursed on holidays and Sundays.

14 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. 8.5 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. 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. 8.6 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. 8.7 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)

15 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. 8.8 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) 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 1 st through December 31 st 2002, may be billed under the Senior Advantage program until December 31 st 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. 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)).

16 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 Timely Filing Requirements and Appeal of Timely Filing 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 Examples System generated claim copies, account print-outs, or reports that indicate the original date that claim was submitted, and Account ledger posting that includes multiple patient submissions to which insurance carrier. Individual Patient ledger CMS UB04 or 1500 with a system *Hand-written or typed documentation is generated date or submission. not acceptable proof of timely filing. 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. Copies of dated letters requesting information, or requesting correct information from the member. *Members are responsible for providing current and appropriate insurance information each time services are rendered by a provider. 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.

17 8.10 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. 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 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) 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) 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.

18 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 have been paid if KPMAS was primary, less any amount for which the member has financial responsibility 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) 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.

19 2. All utilization information submitted must include: 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 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 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) 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

20 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 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.

21 Claims Administration - Provider Fax Transmission Form. **** Faxes should be transmitted in fine mode to fax # **** 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: