Provider Manual. Section 5: Billing and Payment

Transcription

1 Provider Manual

2 TABLE OF CONTENTS SECTION 5 SECTION 5: BILLING AND PAYMENT... 1 INTRODUCTION... 6 CLAIMS SUBMISSION GUIDE HIGHLIGHTS... 7 WHO TO CALL WITH QUESTIONS... 7 NATIONAL PROVIDER IDENTIFIER (NPI)... 8 ELECTRONIC CLAIMS... 8 PAPER CLAIMS... 8 WHERE TO MAIL CLAIMS... 9 HIPAA REQUIREMENTS... 9 PAPER CLAIM TIPS... 9 FEDERAL TAX ID NUMBER SUPPORTING DOCUMENTATION REFERRALS/ AUTHORIZATIONS CLAIM CORRECTIONS CLAIM SUBMISSION TIMEFRAMES CLAIMS PROCESSING TURN-AROUND TIME INCORRECT CLAIM PAYMENTS PROVIDER APPEALS PROVIDER PAYMENT DISPUTES MEMBER HOLD HARMLESS COORDINATION OF BENEFITS (COB) VISITING MEMBER ELECTRONIC DATA INTERCHANGE (EDI) BENEFITS OF EDI CLAIMS SUBMISSION Revised April

3 EDI ROLES UNDERSTANDING ELECTRONIC SUBMISSION PROCESS TO INITIATE ELECTRONIC CLAIM SUBMISSIONS TO INITIATE ELECTRONIC PAYMENT/ REMITTANCE ADVICE TO INITIATE ELECTRONIC FUNDS TRANSFER HIPAA REQUIREMENTS KP REQUIREMENTS KP REQUIREMENTS, CON T SUPPORTING DOCUMENTATION EDI CLAIM ERRORS CORRECTION & RESUBMISSION FOR ACCEPTED EDI CLAIMS CODING & BILLING VALIDATION INTRODUCTION CODING RULE DESCRIPTIONS DO NOT BILL EVENTS (DNBE) CLAIMS COMPLETION REQUIREMENT CMS-1500 CLAIM FORM WHERE TO MAIL CLAIMS NATIONAL PROVIDER IDENTIFIER (NPI) HIPAA REQUIREMENTS CLAIM SUBMISSION TIMEFRAMES BILL FULL CHARGES COORDINATION OF BENEFITS (COB) NO FAULT/WORKERS COMPENSATION/OTHER ACCIDENT RECORD THE AUTHORIZATION NUMBER RECORD THE NAME OF THE PROVIDER YOU ARE COVERING FOR SUBMISSION OF MULTIPLE PAGE CLAIM CLAIM CORRECTIONS ENTERING DATES MULTIPLE DATES OF SERVICE AND PLACE OF SERVICE SUPPORTING DOCUMENTATION Revised April

4 CMS-1500 (08/05) FIELD DESCRIPTIONS CLAIMS COMPLETION REQUIREMENTS UB-04 CLAIM FORM WHERE TO MAIL CLAIMS UB-04 CLAIM FORM NATIONAL PROVIDER IDENTIFIER (NPI) HIPAA REQUIREMENTS CLAIM SUBMISSION TIMEFRAMES BILL FULL CHARGES COORDINATION OF BENEFITS (COB) NO FAULT/WORKERS COMPENSATION/OTHER ACCIDENT RECORD THE AUTHORIZATION NUMBER SUBMISSION OF MULTIPLE PAGE CLAIM SURGICAL AND/OR OBSTETRICAL PROCEDURES ENTERING DATES MULTIPLE DATES OF SERVICE AND PLACE OF SERVICE BILLING INPATIENT CLAIMS THAT SPAN DIFFERENT YEARS INTERIM INPATIENT BILLS CLAIM CORRECTIONS SUPPORTING DOCUMENTATION UB-04 FIELD DESCRIPTIONS ANESTHESIA GLOBAL ANESTHESIA PACKAGE OFFICE-BASED SURGICAL PROCEDURES ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT EXCEPTIONS TO BILLING ANESTHESIA CODES ANESTHESIA MODIFIERS ADDITIONAL SERVICES ABORTION SERVICES BEHAVIORAL HEALTH SERVICES Revised April

5 DURABLE MEDICAL EQUIPMENT (DME) EVALUATION/ MANAGEMENT (E/M) SERVICES EMERGENCY ROOM (ER) SERVICES NEWBORN SERVICES OUTPATIENT REHABILITATION COORDINATION OF BENEFITS (COB) DESCRIPTIONS OF COB PAYMENT METHODOLOGIES COB QUESTIONS HIPAA REQUIREMENTS EOB OR MSN STATEMENT MEMBERS ENROLLED IN TWO KAISER PERMANENTE PLANS IMPORTANT COB POINTS TO REMEMBER COB FIELDS ON THE CMS-1500 CLAIM FORM COB FIELDS ON THE UB-04 CLAIM FORM EXPLANATION OF PAYMENT (EOP) GLOSSARY INDEX Revised April

6 INTRODUCTION NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. Kaiser Foundation Health Plan of Ohio (Kaiser Permanente) has developed this Claims Submission Guide for use by all participating health care Practitioners/Providers and their staffs to: 1) Educate Practitioners/Providers about Kaiser Permanente s claims submission requirements. 2) Reduce the number of claim rejections and/or claim re-submissions because of initial claim errors. 3) Facilitate timely payment of claims. 4) Simplify and clarify increasingly complex coding/billing requirements. Great efforts have been undertaken to make this GUIDE as "user-friendly" as possible. We encourage all Practitioners/Providers and their staffs to become familiar with the requirements outlined in this GUIDE which either conform to or are permitted by applicable federal, state and local regulations. We welcome your input as to how we can make this GUIDE more useful and informative. Please forward any comments/suggestions for documentation improvements to: KAISER PERMANENTE Network Development & Performance Department 1001 Lakeside Avenue, Suite 1200 Cleveland, OH This GUIDE will be updated regularly as programs, policies, and procedures change. Updates will be distributed to all Practitioners/Providers as they occur. When you receive updates, be sure to replace the existing pages in the manual immediately to assure that the information available is current. We value your participation in Kaiser Permanente s programs, and we appreciate your continued support. Revised April

7 CLAIMS SUBMISSION GUIDE HIGHLIGHTS NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. WHO TO CALL WITH QUESTIONS If you have any questions relating to the submission of claims to Kaiser Permanente for processing, please refer to the table below for the correct department/number to call: PLEASE CALL: IF YOU HAVE QUESTIONS ABOUT: TELEPHONE NUMBER(S): NETWORK DEVELOPMENT Option #1: Benefits/Co-Pay Information Member Eligibility Option #2: Admitting a Member to a Hospital Option #3: Medical Policy Questions Referral Policy Referral Questions Option #4: Capitation Questions Claim Payment Inquiries * Claim Status * Claim Submission Contract Questions Credentialing EDI Explanation of Payment (EOP) Fee Schedule Participation Request Participation Status Practice Demographic Updates Provider Appeals Training Withholds * Please allow 20 business days from the date the paper claim was mailed before calling our Network Development Department. NOTE: You may be asked to mail or fax a list of the claims in question if the number of claims you are questioning/researching is large. Local Telephone #: (216) *Select Option 1,2,3 or 4 as appropriate Toll-Free Telephone #: *Select Option 1,2,3 or 4 as appropriate Fax #: Address: Kaiser Permanente Network Development & Performance Department 1001 Lakeside Avenue, Suite 1200 Cleveland, OH Revised April

8 TOPIC NATIONAL PROVIDER IDENTIFIER (NPI) EXPLANATION / INSTRUCTIONS The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that all providers use a standard unique identifier on all standard electronic transactions. Your National Provider Identifier (NPI) must be used on all HIPAAstandard electronic transactions by May 23, ELECTRONIC CLAIMS --Supporting Documentation --Corrections Currently, Kaiser Permanente exchanges the following electronic transactions: Receives: 837P - Professional Healthcare claim 837I - Institutional Healthcare claim Healthcare eligibility benefit inquiry Healthcare claim status inquiry Sends: Functional Acknowledgement Healthcare claim payment/remittance advice Healthcare eligibility benefit response Healthcare claims status response 277U - Unsolicited healthcare claim status response NOTE: Claims submitted electronically must adhere to all Health Insurance Portability and Accountability Act (HIPAA) requirements. Refer to the Electronic Data Interchange (EDI) section (pages 18-21) in this GUIDE for further information/instructions pertaining to the submission of electronic claims, as well as for information regarding the following topics: Submitting supporting documentation with electronic claims (see page 21) Submitting corrections to previously-submitted electronic claims (see page 21) PAPER CLAIMS -- CMS UB-04 NOTE: Kaiser Permanente encourages the electronic submission of all claims. Claims not submitted electronically MUST be submitted on one of the following standard claim forms: CMS-1500 (08/05) Required for all professional services and suppliers. Effective October 2006, the Centers for Medicare & Medicaid Services (CMS) has revised the Form CMS The new (08/05) version will accommodate the reporting of the National Provider Identifier (NPI). Kaiser will begin accepting the new CMS-1500 on April 1, Refer to the Claims Completion Requirements sections pages for further information and instructions pertaining to the submission of CMS-1500 (08/05) paper claims: UB-04 Required for all facilities (i.e., hospitals) services. Any professional services (for example, services rendered by radiologists, ER physicians, etc.) should be billed on CMS-1500 claim forms, unless you are contracted under a GLOBAL rate, in which case professional services should not be billed separately.. Revised April

9 TOPIC PAPER CLAIMS, con t. EXPLANATION / INSTRUCTIONS The National Uniform Billing Committee (NUBC) has approved the new UB-04 (CMS- 1450) as the replacement for the UB-92. Kaiser will begin accepting the new UB-04 on March 1, Refer to the Claims Completion Requirements sections pages for further information and instructions pertaining to the submission of UB-04 paper claims: IMPORTANT: Please use standard claim forms formatted with RED ink to ensure maximum compatibility with Kaiser Permanente s optical scanning equipment. Claim forms formatted with black or blue lines will not scan as efficiently as those formatted with RED. WHERE TO MAIL CLAIMS HIPAA REQUIREMENTS PAPER CLAIM TIPS All paper claims (and any necessary supporting documentation) should be mailed to the following address: Kaiser Permanente P.O. Box 5316 Cleveland, OH All electronic claim submissions must adhere to all HIPAA requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Practitioner/Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at (301) Avoid Highlighter Usage/ Use Blue or Black Ink Do not use a highlighter on any claims or any attachments to a claim (for example, a referral form, EOB statement, etc.). When a claim form or a referral form is scanned, highlighter shading turns black and blocks key data under the highlighter. You may use blue or black ink. Align Your Office Printer Correctly Align your office printer with the fields on the claim form. Letters and numbers that fall on the lines of the form will not scan clearly. Verify that the print is clear and dark. If a printer ribbon or cartridge is light, the claim will not scan clearly and claims processing will be delayed. Use Paper Clips for Attachments Do not use staples for attachments. Paper clips are acceptable. Avoid Handwritten Information Poor, light handwriting affects scanning quality and processing accuracy. Please submit typed claims. Do Not Use Super Bills or Encounter Forms as Claim Forms Office super bill or encounter forms are NOT acceptable as claim forms. These forms delay processing because important claims information is not in the standard format. Send Originals Whenever Possible Do not submit the second or third page of a multi-part claim form. The print is often light, smeared, or unreadable. Avoid the use of photocopies and fax copies as well. Revised April

10 TOPIC EXPLANATION / INSTRUCTIONS PAPER CLAIM TIPS con t. One Member per Claim Form/One Provider per Claim Do not bill for different Members on the same claim form. Do not bill for different Practitioners/Providers on the same claim form. Complete a separate claim form for each Member and for each Practitioner/Provider. Record Each Procedure on a Separate Line Only one procedure should be reported on a claim line number. Do not enter two reimbursable procedures under one claim line. Do Not Record Any Extraneous or Extra Information on Claim Forms Do not list the narrative descriptions of ICD-9-CM codes, CPT codes, etc. on the CMS-1500 (HCFA-1500) claim form. Example: Office or Other Outpatient Visit Record only the code itself (99213) on the claim form, without the accompanying narrative description (Office or Other Outpatient Visit). Do not list any explanations or notes on claim forms, unless you are specifically instructed to do so. Exceptions: Unclassified drugs: Specify the name of the drug and the NDC#. Durable Medical Equipment (DME) special supplies: Specify the durable medical equipment/supply used. FEDERAL TAX ID NUMBER The Federal Tax ID Number as reported on any and all claim forms must match the information filed with the Internal Revenue Service (IRS). (See IRS ALERT Bulletin on page 83 for additional explanatory information.) IMPORTANT: Failure to report the correct Federal Tax ID Number -- as filed with the IRS at the time of incorporation or start of the business -- could result in a 28% backup withholding tax (payable to the IRS) and/or the suspension of any and all payments made to the Practitioner/Provider by Kaiser Permanente, until this matter is resolved. IRS Form W-9: Request for Taxpayer Identification Number and Certification (see sample form on pages 84-87) When completing IRS Form W-9, please note the following: 1) Name This should be the equivalent of your entity name, which you use to file your tax forms with the IRS. Sole Practitioner/Proprietor: List your name, as registered with the IRS. Group Practice/Facility: List your group or facility name, as registered with the IRS. 2) Business Name Leave this field blank, unless you have registered with the IRS as a Doing Business As (DBA) entity. If you are doing business under a different name, enter that name here. 3) Address/City, State, Zip Code Enter the address where Kaiser Permanente should mail your IRS Form Revised April

11 TOPIC FEDERAL TAX ID NUMBER con t. EXPLANATION / INSTRUCTIONS 4) Taxpayer Identification Number (TIN) The number reported in this field (either the social security number or the employer identification number) MUST be used on all claims submitted to Kaiser Permanente. Sole Practitioner/Proprietor: Enter your taxpayer identification number, which will usually be your social security number (SSN), unless you have been assigned a unique employer identification number (because you are doing business as an entity under a different name). Group Practice/Facility: Enter your taxpayer identification number, which will usually be your unique employer identification number (EIN). If you have any questions regarding the proper completion of IRS Form W-9, or the correct reporting of your Federal Taxpayer ID Number on your claim forms, please contact the IRS help line in your area or refer to the following website: irs.gov/formspubs/ Completed IRS Form W-9 should be mailed to the following address: Kaiser Permanente Network Development & Performance Department 1001 Lakeside Avenue, Suite 1200 Cleveland, OH IMPORTANT: If your Federal Tax ID Number should change, please notify our Network Development Department immediately, so that appropriate corrections can be made to Kaiser Permanente s files. SUPPORTING DOCUMENTATION REFERRALS/ AUTHORIZATIONS To expedite claims processing and adjudication, a Practitioner/Provider should submit supporting written documentation (for example, copies of pertinent medical records) with certain types of claims. See the Supporting Documentation Table on page 90 for a list of the claims which usually require supporting documentation. Supporting Documentation Submitted WITH a Claim: When supporting documentation is submitted WITH the corresponding paper claim form, attach/secure the documentation to the paper claim with a paper clip (do not staple) and mail to Kaiser Permanente s mailing address (see page 9 in this section). Supporting Documentation Submitted SEPARATELY From a Claim: When sending supporting documentation SEPARATELY from the claim (for example, when sending in requested medical information for a pended claim) 1) Complete a Supporting Documentation Cover Sheet (see sample and instructions on page 89) for each Member for whom you are submitting paper documentation. 2) Attach the cover sheet to each Member s paper documentation with a paper clip. 3) Mail the supporting documentation as per the instructions on the form. Refer to your Kaiser Permanente Practitioner/Provider Manual (see Section 4) for detailed referral/authorizations and instructions, or call our Network Development Department (Option #3). Revised April

12 TOPIC CLAIM CORRECTIONS EXPLANATION / INSTRUCTIONS CMS-1500 Claim Forms: NOTE: Kaiser Permanente prefers corrections to 837P claims which were already accepted by Kaiser Permanente to be submitted on paper claim forms. Corrections submitted electronically may inadvertently be denied as a duplicate claim. Refer to page 38 within this GUIDE for further information/instructions. When submitting a corrected CMS-1500 paper claim to Kaiser Permanente for processing: 1) Write CORRECTED CLAIM in the top (blank) portion of the standard claim form. 2) Attach a copy of the corresponding page of Kaiser Permanente s Explanation of Payment (EOP) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip. 3) Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address (see page 9 in this section). UB-04 Claim Forms (837I): NOTE: 837I corrections may be submitted electronically. When submitting a corrected UB-04 claim to Kaiser Permanente for processing: Electronic Include the appropriate Type of Bill code when electronically submitting a corrected UB-04 claim to Kaiser Permanente for processing. IMPORTANT: Claims submitted without the appropriate 3 rd digit (XXX) in the Type of Bill code will be denied. Paper Refer to page 52 for further information/instructions pertaining to paper submission of corrected claims to Kaiser Permanente for processing. CLAIM SUBMISSION TIMEFRAMES Initial Claim Submissions: All claims must be submitted for processing within 12 months (365 days) of the date of service. Any claims submitted after 12 months (365 days) from the date of service must be accompanied by documentation as to why the claims should be considered for payment. Complete a Supporting Documentation Cover Sheet (see sample and instructions on page 89 and attach the documentation with a paper clip. Claims submitted without this documentation will be denied. Payment consideration for claims filed/appealed after filing limit: Examples of documentation deemed valid are: 1. Call into Kaiser Permanente Network Development or Customer Service: Provide the date and time that you contacted Kaiser Permanente inquiring about a claim status or payment rejection. If you followed up with an appropriate KP area, we will have documentation of that call and will be able to accept that in order to determine if the filing limit rejection will be overturned. Follow up calls in relation to a previous payment must occur within 180 days of the last processed date. This would be considered as proof of filing. Revised April

13 TOPIC CLAIMS SUBMISSION TIMEFRAMES-con t. EXPLANATION / INSTRUCTIONS 2. Fax Confirmation: Provide a copy of a fax confirmation sheet showing the fax was successful, detailing that you faxed a claim over for processing or reconsideration. This would be considered as proof of filing. 3. KP EDI Claim Receipt Confirmation: KP assigns all claims received a KP claim number whether they are received via paper or electronically. Upon receipt, EDI claims typically generate a confirmation back to the submitter along with the claim number information. This would be considered as proof of filing. 4. Copy of delivery confirmation from U.S. Postal Service or Commercial Carrier (i.e. UPS, FedEx.): If you have a delivery confirmation from a package submitted to KP as it relates to claims involved in a timely filing dispute, we will consider that receipt as proof of filing. CLAIMS PROCESSING TURN-AROUND TIME Clean Claims: Please allow 30 days for Kaiser Permanente to process and adjudicate your claim(s). Claims requiring additional supporting documentation and/or coordination of benefits may take longer to process. NOTE: While Kaiser Permanente may require the submission of specific supporting documentation necessary for benefit determination (including medical and/or coordination of benefits information), Kaiser Permanente may have to make a decision on the claim before such information is received. A "complete or clean" claim is defined as a claim that has no defect or impropriety, including lack of required substantiating documentation from providers, suppliers, or Members or particular circumstances requiring special treatment that prevents timely payments from being made on the claim. INCORRECT CLAIM PAYMENTS If you receive an incorrect payment (i.e., either an overpayment or an underpayment), please do one of the following: Option 1: Do not cash or deposit the incorrect payment check. Mail the incorrect payment check back to Kaiser Permanente, along with a copy of the Explanation of Payment (EOP) and a brief note explaining the payment error to: Kaiser Permanente Recovery Unit P.O. Box Cleveland, OH Note: If Kaiser Permanente s EOP is not available, please record the Member s Medical Record Number on the payment check you are returning. Kaiser Permanente will re-issue and mail you a new, corrected payment check within 30 days. Option 2: Deposit the incorrect Kaiser Permanente payment check in your account. For an Underpayment Error: Write or call our Network Development Department (Option #4) and explain the error. Upon verification of the error, appropriate corrections will be made to Kaiser Permanente s accounting system and the underpayment amount owed you will be added to/reflected in your next Kaiser Permanente reimbursement check. Revised April

14 TOPIC INCORRECT CLAIM PAYMENTS-con t. PROVIDER APPEALS EXPLANATION / INSTRUCTIONS For an Overpayment Error: You may do either one of the following: Write a refund check to Kaiser Permanente for the excess amount paid to you by Kaiser Permanente. Attach a copy of Kaiser Permanente s Explanation of Payment to your refund check, as well as a brief note explaining the error. Attach with a paper clip. NOTE: If Kaiser Permanente s EOP is not available, please record the Member s Medical Record Number on the payment check you are returning. Mail your refund check (and brief note) to: Kaiser Permanente Recovery Unit P.O. Box Cleveland, OH Write or call our Network Development Department (Option #4) and explain the error. Appropriate corrections will be made to Kaiser Permanente s accounting system and the overpayment amount will be automatically deducted from your next Kaiser Permanente reimbursement check. If your office has questions or concerns about the way a particular claim was processed by Kaiser Permanente, please contact our Network Development Department (Option #4). Many questions and issues regarding claim payments, coding, and submission policies can be resolved quickly over the phone or via fax. If your issue cannot be resolved through this initial contact, you will be instructed as follows: Provider Appeals Process: If your concern is determined to be a provider appeal issue, you will be advised to submit your concern in writing to: Kaiser Permanente Appeals Unit P.O. Box Cleveland, OH Fax #: Appeal requests must be received within the same time frames as those that apply to the Member appeals. These time frames are: a. Commercial Members (per the Department of Labor [DOL] and the National Council for Quality Assurance [NCQA]): within 180 calendar days of receipt of the initial adverse determination. b. Medicare Members [per the Center of Medicare and Medicaid Services [CMS]): within 60 calendar days of receipt of the initial adverse determination. c. Federal Employee Members (per the Office of Personnel Management [OPM]): within 6 months of receipt of the initial adverse determination. Notifications: All notifications will be in writing to the Practitioner/Provider, with a copy to the Member when appropriate, and will explain the basis for the claim payment appeals determination. Note: Refer to your Kaiser Permanente Practitioner/Provider Manual (see Section 4.13) for detailed information regarding Provider appeals on behalf of the Member. This process only applies to those claims that have been denied because of the absence of prior authorization where authorization is required. Revised April

15 TOPIC PROVIDER PAYMENT DISPUTES EXPLANATION / INSTRUCTIONS If your office has questions or concerns about the way a particular claim was processed by Kaiser Permanente, please contact our Network Development Department (Option #4). Many questions and issues regarding claim payments, coding, and submission policies can be resolved quickly over the phone or via fax. If your issue cannot be resolved through this initial contact, you will be instructed as follows: Payment Dispute Process: If your concern is determined to be a payment dispute issue, you will be advised to submit your concern in writing to: Kaiser Permanente P.O. Box 5316 Cleveland, OH Attn: Payment Dispute Unit Fax #: (216) Payment disputes must be received within the same time frames as those that apply to appeals. These time frames are: a. Commercial Members (per the Department of Labor [DOL] and the National Council for Quality Assurance [NCQA]): within 180 calendar days of receipt of the initial adverse determination. b. Medicare Members [per the Center of Medicare and Medicaid Services [CMS]): within 60 calendar days of receipt of the initial adverse determination. c. Federal Employee Members (per the Office of Personnel Management [OPM]): within 6 months of receipt of the initial adverse determination. Notifications: If the initial decision is overturned, the Research Specialist will process the claim in dispute within 60 calendar days of receipt of the Payment Dispute form. Your Provider s Explanation of Payment (EOP) will serve to notify you that the claim has been paid. If the initial decision is upheld, the Research Specialist will contact you in writing within 60 calendar days of receipt of the Payment Dispute form to inform you of the rationale for the decision and offer information on any further appeal rights. Note: The Payment Dispute Process is not available for the purpose of filing a Pre- Service Appeal or for the resolution of a denial of a claim due to the absence of prior authorization when authorization is required. The Post Service Appeals Process applies to those claims that have been denied because of the absence of prior authorization where authorization is required. MEMBER HOLD HARMLESS Refer to your Kaiser Permanente Practitioner/Provider Manual (see Section 4.14) for detailed information regarding the Payment Dispute process and corresponding Payment Dispute Form. A Practitioner/Provider should not bill a Member for a service that is not the responsibility of the Member under the Evidence of Coverage, such as an amount denied by KP because of inaccurate coding or the Practitioner s/provider s failure to obtain an Authorization. The Practitioner/Provider may bill for Copayments, Coinsurance amounts, subject to the Deductible or amounts the Member has expressly agreed to pay prior to the services being rendered. Kaiser Permanente Payments: The payments from Kaiser Permanente shall be limited to the amount specified in the Practitioner s/provider s agreement with Kaiser Permanente, less any Copayments, Coinsurance, or Deductibles in accordance with the Member s specific Evidence of Coverage. Revised April

16 TOPIC MEMBER HOLD HARMLESS-con t. EXPLANATION / INSTRUCTIONS Items You May Bill For: The Practitioner/Provider may bill the Member for any applicable Copayments, Coinsurance, or Deductibles, and/or for any non-covered Services as indicated on the Explanation of Payment (EOP) received from Kaiser Permanente. Please note that any non-covered Services require a signed Patient Acknowledgement of Financial Responsibility Form prior to services being rendered, as listed on the form on Page 88. Waiver of Liability: The Patient Acknowledgement of Financial Responsibility Form that is included in your Kaiser Permanente Practitioner/Provider Manual is also included in this GUIDE on page 88. COORDINATION OF BENEFITS (COB) Explanation of Benefit (EOB) or Medicare Summary Notice (MSN) Required: Electronic Claims If Kaiser Permanente is the secondary payer, send the completed electronic claim with the payment fields from the primary insurance carrier. Paper Claims If Kaiser Permanente is the secondary payer, send the completed claim form with a copy of the corresponding Explanation of Benefit (EOB) or Medicare Summary Notice (MSN) from the primary insurance carrier attached to the paper claim to ensure efficient processing/adjudication. Kaiser Permanente cannot process a claim without an EOB or MSN from the primary insurance carrier. If you are submitting a paper claim for more than one member on the same MSN, please attach a copy of the MSN to each claim form being submitted. CMS-1500 claim form Complete Field 29 (Amount Paid) UB-04 claim form Complete Field 54 (Prior Payments) Additional COB Information For Electronic and Paper Claims: Please see the Coordination of Benefits (COB) section for additional information regarding coordination of benefits, and for a list of the specific COB fields which must be completed to ensure accurate COB payment determinations. Reminder: Upon a Member s appointment check in, please verify if there have been any changes to the insurance coverage. This could include more than one coverage. Questions: If you have any questions relating to the coordination of benefits, please call our Network Development Department (Option #4) for assistance. VISITING MEMBER All Kaiser Permanente regions make services available to Members visiting from other regions. Members of Group Health Cooperative are also eligible to receive Visiting Member services in Kaiser Permanente regions. Verifying Eligibility/Benefits: If an individual presents a Member identification card from another Kaiser Permanente region, please call our Network Development Department (Option #1) to verify eligibility and benefits. Revised April

17 TOPIC VISITING MEMBERcon t. EXPLANATION / INSTRUCTIONS Claims Submission: All claims should be submitted directly to Kaiser Permanente for processing, as per the claims submission instructions set forth in this GUIDE. Reimbursement Rates: Practitioners/Providers will be reimbursed at the same rates negotiated with Practitioner/Provider offices for all other Kaiser Permanente Members. Questions: If you have any questions about Visiting Members, please call our Network Development Department (Option #4). Revised April

18 ELECTRONIC DATA INTERCHANGE (EDI) NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500/HCFA-1500 or CMS-1450/UB-92 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. EDI is an exchange of information in a standardized format that adheres to all Health Insurance Portability and Accountability Act (HIPAA) requirements. EDI claims transactions replace the submission of paper claims. The claim status inquiry and response transactions eliminate the need to telephone Kaiser Permanente to determine the status of an outstanding claim. The benefit eligibility transaction eliminates the need to telephone Kaiser Permanente to determine a member s eligibility status. ****NOTE: Kaiser Permanente encourages the electronic submission of all claims. **** TOPIC BENEFITS OF EDI CLAIMS SUBMISSION EDI ROLES UNDERSTANDING ELECTRONIC SUBMISSION PROCESS EXPLANATION / INSTRUCTIONS 1) Reduced Overhead Expenses Administrative expenses are reduced, there is no longer a need to print or mail claims or to contact Kaiser Permanente by phone for information. 2) Improved Data Accuracy Since there is no need to re-enter data, data accuracy of claims is improved, improving claims payment quality and speed. Both the billing software and the EDI clearinghouse apply validations to the data that ensure the claims data is accurate before the claim is processed. 3) Decreased Claim Turnaround Electronic claims can be received more quickly than those submitted on paper. Once received, they can be loaded to the claims processing system more quickly and accurately, enabling a faster turnaround time. 1) Submitter: An EDI submitter is the party sending a transaction. For claims submission, this is usually the Practitioner/Provider or a billing service submitting claims on its behalf. 2) Clearinghouse: An intermediary that receives transactions from multiple submitters and sends transactions to the correct recipient. A clearinghouse may also perform validations and edits on the transactions to ensure their compliance with HIPAA guidelines, or with standards unique to a specific recipient. 3) Recipient: The party receiving a transaction. For claims submission, this is Kaiser Permanente. 1) Practitioners /Providers EDI Responsibilities: A Practitioner/Provider sets up a contract with a Clearinghouse to submit claims to payers. The Practitioner/Provider enters all of the required data claims elements and sends all of this information to the contracted Clearinghouse for further data sorting and distribution. The Practitioner/Provider is responsible for ensuring that the transaction complies with the HIPAA requirements and contains all information necessary to process the claim. Revised April

19 TOPIC UNDERSTANDING ELECTRONIC SUBMISSION PROCESS con t. EXPLANATION / INSTRUCTIONS 2) Clearinghouse s EDI Responsibilities: The clearinghouse receives information from a variety of Practitioners/Providers, The clearinghouse batches all of the information sorts the information by payer, and then sends the information to the correct payer for processing. The Clearinghouse should ensure the transactions are in compliance with the HIPAA requirements, and may apply unique edits specified by the payer. In addition, clearinghouses: Often provide software enabling direct data entry in the Practitioner s/provider s office. Edit the submitted data so that it is accepted by the payer. Transmit the data to the correct payer in a standard format Note: If a Clearinghouse has a contract with a Practitioner/Provider to process claims transactions, but does not have a contract with the payer to send that payer claims transactions, the Clearinghouse will work with other Clearinghouse s to route the claim to the payer. Therefore, the Clearinghouse to which a Practitioner/Provider submits claims may not be the same Clearinghouse that delivers those claims to Kaiser Permanente. 3) Kaiser Permanente s EDI Responsibilities: Kaiser Permanente receives the EDI information from the Clearinghouse distribution, and loads it into Kaiser Permanente s claims processing system. When claims are received, Kaiser Permanente prepares an electronic acknowledgement (997 transaction) which is sent to the Clearinghouse. NOTE: A Practitioner/Provider may work with their Clearinghouse to receive Kaiser Permanente s acknowledgement. When claims are rejected by Kaiser Permanente for fatal front-end errors, Kaiser Permanente returns a claims status transaction (277U) detailing why the claim was rejected. Rejected claims may be re-submitted once they are corrected. When claims are paid, Kaiser Permanente will, if requested, return a payment/remittance advice (835) transaction to the Clearinghouse requested by the provider. TO INITIATE ELECTRONIC CLAIM SUBMISSIONS 1) No Registration with Kaiser Permanente is Required for Claims Submission A Practitioner/Provider does not need to register with Kaiser Permanente to submit claims electronically. It is the Practitioner/Provider s responsibility to set up a contract with a Clearinghouse to process the claim submissions. 2) Electronic Payer ID Each Clearinghouse with which Kaiser Permanente is contracted has a unique Electronic Payer ID identifying Kaiser Permanente of Ohio. When claims are submitted they must be identified with the electronic payer ID assigned by the Clearinghouse that delivers the claims to Kaiser Permanente. Kaiser Permanente of Ohio receives electronic claims from the following clearinghouses: Clearinghouse Kaiser OH Payer ID RelayHealth RH007 Ingenix NG007 Emdeon Capario KS005 Quadax Contact clearinghouse Note: Other Kaiser Permanente regions have different electronic payer IDs. Revised April

20 TOPIC TO INITIATE ELECTRONIC PAYMENT/ REMITTANCE ADVICE EXPLANATION / INSTRUCTIONS 1) Registration Is Required for Electronic Payment/Remittance Advice A Practitioner/Provider must register with both their Clearinghouse and Kaiser Permanente to receive a Payment/Remittance Advice (835) transaction when claims are finalized. 2) Requesting an 835 Registration Form To register for 835, a Practitioner/Provider can: Go to Kaiser Permanente s Provider website (providers.kaiserpermanente.org/oh) and download the registration form. Call the Network Development Department (Option 4) and request the form. the Kaiser Permanente EDI Coordinator (OH-EDI- Coordinator@kp.org) to request the form. Once the form is received by Kaiser Permanente, set-up can take up to two weeks. 2) Paper Remittance Advice Unless requested, Kaiser Permanente will continue to send the Explanation of Payment even when the Electronic Payment/Remittance advice transaction is enabled. TO INITIATE ELECTRONIC FUNDS TRANSFER While not technically an EDI transaction, Electronic Funds Transfer (EFT) or Direct Deposit is also available from Kaiser Permanente. An EFT transaction replaces a paper check for the payment of claims. Requesting an EFT Authorization Agreement To request an EFT Authorization Agreement, a Practitioner/Provider can: Go to Kaiser Permanente s Provider website (providers.kaiserpermanente.org/oh) and download the form. Call the Network Development Department (Option 4) and request the form. the Kaiser Permanente EDI Coordinator (OH-EDI- Coordinator@kp.org) to request the form. Once the form is received by Kaiser Permanente, set-up and pre-payment testing with the bank can take up to four weeks. HIPAA REQUIREMENTS Claims submitted electronically must adhere to all Health Insurance Portability and Accountability Act (HIPAA) requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Practitioner/Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at (301) KP REQUIREMENTS Additional Kaiser Permanente EDI data requirements are reflected within the Kaiser Permanente EDI Trading Partner Companion document, which may be obtained by contacting the Network Development Department (Option #4). Items of note within this document include: Unique Provider Per Claim In cases where there are multiple providers for the same claim, please split Revised April

21 TOPIC KP REQUIREMENTS, con t. EXPLANATION / INSTRUCTIONS the claim by provider and list the individual provider only at the claim level. Kaiser Permanente Member Identification Number (Medical Record Number) Subscriber vs Patient: Submit claims using only the patient's information (e.g. name, date of birth, medical record number/id). Do not use the subscriber's information. Since each Kaiser member has a unique medical record number/id, they are considered their own subscriber for electronic transmissions, i.e. patient relationship = self (18). Professional claims: Paper: blocks #1a, 2, 3, 4, 5, 6, 7 EDI: 2010BA Institutional claims: Paper: blocks #12, 13, 14, 15, 58, 59, 60 EDI: 2010BA IMPORTANT: Each Kaiser Permanente Member has a unique Member identification number (Medical Record Number). Do not use a parent s Kaiser Permanente Medical Record Number on a claim for a child; similarly, do not use a spouse s Medical Record Number on a claim for the other spouse. SUPPORTING DOCUMENTATION EDI CLAIM ERRORS CORRECTION & RESUBMISSION FOR ACCEPTED EDI CLAIMS To expedite claims processing, a Practitioner/Provider should submit supporting written documentation (for example, copies of pertinent medical records) with certain types of claims. See the Supporting Documentation Table on page 90 for a list of the claims which usually require supporting documentation. Supporting Documentation Submitted Separately From a Claim: When sending supporting documentation separately from the claim (for example, when sending in requested medical information for a pended claim) 1) Complete a Supporting Documentation Cover Sheet (see sample and instructions on page 89) for each Member. 2) Attach the cover sheet to each Member s paper documentation with a paper clip. 3) Mail the supporting documentation as per the instructions on the form. All electronic claim submissions are monitored to ensure that an acceptable percentage of claims are error-free. Kaiser Permanente will contact the Practitioner/Provider if a high rate of fatal errors are detected in their EDI claim submissions. The error(s) will be analyzed and resolved by working with the Practitioner/Provider office or their billing service. CMS-1500 Claim Forms: (837P) Kaiser Permanente prefers corrections to 837P claims which were already accepted by Kaiser Permanente to be submitted on paper claim forms. Corrections submitted electronically may inadvertently be denied as a duplicate claim. Refer to page 38 within this GUIDE for further information and instructions. UB-04 Claim Forms: (837I) NOTE: 837I corrections may be submitted electronically Electronic Include the appropriate Type of Bill code when electronically submitting a corrected 837I claim to Kaiser Permanente for processing. IMPORTANT: Claims submitted without the appropriate 3 rd digit (XXX) in the Type of Bill code will be denied. Paper Refer to page 49 for further information and instructions pertaining to paper Revised April

22 TOPIC EXPLANATION / INSTRUCTIONS submission of corrected claims to Kaiser Permanente for processing. Revised April

23 CODING & BILLING VALIDATION NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. INTRODUCTION Kaiser Permanente uses code editing software from third party vendors to assist in determining the appropriate handling and reimbursement of claims. Currently, Kaiser Permanente has selected Claims Xten which in turn uses software from McKesson and Claims Edit System (CES) Knowledgebase. From time to time, Kaiser Permanente may change this coding editor or the specific rules that it uses in analyzing claims submissions. Kaiser Permanente s goal is to help ensure the accuracy of claims payments. Claims Xten is a code editor software application designed to evaluate professional claims data including HCPCS and CPT codes as well as associated modifiers. IntelliClaim is a rule-based application; some of these rules have been chosen to meet Kaiser Permanente s goals of increased accuracy in claims payment. Claims XTen assists Kaiser Permanente in identifying various categories of claims coding and possible inconsistencies. Claims with coding errors/inconsistencies are pended to the Medical Claim Review staff for manual review. Each claim is validated against Kaiser Permanente s payment criteria, and then is subsequently released for processing. This process has a goal of improving the accuracy of coding and consistency in claims payment procedures. In order to help illustrate how this process works, examples have been provided where appropriate. If you have questions about the application of these rules, please contact our Network Development Department. Revised April

24 CODING RULE DESCRIPTIONS EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 1 MULTIPLE PROCEDURE REDUCTION # 2 OUTPATIENT CONSULTATIONS Rule Description: Identifies procedures that require a reduction based on multiple procedure guidelines. Rule Justification: American Medical Association (AMA) guidelines establish that certain procedures require the billing of the multiple procedure modifiers. Any procedure included in Appendix D or E of the Current Procedural Terminology book are exempt and not included in this list of procedures. Rule Application: Use all procedures in the surgical section ( ) from the Current Procedural Terminology book to determine procedure codes that will accept the multiple modifier. Any codes the AMA has designated to be Add-On codes or Modifier 51 Exempt will not be considered. Multiple surgeries are indicated by use of modifier 51 The primary procedure is identified by the highest total RVU as set by CMS Example: Multiple surgeries are separate procedures performed by a Practitioner/Provider on the same patient at the same operative session or on the same day. KP will reimburse for multiple procedures performed during the same operative session according to the following schedule: 1st (major) procedure 100% of allowed fee, no modifier required 2nd procedure.50% of allowed fee, modifier 51 required 3rd procedure..50% of allowed fee, modifier 51 required 4th procedure... 50% of allowed fee, modifier 51 required Each procedure after the fourth procedure will require submission of documentation and Kaiser Permanente review, to determine an appropriate reimbursement amount. Rule Description: Identifies office or other outpatient consultations that should have been billed at the appropriate level of office visit, established patient, or subsequent hospital care. Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." Furthermore, "If subsequent to the completion of the consultation, the consultant assumes responsibility for the management of a portion or all of the patient's condition[s], the follow-up consultation codes should not be used." Rule Application: Deny the consultation with the reason code indicating the denial reason. Match on the first three digits of an ICD9 code to determine same diagnosis. Definition: A non-initial consultation is a consultation billed with a date of service within 6 months of another consultation. Example: Office or other outpatient consultation codes ( ) are services provided by a Practitioner/Provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician. These consultation services should be performed at the written or verbal request of another Practitioner/Provider and documented in the patient's medical record. If the consulting Practitioner/Provider assumes responsibility for the management of a portion or all of the patient's condition, the follow-up visits should be coded using the established patient office evaluation and management codes DOS 1/5/04 Dx Code of DOS 3/1/04 Dx Code of Service for DOS 3/1/04 will be denied. Revised April

25 EDIT RULE # / NAME # 3 CONFIRMATORY CONSULTATION CODING RULE DESCRIPTIONS / RULE JUSTIFICATION Rule Description: Identifies confirmatory consultations that should have been billed at the appropriate level of office visit, established patient, or subsequent hospital care. Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." Furthermore, "If subsequent to the completion of the consultation, the consultant assumes responsibility for the management of a portion or all of the patient's condition[s], the follow-up consultation codes should not be used." Rule Application: If a confirmatory consultation with the same diagnosis as a previously billed confirmatory consultation is detected, the consultation will be denied. Definition: A non-initial confirmatory consultation is a consultation billed with a date of service within 6 months of another consultation. Example: The following codes are used to report the E & M services provided to patients when the consulting Practitioner/Provider is aware of the confirmatory nature of the opinion sought ( ). # 4 INITIAL INPATIENT CONSULTATIONS If the consulting Practitioner/Provider initiates treatment after the initial confirmatory consultation, and participates thereafter in the patient's management, then subsequent established patient codes should be used. Rule Description: Identifies initial inpatient consultations that should have been billed at the appropriate level of subsequent hospital care. Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." Furthermore, "If subsequent to the completion of the consultation, the consultant assumes responsibility for the management of a portion or all of the patient's condition[s], the follow-up consultation codes should not be used." Rule Application: AMA/CPT industry standard of payment is followed for paying initial inpatient consultations, only when they are truly the initial. # 5 CONSULTATIONS BY PRIMARY CARE PHYSICIANS (PCP) # 6 NEW PATIENT CODE FOR ESTABLISHED PATIENT Example: A consultation is a type of service provided by a Practitioner/Provider whose opinion or advice regarding evaluation and management of a specific problem is requested by another Practitioner/Provider. CPT states that only one initial consultation should be reported by a Consultant per admission utilizing the initial inpatient consultation codes ( ). Rule Description: Identifies consultation codes that are billed by the Member's Primary Care Physician (PCP). Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. Rule Application: All consultation will be denied when billed by the Member s PCP, except for claims submitted with a pre-op diagnosis (V72.81-V72.85) when appropriate. Rule Description: Identifies new patient procedure codes that are submitted for established patients. Rule Justification: According to the AMA "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." Rule Application: Revised April

26 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 6 cont. Deny with a reason code indicating the denial reason when a Practitioner/Provider bills more than one new patient code for the same member. In addition, same group, same specialty within the 3 years will be denied. The time period is three (3) years to determine if the visit is for a new patient. # 7 GLOBAL SURGICAL PACKAGE (GSP) Example: Member ID 1234 DOS 1/5/ This service will be denied Member ID 1234 DOS 12/20/ This service will be approved Rule Description: Identifies Evaluation & Management (E/M) or certain supply codes billed within a procedure s follow-up period. Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines have established that the concept of the global surgical package applies to certain procedures. Additional payment should not be made for services that fall within the follow-up days. Rule Application: Deny E/M codes and supplies billed within the global surgical package for surgeries with global periods of 10 or 90 days. Use Modifiers 22, 24, 25, 27, 59 and 79 if applicable. Example: A global surgical package is an all inclusive fee for the surgical procedure which includes the surgery and some pre-operative and post-operative care. Below outlines types of global surgical packages and what each package includes. Major Surgery: The following services are included in the global surgical package: Pre-operative visit/services, in or out of the hospital, one day prior to surgery all intra-operative procedures medical/surgical services for complications which DO NOT require a return trip to the Operating Room all related post-operative care and visits, for a period of 90 days following surgery Minor Surgery: The following services are included in the global surgical package: The Practitioner s/provider s visit/services performed on the day of surgery the procedure itself all related postoperative care and visits, for a period of ten days after surgery Endoscopic Procedures: For endoscopic procedures, the global "package" includes: The Practitioner s/provider s visit/services on the day of the procedure, The procedure itself, There is NO post-operative period for endoscopic procedures performed through an existing body orifice; procedures requiring an incision for insertion of a scope (for example, a laparoscopic cholecystectomy) will be subject to either the MAJOR or MINOR surgical policy, whichever is appropriate. # 8 SAME DAY SURGERY INCLUSIVE Rule Description: Identifies supplies that have been submitted on the same day as a surgical procedure. Rule Justification: According to the Centers for Medicare & Medicaid Services (CMS) Program Manuals - Medicare Carriers (PUB. 14), guidelines have established that additional payment should not be made for some supplies when billed on the same day as certain surgical procedures. This list includes, but is not limited to, "Items such as Revised April

27 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes. # 9 MCKESSON BUNDLING Rule Application: Deny supplies when billed on the same day as a surgery. Rule Description: Identifies procedures that have been unbundled according to the McKesson CES product. Rule Justification: The McKesson CES product has identified rebundling coding relationships. Coding relationships are established and influenced by CPT Code definitions, CPT Instructions and Guidelines, Medicare Guidelines, Physician Specialty Organizations, McKesson s Clinical Staff. Edit level justifications are available upon request. Rule Application: Use McKesson edits for all claims. Definition: Procedure unbundling occurs when two or more CPT-4 procedures are used to describe a procedure performed, when a single, more comprehensive, CPT-4 procedure code exists that accurately describes the entire procedure performed or when mutually exclusive procedures (procedures which would not be reasonably performed at the same session by the same provider on the same Member) are reported. Example: Billing the following 2 codes together: Total abdominal hysterectomy (corpus and cervix) with or without removal of tubes; with or without removal of ovary(s) Pelvic exenteration for gynecologic malignancy with total abdominal hysterectomy or cervicectomy with or without removal of tube(s); with or without removal of ovary(s) # 10 CMS CORRECT CODING INITIATIVE BUNDLING would be rebundled into Rule Description: Identifies procedures that have been unbundled according to the Correct Coding Initiative. Rule Justification: The correct coding initiative coding policies are based on coding conventions defined in the American Medical Association's CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice and review of current coding practice. Rule Application: Use CMS CCI edits for all claims. Deny the code with the lowest work RVU for mutually exclusive procedures Apply the Correct Coding Initiative modifier overrides 25, 58, 59, 78, 79, E1-E4, F1-F9, FA, LC, LD, LT, RC, RT, T1-T9, and TA if appropriate. Definition: Procedure unbundling occurs when two or more CPT-4 procedures are used to describe a procedure performed, when a single -- more comprehensive -- CPT-4 procedure code exists that accurately describes the entire procedure performed or when mutually exclusive procedures (procedures which would not be reasonably performed at the same session by the same provider on the same member) are reported. Example: Billing the following 2 codes together: 58150: Total abdominal hysterectomy (corpus and cervix) with or without removal of tubes; with or without removal of ovary(s). Revised April

28 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION 58240: Pelvic exenteration for gynecologic malignancy with total abdominal hysterectomy or cervicectomy with or without removal of tube(s); with or without removal of ovary(s) # 11 CMS ALWAYS BUNDLED PROCEDURES # 12 ANESTHESIA CROSSWALK would be rebundled into Rule Description: Identifies procedures indicated by the Centers for Medicare & Medicaid Services (CMS) as always bundled when billed with any other procedure. Rule Justification: According to CMS National Physician Fee Schedule Relative Value File, this procedure has a status code indicator of "B", which is defined as: "Payment for covered services is always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes and no separate payment is made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident." Rule Application: Deny services indicated by CMS as always bundled when billed with any other procedure not indicated as always bundled. Rule Description: Identifies and crosswalks non-anesthesia services to a designated anesthesia code as appropriate based on the provider's specialty. Rule Justification: The McKesson Anesthesia Crosswalk Table converts E/M, surgery, radiology, laboratory/pathology, and medicine codes to anesthesia codes as appropriate when a claim for anesthesia services, as identified by provider type, specialty, or identification number is submitted with other than a designated anesthesia code ( ). Rule Application: Use McKesson s crosswalk list to crosswalk any non-anesthesia codes billed by an anesthesiologist to the appropriate anesthesia code and deny with anesthesia reason code. For non-anesthesia codes that have a one to many crosswalk, flag the code for review and deny anesthesia with denial reason code. For non-anesthesia codes that do not have an established crosswalk, flag the code for review and deny anesthesia with denial reason code. # 13 HOLIDAY Example: Code would be denied because the anesthesia code of is a valid crosswalk. Rule Description: Identifies misuse of procedure codes designated for Federal holidays or Sundays. Rule Justification: According to the AMA, this procedure code has been defined as "Services requested on Sundays and holidays in addition to basic service." The date of service on this line is not a Federal holiday or a Sunday. Rule Application: Deny code when it is NOT billed on a Sunday or Federal holiday. Example: A provider billed and the date of service is NOT 12/31/2009 or 12/25/2009. # 14 GENDER SPECIFIC CODES Rule Description: Identifies procedures and diagnoses that are inconsistent with the Member's gender. Rule Justification: The McKesson CES product has identified this procedure or diagnosis as gender specific. The procedure code or diagnosis on this line is not consistent with the Member's gender. Revised April

29 EDIT RULE # / NAME # 15 PROCEDURES NOT COVERED # 16 UNLISTED PROCEDURE RULE CODING RULE DESCRIPTIONS / RULE JUSTIFICATION Rule Application: Use McKesson s list to deny any claim lines with procedures or diagnoses that are inconsistent with the Member s gender. Rule Description: Identifies procedure codes that are typically not covered by the plan. Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines or industry accepted standards establish that certain procedures are not covered by the plan. In regards to CMS not covered services, procedures with a Status Indicator of E, G, I, N, P, or X in the National Physician Fee Schedule Relative Value File are included in this list of procedures. Rule Application: Deny procedure codes that are not covered. Services not covered by Medicare and which are covered by Kaiser Permanente are excluded from this rule. Rule Description: Identifies procedure codes that are "unlisted." Rule Justification: The McKesson CES product has identified procedure codes that contain phrases in their descriptions such as not elsewhere specified or not otherwise specified. Rule Application: Pend for review CPT codes that are unlisted procedures. Definition: An unlisted procedure is a "catch all" code for a procedure that cannot be assigned a more specific procedure code. These procedures are identified in CPT-4 with the word "unlisted" in the procedure code s description. # 17 DUPLICATE LINE ITEMS Example: Unlisted musculoskeletal procedure, head (21499). Clinical Review staff will review all claims with an unlisted procedure code listed on the claim form. After a detailed review of the claim -- and any required supporting documentation -- Clinical Review staff may be able to assign a more specific CPT code to the procedure. Rule Description: Identifies line items that have been submitted on a previous claim. Rule Justification: Duplicate claim lines match a previous claim's Member, Practitioner/Provider, procedure code, modifier, date of service, quantity, and billed amount. Rule Application: Deny the claim line based on a match on Member ID, procedure code, Provider ID or vendor Federal Tax Identification Number, date of service, requested amount, quantity and modifier. An exact match is not required on Evaluation and Management CPT codes. # 18 PROFESSIONAL/ TECHNICAL CODES VS. MODIFIERS Rule Description: Identifies situations where a modifier 26, denoting professional component, should have been reported for the procedure performed at the noted place of service. Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines establish that certain procedures, when performed in certain settings, require the billing of the professional component modifier. Procedures with a "PCTC Ind" indicator of 1 or 6 in the National Physician Fee Schedule Relative Value File are included in this list of procedures. Rule Application: Add the professional component (modifier 26) when an applicable procedure is performed in a facility setting by a non-hospital Provider. Use CMS s list of procedures that will accept technical/professional component split. Revised April

30 EDIT RULE # / NAME # 19 INVALID ASSISTANT SURGEON CODING RULE DESCRIPTIONS / RULE JUSTIFICATION Rule Description: Identifies surgical procedures billed with an assistant surgeon modifier that typically do not require an assistant surgeon. Rule Justification: The Centers for Medicare Services (CMS) guidelines establish that certain procedures do not warrant an assistant surgeon. Procedures with an "Asst Surg" indicator of 1 or 9 in the National Physician Fee Schedule Relative Value File are included in this list of procedures. Rule Application: Use CMS s list to identify codes that typically do not require an assistant surgeon in the procedure, but have an assistant surgeon modifier attached, and deny those procedures. Definition: An assistant at surgery is defined as an individual who assists the primary surgeon during surgery. An assistant at surgery can be another physician, a physician s assistant (PA), or a qualified resident. Example: CMS has identified a list of procedures which require the skills of an assistant surgeon. Kaiser Permanente reviews all "assistant surgeon" claims to determine the appropriateness of the assistant surgeon s services. Kaiser Permanente uses physician consultants, as well as current, publicly available assistant surgeon guidelines (CMS). # 20 FILING DEADLINES Rule Description: Identifies claim lines that have been submitted after the filing deadline. Rule Justification: According to the Centers for Medicare & Medicaid Services (CMS) Program Manuals - Medicare Carriers (PUB. 14), "the terms of the law require that the claim be filed no later than the end of the calendar year following the year in which the service was furnished, except as follows: The time limit on filing claims for service furnished in the last 3 months of a year is the same as if the services had been furnished in the subsequent year. Thus, the time limit on filing claims for services furnished in the last 3 months of the year is December 31 of the second year following the year in which the services were rendered." Rule Application: The decision is to compare the date of service to the received date to determine whether a claim has been filed on time. Contracted Providers Deny claims submitted beyond the Kaiser Permanente initial claims submission of 12 months from date of service. Non Contracted Providers Deny claims submitted beyond the CMS filing deadline. # 21 DELETED CODES Rule Description: Identifies procedures codes deleted by the AMA received after CMS submission guidelines. Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines have established that AMA deleted CPT and HCPCS codes should not be reimbursed when they are submitted after the procedure code's deletion and beyond the permitted submission period. Rule Application: If a claim line has a date of service in the current year, CMS permits a three-month grace period (based on the date the claim is received). When a claim is received beyond the grace period, deny the code. Revised April

31 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION Example: Complete ventricular decortication, with cardiopulmonary bypass (Code deleted in 1990; to report, use 33031). # 22 ADD-ON CODES Rule Description: Identifies an add-on code billed without the presence of a primary service/procedure. Rule Justification: According to the AMA, "add-on codes are always performed in addition to the primary service/procedure, and must never be reported as a stand-alone code." The indicated add-on procedure has been identified because this provider has not billed it's related primary service/procedure for this Member on the same date of service. Rule Application: Deny add-on codes when billed without the appropriate base code. Example: (Base Code) billed with (Add-on) # 23 BILATERAL Rule Description: Identifies the same surgical code being billed twice without the appropriate use of modifier 50. Rule Justification: When performed bilaterally, the same surgical procedure should not be billed twice. Kaiser Permanente s reimbursement guidelines require the code to be billed on one line with a bilateral modifier indicated. Rule Application: Modify lines for bilateral procedures that are submitted incorrectly. The decision determines an incorrect submission by the presence of the same surgical code billed twice for the same date of service. Definition: Bilateral procedures are surgeries performed on both sides of the body during the same operative session or on the same day. Example: If two codes are billed, and both have a -50 modifier, the Plan will pay one line with the - 50 modifier accordingly, and deny one line. First (bilateral) procedure: Report the appropriate 5-digit CPT code, which describes the bilateral procedure, with a modifier -50 as required. Second (bilateral) procedure: The same 5-digit CPT code for the second procedure will be denied. # 24 INVALID BILATERAL Example: A bilateral mastectomy should be reported as follows: (Mastectomy, simple, complete) Add Modifier 50 Rule Description: Identifies inappropriate use of the bilateral modifier. Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines have established that certain procedures are eligible to be performed bilaterally. The submitted procedure does not have a "Bilat Surg" indicator of 1 or 3 in the National Physician Fee Schedule Relative Value File. Rule Application: Deny procedure codes that have a bilateral modifier and are not eligible for this modifier according to CMS. Use modifier -50 to identify procedures performed bilaterally. Example: Revised April

32 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION Incorrect Billing: Line Line Correct Billing: Line # 25 BASE CODE QUANTITY Correct Billing: Line Line Rule Description: Identifies situations where a Practitioner/Provider is billing a primary service/procedure with a quantity greater than one, rather than billing the appropriate add-on code(s). Rule Justification: When a Practitioner/Provider is billing a primary service/procedure with a quantity greater than one, those additional services beyond the primary service/procedure should be billed as add-on codes. According to the AMA, add-on procedures are to be listed in addition to the primary service/procedure. Rule Application: Deny base codes when billed with a quantity greater than one. DO NOT BILL EVENTS (DNBE) Kaiser Foundation Health Plan of Ohio s DNBE 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 Centers for Medicaid and Medicare Services (CMS) National Coverage Determinations for surgical errors and the published listing of CMS Hospital Acquired Conditions, as may be amended from time to time. The DNBE policy will apply to all claims for all Members enrolled in Kaiser Permanente. Kaiser Permanente expects Plan Providers to report every DNBE as set forth in Section 8.31of this Manual. Waive or Reimburse Fees Plan Providers may not be compensated for Services directly related to any Do Not Bill Event (as defined below) and may be required to waive Member Cost Share associated with, and hold Members harmless from, any liability for Services directly related to DNBE. Plan Providers shall waive fees otherwise owed by Payors and Members (or reimburse such fees that may have already been paid by Payors or Members) that are directly related to the DNBE, whether the DNBE is reported by the Plan Provider or later discovered by Kaiser Permanente. Directly related fees mean fees associated with the Medically Necessary health care Services required to treat the DNBE, taking into account all relevant factors. Surgical Do Not Bill Events include the following surgical errors (SEs) identified by CMS in its National Coverage Determinations (NCD) that occur in any care setting: Wrong surgery or other invasive procedure performed on patient. Surgery or other invasive procedure performed on wrong patient. Surgery or other invasive procedure performed on wrong body part. The Hospital Acquired Conditions (HAC) identified by CMS that occur in a general hospital or acute care setting are as follows: Revised April

33 Intravascular air embolism that occurs while being cared for in a health care facility. Blood incompatibility (hemolytic reaction due to administration of ABO/HLA incompatible blood or blood products). Pressure ulcer (stage three or four) acquired after admission to a health care facility Falls and Trauma (fractures, dislocations, intracranial injuries, crushing injuries, burns, electric shock). Catheter associated urinary tract infection. Vascular catheter associated infection. Manifestation of poor glycemic control (diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma, secondary diabetes with ketoacidosis, and secondary diabetes with hypersmolarity). Mediastinitis following coronary artery bypass graft. Surgical site infection following orthopedic procedures (spine, neck, shoulder, elbow). Surgical site infection following bariatric surgery for obesity (laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery). Deep vein thrombosis or pulmonary embolism following orthopedic procedures (total knee or hip replacement). Any new HAC later added by CMS. In any care setting, the following HAC if not present on admission for inpatient services or if not present prior to provision of other Services: Removal (if medically indicated) of foreign object retained after surgery (RFO). Claims Submission Related to a Do Not Bill Event Kaiser Permanente will follow the CMS billing requirements for Services directly related to a DNBE. UB-04 If you submit a UB-04 Claim (or its successor) or Institutional 837 electronic transaction for inpatient facility Services to a Member wherein a HAC (including a RFO) has occurred, you must include the following information: o Present on Admission (POA) indicators, applicable International Classification of Diseases (ICD) codes and all applicable standard modifiers (including CMS National Coverage Determination (NCD) modifiers for Surgical Errors) in the manner required by CMS for Medicare fee-for-service claims. o Submit Services directly related to a DNBE as a no-pay claim (Type of Bill 110). If there are also unrelated Services provided during the same stay as the DNBE, you must split the Claim and submit both a no-pay claim (Type of Bill 110) setting forth all Services directly related to the DNBE including the applicable ICD codes, present on admission indicators and all standard modifiers (including CMS National Coverage Determination modifiers for Surgical Errors) in the manner required by CMS for Medicare fee-for-service claims and a Type of Bill 11X (with the exception of 110) setting forth all Covered Services not directly related to the DNBE. CMS 1500 If you submit a CMS 1500 form (or its successor) or Professional 837 electronic transaction for any inpatient or outpatient professional Services provided to a Member wherein a SE or RFO has occurred, you must include the applicable ICD codes Revised April

34 and all applicable standard modifiers (including CMS NCD HCPCS modifiers for Surgical Errors) for the associated charges on all lines related to the surgical error in the manner required by CMS for Medicare fee-for-service claims as follows: o o o PA: Surgery on Wrong Body Part. PB: Surgery on Wrong Patient. PC: Wrong Surgery on Patient. Additionally, the UB-04, CMS 1500 form or 837 Institutional/Professional electronic transactions should reflect all Services provided (including those related to a DNBE) and all associated fees (including those related to the DNBE) with an adjustment in fees to reflect the waiver of fees directly related to the DNBE. Revised April

35 CLAIMS COMPLETION REQUIREMENT CMS-1500 CLAIM FORM NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. HIGHLIGHTS TOPIC WHERE TO MAIL CLAIMS NATIONAL PROVIDER IDENTIFIER (NPI) INSTRUCTIONS All paper claims (and any necessary supporting documentation) should be mailed to the following address: Kaiser Permanente P.O. Box 5316 Cleveland, OH The revised CMS-1500 (08/05) accommodates NPI numbers and are expected by Kaiser when claims are billed using the revised form. The NPI Number should be entered in the following fields for the stated provider types. Rendering Physician should enter their NPI number in the non-shaded area in Field 24J. Service Facility Field 32a Billing Provider Field 33a HIPAA REQUIREMENTS All electronic claim submissions must adhere to all Health Insurance Portability and Accountability Act (HIPAA) requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Practitioner/Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at (301) For additional requirements, please contact the Network Development Department (Option #4) to obtain a current list of Clearinghouses, or refer to the Kaiser Permanente EDI Trading Partner Companion document. CLAIM SUBMISSION TIMEFRAMES Initial Claim Submissions: All claims must be submitted for processing within 12 months (365 days) of the date of service. Any claims submitted after 12 months (365 days) from the date of service must be accompanied by documentation as to why the claims should be considered for payment. Complete a Supporting Documentation Cover Sheet (see sample and instructions on page 89) and attach the documentation with a paper clip. Claims submitted without this documentation will be denied. Revised April

36 TOPIC CLAIM SUBMISSION TIMEFRAMES-con t. INSTRUCTIONS Coordination of Benefits (COB) Claim Submissions: If Kaiser Permanente is the secondary payer, any Coordination of Benefits (COB) claims must be submitted within 45 days of the date of the Explanation of Benefits (EOB) or MSN for payment consideration. If we do not receive an Explanation of Benefits (EOB) or MSN the claim will be denied for lack of information. If you are submitting a paper claim for more than one member on the same MSN, please attach a copy of the MSN to each claim form being submitted. Claim Corrections: Claim corrections should be submitted for processing as soon as possible after the discrepancy is discovered, but no later than 180 days from the date of initial payment, with proof of acceptable initial timely claim filing. If there are extenuating circumstances that did not allow you to file the correction within 180 days please submit documentation with your request for reconsideration. Payment consideration for claims filed/appealed after filing limit: Examples of documentation deemed valid are: 1. Call into Kaiser Permanente Network Development or Customer Service: Provide the date and time that you contacted Kaiser Permanente inquiring about a claim status or payment rejection. If you followed up with an appropriate KP area, we will have documentation of that call and will be able to accept that in order to determine if the filing limit rejection will be overturned. Follow up calls in relation to a previous payment must occur within 180 days of the last processed date. This would be considered as proof of filing. 2. Fax Confirmation: Provide a copy of a fax confirmation sheet showing the fax was successful, detailing that you faxed a claim over for processing or reconsideration. This would be considered as proof of filing. 3. KP EDI Claim Receipt Confirmation: KP assigns all claims received a KP claim number whether they are received via paper or electronically. Upon receipt, EDI claims typically generate a confirmation back to the submitter along with the claim number information. This would be considered as proof of filing. BILL FULL CHARGES 4. Copy of delivery confirmation from U.S. Postal Service or Commercial Carrier (i.e. UPS, FedEx.): If you have a delivery confirmation from a package submitted to KP as it relates to claims involved in a timely filing dispute, we will consider that receipt as proof of filing. All Practitioners/Providers (including assistant surgeons) should bill full charges based on your universal charge master unless otherwise instructed. Please do not bill charges based on your contracted rates. Any necessary payment reductions will be made during claims adjudication (for example, multiple surgery reductions, maximum allowable limitations, copayments, etc.). Example: ENT Specialist performs the following bilateral, multiple procedures: Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) Nasal/sinus endoscopy, surgical, with maxillary antrosomy Revised April

37 TOPIC BILL FULL CHARGEScon t. INSTRUCTIONS Correct Way to Bill CPT/HCPCS MODIFIER $ CHARGES $ $3000 Incorrect Way to Bill CPT/HCPCS MODIFIER $ CHARGES $ $ $ $750 This is the correct way to bill for bilateral multiple procedures. Any necessary payment reductions will be made during claims adjudication. The Practitioner/Provider should NOT reduce his/her usual charges (i.e., $750). This will automatically be done by Kaiser Permanente during claims adjudication. COORDINATION OF BENEFITS (COB) NO FAULT/WORKERS COMPENSATION/OTHER ACCIDENT EOB or MSN Required: Electronic Claims Coordination of Benefits (COB) Kaiser Permanente can receive COB information from the provider through the 837 claims transaction, including prior payment information from other payers such as Medicare. This allows transmission of the entire claim with COB electronically. Please include all elements where available, including CAS segments with the appropriate group and reason codes. Please contact your software vendor or clearinghouse for their capability. Paper Claims If Kaiser Permanente is the secondary payer, send the completed claim form with a copy of the corresponding Explanation of Benefit (EOB) or Medicare Summary Notice (MSN) from the primary insurance carrier attached to ensure efficient processing/ adjudication. Kaiser Permanente cannot process a claim without an EOB or MSN from the primary insurance carrier. CMS-1500 claim form Complete Field 29 (Amount Paid) Additional COB Information: Please see the COB section in this GUIDE for additional information regarding coordination of benefits, and for a list of the specific COB fields on the CMS-1500 claim form which must be completed to ensure accurate COB payment determinations by Kaiser Permanente. Questions: If you have any questions relating to the Coordination of Benefits, please call our Network Development Department (Option #4) for assistance. Be sure to indicate on the CMS-1500 claim form in the Is Patient s Condition Related To fields (Fields 10a-10c), whenever No Fault, Workers Compensation, or Other Accident situations apply. RECORD THE AUTHORIZATION NUMBER If applicable, enter the Authorization Number (Field 23) and the Name Of The Referring Provider (Field 17) on the claim form, to ensure efficient claims processing and handling. Revised April

38 TOPIC RECORD THE NAME OF THE PROVIDER YOU ARE COVERING FOR INSTRUCTIONS When covering for another Practitioner, submit a CMS-1500 claim form for these services and enter the name of the physician you are covering for in Field 19 (Reserved for Local Use). NOTE: If a non-participating Practitioner/Provider will be covering for you in your absence, please notify that individual of this requirement. SUBMISSION OF MULTIPLE PAGE CLAIM CLAIM CORRECTIONS ENTERING DATES If due to space constraints you must use a second claim form, please write continuation at the top of the second form, and attach the second claim form to the first claim with a paper clip. Enter the TOTAL CHARGE (Field 28) on the last page of your claim submission. CMS-1500 Claim Forms: NOTE: Kaiser Permanente prefers corrections to CMS-1500 claims which were already accepted by Kaiser Permanente (regardless whether these claims were submitted on paper or electronically) to be submitted on paper claim forms. Corrections submitted electronically may inadvertently be denied as a duplicate claim. When submitting a corrected CMS-1500 paper claim to Kaiser Permanente for processing: 1) Write CORRECTED CLAIM in the top (blank) portion of the standard claim form. 2) Attach a copy of the corresponding page of Kaiser Permanente s Explanation of Payment (EOP) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip. 3) Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address (see page 35 in this section). All dates (dates of birth, dates of service, etc.) must be reported in the following format: month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2003 CONSECUTIVE DATES OF SERVICE Consecutive dates of service can be billed on one claim line as long as the units entered in Field 24g equal the total number of days billed. Example: Correct Way to Bill CPT/HCPCS DATE OF SERVICE UNITS /05/ /07/ /09/ /13/ Incorrect Way to Bill CPT/HCPCS DATE OF SERVICE UNITS /05/ /13/ For consecutive dates of service, the Units field should equal the total number of days billed on each claim line. Do not enter a date span on the claim line if the services are not performed on consecutive dates. Claims will be denied for the exact dates of service. MULTIPLE DATES OF SERVICE AND PLACE OF SERVICE DIFFERENT PLACES OF SERVICE When services are rendered in DIFFERENT places of service (locations), a separate claim form must be submitted for EACH different place of service. Revised April

39 TOPIC INSTRUCTIONS SAME PLACES OF SERVICE Whenever services are provided in the SAME place of service, on DIFFERENT dates, these services may be reported and listed as separate lines on ONE claim form, along with the corresponding date, diagnosis code(s), procedure code(s), and charges. See the table on pages for detailed instructions for billing same/multiple dates of service and places of service. SUPPORTING DOCUMENTATION To expedite claims processing, please submit supporting written documentation (for example, copies of pertinent medical records) with certain types of claims. See the Supporting Documentation Table on page 90 for a list of the claims which usually require supporting documentation. Supporting Documentation Submitted WITH a Claim: When supporting documentation is submitted WITH the corresponding paper claim form, attach/secure the documentation to the paper claim with a paper clip (do not staple) and mail to Kaiser Permanente s mailing address (see page 35 in this section). Supporting Documentation Submitted SEPARATELY From a Claim: When sending supporting documentation SEPARATELY from the claim (for example, when sending in requested medical information for a pended claim). 1) Complete a Supporting Documentation Cover Sheet (see sample for and instructions on page 89) for each Member for whom you are submitting paper documentation. 2) Attach the routing slip to each Member s paper documentation with a paper clip. 3) Mail the supporting documentation as per the instructions on the form. Revised April

40 CMS-1500 (08/05) FIELD DESCRIPTIONS The fields identified in the table below as Required must be completed when submitting a CMS-1500 (08/05) claim form to Kaiser Permanente for processing: Note: The required fields for submission shown below are required by Kaiser Permanente but not necessarily required by CMS or other payers. For Medicare Members, please refer to Medicare Billing Requirements for appropriate field requirements and instructions/examples. FIELD # CMS-1500 (08/05) FIELD DESCRIPTIONS 1 MEDICARE/ MEDICAID/ TRICARE CHAMPUS/ CHAMPVA/ GROUP HEALTH PLAN/FECA BLK LUNG/OTHER REQUIRED FIELDS FOR CLAIM SUBMISSIONS Not Required CONTENT DESCRIPTION Check the type of health insurance coverage applicable to this claim by checking the appropriate box.. 1a INSURED S I.D. NUMBER Required Enter the Subscriber s plan identification number. 2 PATIENT S NAME Required Enter the patient s name. When submitting newborn claims, enter the newborn s first and last name. 3 PATIENT'S BIRTH DATE AND SEX Required Enter the Patient s date of birth and gender stated as month, day and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/ INSURED'S NAME Required Name of the insured (Last Name, First Name, Middle Initial), unless the insured and the patient are the same then the word SAME may be entered. 5 PATIENT'S ADDRESS Required Enter the patient s mailing address and telephone number. On the first line, enter the STREET ADDRESS; the second line is for the CITY and STATE; the third line is for the ZIP CODE and PHONE NUMBER. 6 PATIENT'S RELATIONSHIP TO INSURED Required if applicable 7 INSURED'S ADDRESS Required if applicable 8 PATIENT STATUS Required if applicable Check the appropriate box for the patient s relationship to the insured. Enter the insured s address (STREET ADDRESS, CITY, STATE, ZIP CODE) and telephone number. When the address is the same as the patient s the word SAME may be entered. Check the appropriate box for the patient s MARITAL STATUS, and check whether the patient is EMPLOYED or is a STUDENT. 9 OTHER INSURED'S NAME Required When additional insurance coverage exists, enter the last name, first name and middle initial of the insured. 9a OTHER INSURED S POLICY OR GROUP Required if NUMBER applicable Enter the policy and/or group number of the insured individual named in Field 9 (Other Insured s Name) above. NOTE: For each entry in Field 9A, there must be a corresponding entry in Field 9d. Revised April

41 FIELD # 9b 9c CMS-1500 (08/05) FIELD DESCRIPTIONS OTHER INSURED S DATE OF BIRTH/SEX EMPLOYER S NAME OR SCHOOL NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required if applicable Required if applicable CONTENT DESCRIPTION Enter the other insured s date of birth and sex. The date of birth must include the month, day, and FOUR DIGITS for year (MM/DD/YYYY). Example: 01/05/2009 Enter the name of the other insured s EMPLOYER or SCHOOL NAME (if a student). Enter the name of the other insured s INSURANCE PLAN or program. 9d INSURANCE PLAN NAME OR PROGRAM NAME Required if applicable 10a-c IS PATIENT CONDITION RELATED TO Required Check Yes or No to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in field d RESERVED FOR LOCAL USE Not Required Leave blank. 11 INSURED S POLICY NUMBER OR FECA NUMBER NOTE: If yes there must be a corresponding entry in Field 14 (Date of Current Illness/Injury). Place (State) - enter the State postal code. Required if applicable If there is insurance primary to Medicare, enter the insured s policy or group number. 11a INSURED S DATE OF BIRTH Required Enter the insured s date of birth and sex, if different from Field 3. The date of birth must include the month, day, and FOUR digits for the year (MM/DD/YYYY). Example: 01/05/ b 11c 11d EMPLOYER S NAME OR SCHOOL Required if NAME applicable INSURANCE PLAN OR PROGRAM Required NAME IS THERE ANOTHER HEALTH BENEFIT Required PLAN? Enter the name of the employer or school (if a student), if applicable. Enter the insurance plan or program name. Check yes or no to indicate if there is another health benefit plan. For example, the patient may be covered under insurance held by a spouse, parent, or some other person. 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE 13 INSURED'S OR AUTHORIZED PERSON'S SIGNATURE 14 DATE OF CURRENT ILLNESS, INJURY, PREGNANCY Not Required Not Required Not Required If yes then fields 9 and 9a-d must be completed. Have the patient or an authorized representative SIGN and DATE this block, unless the signature is on file. If the patient s representative signs, then the relationship to the patient must be indicated. Have the patient or an authorized representative SIGN this block, unless the signature is on file. Enter the date of the current illness or injury. If pregnancy, enter the date of the patient s last menstrual period. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2009 Revised April

42 FIELD # CMS-1500 (08/05) FIELD DESCRIPTIONS 15 IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS 16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required Not Required CONTENT DESCRIPTION Enter the previous date the patient had a similar illness, if applicable. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2009 Enter the from and to dates that the patient is unable to work. The dates must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/ NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Required if applicable Enter the FIRST and LAST NAME of the referring or ordering physician. 17a OTHER ID # Required In the shaded area, the non-npi ID number of the physician whose name is listed in Field 17. Also listed is the qualifier identifying the number in the field to the right of 17a. The NUCC defines the following qualifiers: 0B - State License Number 1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number 1H - CHAMPUS Identification Number EI - Employer s Identification Number G2 - Provider Commercial Number LU - Location Number N5 - Provider Plan Network Identification Number SY - Social Security Number X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy 17b NPI NUMBER Required In the non-shaded area enter the NPI number of the referring provider. 18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES Required if applicable 19 RESERVED FOR LOCAL USE Required if applicable 20 OUTSIDE LAB CHARGES Not Required Leave Blank 21 DIAGNOSIS OR NATURE OF ILLNESS Required OR INJURY 22 MEDICAID RESUBMISSION Not Required Leave Blank 23 PRIOR AUTHORIZATION NUMBER Required if applicable Block is completed when a medical service is furnished as a result of, or subsequent to, a related hospitalization. If you are covering for another physician, enter the name of the physician (for whom you are covering) in this field. If a Non-Participating Practitioner/Provider will be covering for you in your absence, please notify that individual of this requirement. Enter the diagnosis/condition of the patient, indicated by an ICD-9-CM code number. Enter up to 4 diagnostic codes, in PRIORITY order (primary, secondary condition). Enter the prior authorization number for those procedures requiring prior approval. Revised April

43 FIELD # CMS-1500 (08/05) FIELD DESCRIPTIONS 24a - g SUPPLEMENTAL INFORMATION REQUIRED FIELDS FOR CLAIM SUBMISSIONS Required if applicable CONTENT DESCRIPTION Supplemental information can only be entered with a corresponding, completed service line. The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. When reporting additional anesthesia services information (e.g., begin and end times), narrative description of an unspecified code, NDC, VP HIBCC codes, OZ GTIN codes or contract rate, enter the applicable qualifier and number/code/information starting with the first space in the shaded line of this field. Do not enter a space, hyphen, or other separator between the qualifier and the number/code/information. The following qualifiers are to be used when reporting these services. 7 - Anesthesia information ZZ - Narrative description of unspecified code N4 - National Drug Codes (NDC) VP - Vendor Product Number Health Industry Business Communications Council (HIBCC) Labeling Standard OZ - Product Number Health Care Uniform Code Council Global Trade Item Number (GTIN) CTR - Contract rate 24a DATE(S) OF SERVICE Required Enter the month, day, and year (MM/DD/YY) date when each procedure, service, or supply that was rendered. Services must be entered chronologically (starting with the oldest date first). For each service date listed/billed, the following fields must also be entered: Units, Charges/Amount/Fee, Place of Service, Procedure Code, and corresponding Diagnosis Code. IMPORTANT: Do not submit a claim with a future date of service. Claims can only be submitted once the service has been rendered (for example: durable medical equipment). 24b PLACE OF SERVICE Required Enter the place of service code for each item used or service performed. Revised April

44 FIELD # CMS-1500 (08/05) FIELD DESCRIPTIONS REQUIRED FIELDS FOR CLAIM SUBMISSIONS CONTENT DESCRIPTION 24c EMG Required Enter Y for "YES" or leave blank if "NO" to indicate an EMERGENCY as defined in the electronic 837 Professional 4010A1 implementation guide. 24d PROCEDURES, SERVICES, OR SUPPLIES: CPT/HCPCS, MODIFIER Required CPT/HCPCS codes and MODIFIERS reflecting the procedures performed, services rendered, or supplies used. IMPORTANT: Enter the anesthesia time, reported as the beginning and end times of anesthesia in military time under the appropriate procedure code. 24e DIAGNOSIS POINTER Required Diagnosis code reference number (pointer) as it relates the date of service and the procedures shown in Field 21. When multiple services are performed, the primary reference number for each service should be listed first, and other applicable services should follow. The reference number(s) should be a 1, or a 2, or a 3, or a 4; or multiple numbers as explained. IMPORTANT: (ICD-9-CM diagnosis codes must be entered in Item Number 21 only. Do not enter them in 24E.) 24f $ CHARGES Required FULL CHARGE for each listed service. Any necessary payment reductions will be made during claims adjudication (for example, multiple surgery reductions, maximum allowable limitations, co-pays etc). Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number. 24g DAYS OR UNITS Required Number of days or units in this block. (For example: units of supplies, etc.) 24h EPSDT FAMILY PLAN Not Required Leave Blank When entering the NDC units in addition to the HCPCS units, enter the applicable NDC units qualifier and related units in the shaded line. The following qualifiers are to be used: F2 - International Unit ML - Milliliter GR - Gram UN Unit Revised April

45 FIELD # CMS-1500 (08/05) FIELD DESCRIPTIONS REQUIRED FIELDS FOR CLAIM SUBMISSIONS CONTENT DESCRIPTION 24i ID. QUAL Required Enter in the shaded area of 24I the qualifier identifying if the number is a non- NPI. The Other ID# of the rendering provider is reported in 24J in the shaded area. The NUCC defines the following qualifiers: 0B - State License # 1B - Blue Shield Provider # 1C - Medicare Provider # 1D - Medicaid Provider # 1G - Provider UPIN # 1H - CHAMPUS ID # EI - Employer s ID # G2 - Provider Commercial # LU - Location Number N5 - Provider Plan Network ID # SY - Social Security # (The social security number may not be used for Medicare.) X5 - State Industrial Accident Provider # ZZ - Provider Taxonomy # 24j RENDERING PROVIDER ID # Required Enter the NPI number in the non-shaded area of the field. 24k RESERVED FOR LOCAL USE Not Required Leave Blank Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b. 25 FEDERAL TAX ID NUMBER Required Enter the physician/supplier federal tax I.D. number or Social Security number. Enter an X in the appropriate box to indicate which number is being reported. Only one box can be marked. IMPORTANT: The Federal Tax ID Number in this field must match the information on file with the IRS. 26 PATIENT'S ACCOUNT NO. Required Enter the Members account number assigned by the practitioner s/provider s accounting system. 27 ACCEPT ASSIGNMENT Not Required Leave Blank IMPORTANT: This field aids in patient identification by the Practitioner/Provider. 28 TOTAL CHARGE Required Enter total charges for the services rendered (total of all the charges listed in Field 24f). Revised April

46 FIELD # CMS-1500 (08/05) FIELD DESCRIPTIONS REQUIRED FIELDS FOR CLAIM SUBMISSIONS 29 AMOUNT PAID Required if applicable CONTENT DESCRIPTION Enter amount paid (i.e., Member copayments or other insurance payments) to date in this field for the services billed. 30 BALANCE DUE Required Enter the balance due (total charges less the amount paid). 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS 32 SERVICE FACILITY LOCATION INFORMATION Required Required Signature of the physician/supplier or his/her representative, and the date the form was signed. For claims submitted electronically, a computer printed name will appear as the signature of the health care practitioner or person entitled to reimbursement. Name and address of the facility where services were rendered (if other than patient s home or physician s office). Enter the name and address information in the following format: 1st Line Name 2nd Line Address 3rd Line City, State and Zip Code Do not use commas, periods, or other punctuation in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101 ). Enter a space between town name and state code; do not include a comma. When entering a 9 digit zip code, include the hyphen. 32a NPI # Required NPI number of the service facility location in 32. Revised April

47 FIELD # CMS-1500 (08/05) FIELD DESCRIPTIONS REQUIRED FIELDS FOR CLAIM SUBMISSIONS CONTENT DESCRIPTION 32b OTHER ID # Required In the shaded area enter the two digit qualifier identifying the non-npi number followed by the ID number, related to the servicing facility. Do not enter a space, hyphen, or other separator between the qualifier and number. 0B - State License # 1B - Blue Shield Provider # 1C - Medicare Provider # 1D - Medicaid Provider # 1G - Provider UPIN # 1H - CHAMPUS ID # EI - Employer s ID # G2 - Provider Commercial # LU - Location Number N5 - Provider Plan Network ID # SY - Social Security # (The social security number may not be used for Medicare.) X5 - State Industrial Accident Provider # ZZ - Provider Taxonomy # 33 BILLING PROVIDER INFO & PH # Required The name, address, and phone number of the billing entity. 33a NPI # Required The NPI number of the billing entity in b OTHER ID # Required In the shaded area enter the two digit qualifier identifying the non-npi number followed by the ID number, related to the billing entity. Do not enter a space, hyphen, or other separator between the qualifier and number. 0B - State License # 1B - Blue Shield Provider # 1C - Medicare Provider # 1D - Medicaid Provider # 1G - Provider UPIN # 1H - CHAMPUS ID # EI - Employer s ID # G2 - Provider Commercial # LU - Location Number N5 - Provider Plan Network ID # SY - Social Security # (The social security number may not be used for Medicare.) X5 - State Industrial Accident Provider # ZZ - Provider Taxonomy # Revised April

48 Revised April

49 CLAIMS COMPLETION REQUIREMENTS UB-04 CLAIM FORM NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. IMPORTANT: All established CMS-1450 (UB-04) coding/billing instructions as outlined in the UB-04 National Uniform Billing Data Specifications Manual should be followed when completing CMS-1450 (UB-04) inpatient and/or outpatient claims. HIGHLIGHTS TOPIC WHERE TO MAIL CLAIMS INSTRUCTIONS All paper claims (and any necessary supporting documentation) should be mailed to the following address: Kaiser Permanente P.O. Box 5316 Cleveland, OH UB-04 CLAIM FORM NATIONAL PROVIDER IDENTIFIER (NPI) CMS-1450 (UB-04) claim forms must be used by all facilities. Professional services (for example, services rendered by radiologists, ER physicians, etc.) should be billed on CMS-1500 claim form, unless you are contracted under a GLOBAL rate (in which professional services should NOT be billed separately). (See Claims Completion Requirements CMS-1500 section for claim form instructions). The new CMS-1450 (UB-04) form accommodates the use of National Provider Identifier (ID) numbers for all providers. The NPI Number should be entered in the following fields for the stated provider types. Rendering Physician should enter their NPI number in the non-shaded area in Field 56 (NPI). Attending Physician Field 76 Operating Physician Field 77 Other Physicians Field HIPAA REQUIREMENTS Revised April All electronic claim submissions must adhere to all Health Insurance Portability and Accountability Act (HIPAA) requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Practitioner/Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at For additional requirements, please contact the Network Development Department (Option #4) to obtain a current list of Clearinghouses, or refer to the Kaiser Permanente EDI Trading Partner Companion document.

50 TOPIC CLAIM SUBMISSION TIMEFRAMES INSTRUCTIONS Initial Claim Submissions: All claims must be submitted for processing within 12 months (365 days) of the date of service. Any claims submitted after 12 months (365 days) from the date of service must be accompanied by documentation as to why the claims should be considered for payment. Complete a Supporting Documentation Cover Sheet (see sample and instructions on page 91) and attach the documentation with a paper clip. Claims submitted without this documentation will be denied. BILL FULL CHARGES Claim Corrections: Claim corrections should be submitted for processing as soon as possible after the discrepancy is discovered, but no later than 180 days from the date of initial payment, with proof of acceptable initial timely claim filing. If there are extenuating circumstances that did not allow you to file the correction within 180 days please submit documentation with your request for reconsideration. Full charges based on your universal charge master should be billed for all services unless otherwise instructed. Please do not bill charges based on your contracted rates. Any necessary payment reductions will be made during claims adjudication (for example, maximum allowable limitations, co-payments, etc.). Example: A facility performs a surgical procedure Rev Code 360: Surgery Correct Way to Bill REV CODE $ CHARGES 360 $3500 Incorrect Way to Bill REV CODE $ CHARGES 360 $1750 This is the correct way to bill for a surgical procedure. Any necessary payment reductions will be made during claims adjudication. The Practitioner/Provider should NOT reduce his/her usual charges (i.e., $1750). This will automatically be done by Kaiser Permanente during claims adjudication. Revised April

51 TOPIC COORDINATION OF BENEFITS (COB) NO FAULT/WORKERS COMPENSATION/OTHER ACCIDENT RECORD THE AUTHORIZATION NUMBER INSTRUCTIONS EOB or MSN Required: Electronic Claims If Kaiser Permanente is the secondary payer, send the completed electronic claim with the payment fields from the primary insurance carrier. Paper Claims If Kaiser Permanente is the secondary payer, send the completed claim form with a copy of the corresponding Explanation of Benefit (EOB) or Medicare Summary Notice (MSN) from the primary insurance carrier attached to the paper claim to ensure efficient processing/ adjudication. Kaiser Permanente cannot process a claim without an EOB or MSN from the primary insurance carrier. UB-04 Complete Field 54 (Prior Payments) Additional COB Information: Please see the COB section in this GUIDE for additional information regarding coordination of benefits, and for a list of the specific COB fields on the UB-04 claim forms which must be completed to ensure accurate COB payment determinations by Kaiser Permanente. Questions: If you have any questions relating to the Coordination of Benefits, please call our Network Development Department (Option #4) for assistance. Whenever No Fault, Workers compensation, or Other Accident situations apply be sure to indicate using: UB-04 claim form the: Condition Codes fields (Fields 19-28), Occurrence Code/Date fields (Fields 31-34), and Value Codes fields (Fields 39-41) Refer to your UB-04 Manuals for the correct codes to use in these fields. If applicable, enter the Authorization Number in Field 63 (Treatment Authorization Codes), and the Name of the Referring Physician for Outpatient claims or the Attending Physician for Inpatient claims in Field 76 (Attending - Last/First/NPI/QUAL/ID) to ensure efficient claims processing and handling. SUBMISSION OF MULTIPLE PAGE CLAIM If due to space constraints you must use a second claim form, please write continuation at the top of the second form, and attach the second form to the first claim with a paper clip. Enter the TOTAL CHARGE (Field 47) on the last page of your claim submission. SURGICAL AND/OR OBSTETRICAL PROCEDURES ENTERING DATES MULTIPLE DATES OF SERVICE AND PLACE OF SERVICE If any surgical and/or obstetrical procedures were performed, record the ICD-9-CM principal procedure code and date in Field 74, and enter any additional ICD-9-CM procedure codes and corresponding dates in Field 74A-E. All dates (dates of birth, dates of service, etc.) must be reported in the following format: month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2003 DIFFERENT Place Of Service In most instances, when services are rendered in DIFFERENT places of service (locations), a separate claim form must be submitted for EACH different place of service. SAME Place Of Service Whenever services are provided in the SAME place of service, on DIFFERENT dates of service, these services may be reported and listed as Revised April

52 TOPIC MULTIPLE DATES OF SERVICE AND PLACE OF SERVICE-con t. INSTRUCTIONS separate lines on ONE claim form, along with the corresponding date, diagnosis code(s), procedure code(s), and charges. See the table on pages for detailed instructions for billing same/multiple dates of service and places of service. BILLING INPATIENT CLAIMS THAT SPAN DIFFERENT YEARS (Year-end Billing) When an inpatient claim spans different years (for example, the patient was admitted in December and was discharged in January of the following year), it is NOT necessary to submit two claims for these services. Bill all services for this inpatient stay on one claim form (if possible), reflecting the correct date of admission and the correct date of discharge. Kaiser Permanente will apply the appropriate/applicable payment methodologies when processing these claims. INTERIM INPATIENT BILLS DRG/Case Rate/Other Reimbursement Contracts: Facilities contracted with Kaiser Permanente under a DRG, case-rate or other payment methodology CANNOT submit interim inpatient bills; bills can only be submitted upon patient discharge. Per Diem: Skilled nursing facilities contracted with Kaiser Permanente under a per diem methodology may submit interim inpatient bills on a monthly basis for prolonged patient hospitalizations. Be sure to indicate via appropriate codes in Field 22 (Discharge Status Code) and Field 4 (Type of Bill) that this is an interim inpatient bill. CLAIM CORRECTIONS UB-04 Claim Forms: NOTE: Corrections may be submitted EITHER electronically or on paper. When submitting a corrected UB-04 claim to Kaiser Permanente for processing: Electronic Include the appropriate Type of Bill code when electronically submitting a corrected UB-04 claim to Kaiser Permanente for processing. IMPORTANT: Claims submitted without the appropriate 3 rd digit (XXX) in the Type of Bill code will be denied. Paper 1) Write CORRECTED CLAIM in the top (blank) portion of the standard claim form. 2) Attach a copy of the corresponding page of Kaiser Permanente s Explanation of Payment (EOP) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. 3) Use the appropriate Type of Bill (Field 4) code when submitting a claim on a UB-04 form. IMPORTANT: Claims submitted without the appropriate 3 rd digit (XXX) in the Type of Bill code will be denied. 4) Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address (see page 49 in this section). Revised April

53 TOPIC SUPPORTING DOCUMENTATION INSTRUCTIONS To expedite claims processing and adjudication, a Practitioner/Provider should submit supporting written documentation (for example, copies of pertinent medical records) with certain types of claims. See Supporting Documentation Table on page 90 for a list of the claims which usually require supporting documentation. Supporting Documentation Submitted WITH a Claim: When supporting documentation is submitted WITH the corresponding paper claim form, attach/secure the documentation to the paper claim with a paper clip (do not staple) and mail to Kaiser Permanente s mailing address (see page 49 in this section). Supporting Documentation Submitted SEPARATELY From a Claim: When sending supporting documentation SEPARATELY from the claim (for example, when sending in requested medical information for a pended claim). 1) Complete a Supporting Documentation Cover Sheet (see sample and instructions on page 89) for each Member for whom you are submitting paper documentation. 2) Attach the routing slip to each Member s paper documentation with a paper clip. 3) Mail the supporting documentation as per the instructions on the form. Revised April

54 UB-04 FIELD DESCRIPTIONS The fields identified in the table below as Required must be completed when submitting a CMS (UB-04) claim form to Kaiser Permanente for processing: Please Note: The fields required for submission below are required by Kaiser Permanente but not necessarily by CMS or other payers. For Medicare members, please refer to Medicare s billing requirements for appropriate field requirements and instructions or examples. FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 1 PROVIDER NAME and ADDRESS 2 PAY-TO NAME, ADDRESS, CITY/STATE, ID # Required Required Enter the name and address of the hospital or person who rendered the services being billed. Enter the name and address of the hospital or person to receive the reimbursement. 3a PATIENT CONTROL NUMBER Required Enter the member s control number. IMPORTANT: This field aids in patient identification by the Practitioner/Provider. 3b MEDICAL RECORD NUMBER Not Required Enter the number assigned to the patient s medical/health record by the provider. 4 TYPE OF BILL Required Enter the appropriate code to identify the specific type of bill being submitted. This code is required for the correct identification of inpatient vs. outpatient claims voids, etc. 5 FEDERAL TAX NUMBER 6 STATEMENT COVERS PERIOD Required Required Enter the federal tax ID of the hospital or person entitled to reimbursement. Enter the beginning and ending date of service included in the claim. 7 BLANK Not Required Leave blank. 8 PATIENT NAME Required Enter the member s name. 9 PATIENT ADDRESS Required Enter the member s address. 10 PATIENT BIRTH DATE Required Enter the member s birth date. 11 PATIENT SEX Required Enter the member s gender. 12 ADMISSION DATE Required For inpatient claims only, enter the date of admission. 13 ADMISSION HOUR Required For either inpatient OR outpatient care, enter the 2- digit code for the hour during which the member was admitted or seen. 14 ADMISSION TYPE Required Indicate the type of admission (e.g. emergency, urgent, elective, and newborn). 15 Point of Origin for Admission or Visit 16 DISCHARGE HOUR (DHR) Required Required if Applicable Enter the appropriate code which defines the point of origin for this patient s admission or visit. Enter the two-digit code for the hour during which the member was discharged. 17 PATIENT STATUS Required Enter the discharge status code. Revised April

55 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES CONDITION CODES Required if Applicable Enter any applicable codes which identify conditions relating to the claim that may affect claims processing. 29 ACCIDENT (ACDT) STATE Not Required Enter the two-character code indicating the state in which the accident occurred which necessitated medical treatment. 30 BLANK Not Required Leave blank OCCURRENCE CODES AND DATES OCCURRENCE SPAN CODES AND DATES Required if Applicable Required if Applicable Enter the code and the associated date defining a significant event relating to this bill that may affect claims processing. Enter the occurrence span code and associated dates defining a significant event relating to this bill that may affect claims processing. 37 BLANK Not Required Leave blank. 38 RESPONSIBLE PARTY Not Required Enter the responsible party name and address VALUE CODES and AMOUNT Required if Applicable Enter the code and related amount/value which is necessary to process the claim. 42 REVENUE CODE Required Identify the specific accommodation, ancillary service, or billing calculation, by assigning an appropriate revenue code. 43 REVENUE DESCRIPTION 44 PROCEDURE CODE AND MODIFIER Not Required Required Enter the revenue description. For ALL outpatient claims, enter BOTH a revenue code in Field 42 (Rev. CD.), and the corresponding CPT/HCPCS procedure code in this field. 45 SERVICE DATE Required Outpatient Series Bills: A service date must be entered for all outpatient series bills whenever the from and through dates in Field 6 (Statement Covers Period: From/Through) are not the same. Submissions that are received without the required service date(s) will be rejected with a request for itemization. 46 UNITS OF SERVICE Required The units of service. Multiple/Different Dates of Service: Multiple/different dates of service can be listed on ONE claim form. List each date on a separate line on the form, along with the corresponding revenue code (Field 42), procedure code (Field 44), and total charges (Field 47). 47 TOTAL CHARGES Required Indicate the total charges pertaining to the related revenue code for the current billing period, as listed in Field BLANK Not Required Leave blank. 48 NON COVERED CHARGES Not Required Enter any non-covered charges. Revised April

56 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 50 PAYER NAME Required Enter (in appropriate ORDER on lines A, B, and C) the NAME and NUMBER of each payer organization from whom you are expecting payment towards the claim. 51 HEALTH PLAN ID Required Enter the provider number 52 RELEASE OF INFORMATION (RLS INFO) 53 ASSIGNMENT OF BENEFITS (ASG BEN) Not Required Required if Applicable Enter the release of information certification number Enter the assignment of benefits certification number. 54a-c PRIOR PAYMENTS Required if Applicable If payment has already been received toward the claim by one of the payers listed in Field 50 (Payer) prior to the billing date, enter the amounts here. 55 ESTIMATED AMOUNT DUE 56 NATIONAL PROVIDER IDENTIFIER (NPI) Not Required Required Enter the estimated amount due. Enter the service provider s National Provider Identifier (NPI). 57 OTHER PROVIDER ID Required Enter the service provider s Kaiser-assigned provider ID. 58 INSURED S NAME Required Enter the subscriber s name. 59 PATIENT S RELATION TO INSURED Required if Applicable Enter the member s relationship to the subscriber. 60 INSURED S UNIQUE ID Required Enter the insured person s unique individual member identification number (medical/health record number), as assigned by Kaiser. 61 INSURED S GROUP NAME 62 INSURED S GROUP NUMBER 63 TREATMENT AUTHORIZATION CODE 64 DOCUMENT CONTROL NUMBER Required if Applicable Required if Applicable Required if Applicable Not Required Enter the insured s group name. Enter the insured s group number as shown on the identification card. For Prepaid Services claims enter "PPS". For ALL inpatient and outpatient claims, enter the referral number. Enter the document control number related to the member or the claim. 65 EMPLOYER NAME Required if Applicable Enter the employer s name. 66 DX VERSION QUALIFIER 67 PRINCIPAL DIAGNOSIS CODE 67 A-Q OTHER DIAGNOSES CODES Not Required Required Required if Applicable Indicate the type of diagnosis codes being reported. Note: At the time of printing, Kaiser only accepts ICD-9-CM diagnosis codes on the UB-04 Enter the principal diagnosis code, on all inpatient and outpatient claims. Enter other diagnoses codes corresponding to additional conditions. Diagnosis codes must be carried to their highest degree of detail. Revised April

57 FIELD NUMBER FIELD NAME REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 68 BLANK Not Required Leave blank. 69 ADMITTING DIAGNOSIS Required Enter the admitting diagnosis code on all inpatient claims. 70 (a-c) REASON FOR VISIT (PATIENT REASON DX) Not Required Enter the diagnosis codes indicating the patient s reason for outpatient visit at the time of registration. 71 PPS CODE Required if Applicable Enter the DRG number which the procedures group, even if you are being reimbursed under a different payment methodology. 72 EXTERNAL CAUSE OF INJURY CODE (ECI) Required if Applicable Enter an ICD-9-CM E-code in this field (if applicable). 73 BLANK Not required Leave blank. 74 PRINCIPAL PROCEDURE CODE AND DATE Required if Applicable Enter the ICD-9-CM procedure CODE and DATE on all inpatient AND outpatient claims for the principal surgical and/or obstetrical procedure which was performed (if applicable). 74 (a e) OTHER PROCEDURE CODES AND DATES Required if Applicable Enter other ICD-9-CM procedure CODE(S) and DATE(S) on all inpatient AND outpatient claims (in fields A through E ) for any additional surgical and/or obstetrical procedures which were performed (if applicable). 75 BLANK Not required Leave blank. 76 ATTENDING PHYSICIAN / NPI / QUAL / ID 77 OPERATING PHYSICIAN / NPI/ QUAL/ ID OTHER PHYSICIAN/ NPI/ QUAL/ ID Required Required If Applicable Required if Applicable Enter the National Provider Identifier (NPI) and the name of the attending physician for inpatient bills or the physician that requested the outpatient services. Inpatient Claims Attending Physician Enter the full name (first and last name) of the physician who is responsible for the care of the patient. Outpatient Claims Referring Physician For ALL outpatient claims, enter the full name (first and last name) of the physician who referred the Member for the outpatient services billed on the claim. Enter the National Provider Identifier (NPI) and the name of the lead surgeon who performed the surgical procedure. Enter the National Provider Identifier (NPI) and name of any other physicians. 80 REMARKS Not Required Special annotations may be entered in this field. 81 CODE-CODE Not required Enter the code qualifier and additional code, such as marital status, taxonomy, or ethnicity codes, as may be appropriate. Revised April

58 Revised April

59 ANESTHESIA NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. Kaiser Permanente provides coverage for anesthesia services that are medically necessary as part of authorized medical or surgical care in accordance with the Member s Evidence of Coverage. TOPIC GLOBAL ANESTHESIA PACKAGE OFFICE-BASED SURGICAL PROCEDURES ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT EXPLANATION/INSTRUCTIONS The global anesthesia package includes: The performance of a pre-anesthetic examination and evaluation (even if the exam is done on a date different from the date of surgery) The administration of the anesthetic The administration of fluids and/or blood incidental to the delivery of anesthesia (or the procedure being performed) The usual monitoring services (ECG, blood pressure, etc.) The provision of post-operative anesthesia care (post-operative visit) When an office-based surgical procedure is performed, reimbursement for the procedure includes reimbursement for anesthesia services as part of the global surgical fee, because it is expected that appropriate anesthesia will be administered with the office-based procedure. Kaiser Permanente reimburses participating providers for anesthesia services based on nationally recognized criteria for reporting of anesthesia services, including: The American Medical Association (AMA) CPT codes ( ) American Society of Anesthesiologists (ASA) Relative Value Guide (RVG) Medicare Guidelines BASE UNITS: Providers are NOT to indicate the ASA base unit values in the Days/Units field on the CMS 1500 (Field 24, Box G). Base units are determined as defined by the American Society of Anesthesiologists Relative Value Guide. The base units assigned to a procedure are intended to demonstrate the relative complexity of a specific procedure and include the value of all anesthesia services, except the value of the actual time spent administering the anesthesia. Kaiser Permanente stores the base unit value within our claims system and will calculate the anesthesia payment of the base units according to the information provided on the claim. REPORTING OF ANESTHESIA TIME: Anesthesia time begins when the anesthesiologist starts to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area. Anesthesia time ends when the anesthesiologist is no longer in personal attendance, which is when the patient may be safely placed under postoperative supervision. Time units are calculated by allowing 1 unit for each 15 minute interval or remaining fraction thereof. Providers are to show time as follows. Revised April

60 TOPIC ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT con t. EXPLANATION/INSTRUCTIONS Paper: Providers are to show time as total number of minutes in the Units field (Item 24, Box G). EDI: 837 Professional Claim Service Line - Unit or Basis for Measurement Loop: 2400 Segment: SV103 Description: For claims requiring minutes, such as Anesthesia claims, please submit using the qualifier of "MJ" to denote minutes in loop 2400 SV103. Example: Submitted claim line with 100 minutes. SV1*HC:01967*12.25*MJ*100****1:2:3**N~ REIMBURSEMENT: Payment for most anesthesia services is based on: The base unit value Plus anesthesia time units Multiplied by the fee schedule conversion factor, as appropriate. Other services are reimbursed based upon the CPT code. EXCEPTIONS TO BILLING ANESTHESIA CODES MULTIPLE SURGICAL PROCEDURES: When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex with the multiple procedure modifier -51 is reported. The time reported is the combined total of all procedures reported on the primary procedure. Anesthesiologists should bill using anesthesia codes only, unless one or more of the following services was performed by the anesthesiologist (in which case the appropriate non-anesthesia CPT code(s) may be reported and billed in accordance with CMS guidelines): Evaluation and management services Hospital inpatient services Consultations Critical care services Pain management Nerve blocks Destruction by neurolytic agents Services not included in the global anesthesia fee Other miscellaneous services QUALIFYING CIRCUMSTANCES: CPT codes 99100, 99116, and represent various patient conditions that may impact the anesthesia service provided. Such codes may be billed in addition to the anesthesia being billed. Charges for these codes are to be shown on the same line as the CPT Qualifying Circumstances Code in Field 24, Box F on the CMS PATIENT-CONTROLLED ANALGESIA (PCA): Benefits may be available for the administration of patient-controlled analgesia (PCA) following a surgical procedure. PCA billed by a surgeon is covered as part of the global surgical package and is not separately reimbursable. PCA reimbursements are limited to anesthesiologists only. An anesthesiologist s services for PCA should be submitted as a single line on the Revised April

61 TOPIC EXCEPTIONS TO BILLING ANESTHESIA CODES-con t. EXPLANATION/INSTRUCTIONS claim form as follows: Span the dates to include the entire care for the PCA (reimbursement will be made as a global allowance, and will include the entire course of PCA). Any hospital care provided by the anesthesiologist subsequent to the initial day of PCA will be considered covered under the global PCA fee. Use CPT code when billing for PCA services. CONSCIOUS SEDATION: Sedation with or without analgesia (conscious sedation), CPT codes , are considered eligible for reimbursement when billed by an anesthesiologist, pain management or certified registered nurse anesthetist. ANESTHESIA MODIFIERS Revised April Personally Performed or Medically-Directed/Supervised Anesthesia Services: Use an appropriate HCPCS anesthesia modifier to denote whether the anesthesia services were personally performed, medically directed, or medically supervised: AA - Anesthesia service performed personally by the Anesthesiologist AD - Medical supervision by a physician of more than four concurrent procedures G8 - Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures G9 - Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals QX - CRNA service with medical direction by a physician QY - Medical direction of one CRNA by the QZ - CRNA service without medical direction by a physician QS - Monitored anesthesia care service (can be billed by a CRNA or a physician) GC - These services have been performed by a resident under the direction of a teaching physician. Physical Status Modifiers: As indicated in the CPT book, the following physical status modifiers should be appended to the CPT anesthesia code to distinguish between the various levels of complexity of the anesthesia service(s) provided: P1 - A normal healthy patient P2 - A patient with mild systemic disease P3 - A patient with severe systemic disease P4 - A patient with severe systemic disease that is a constant threat to life P5 - A moribund patient who is not expected to survive without the operation P6 - A declared brain-dead patient whose organs are being removed for donor purposes DO NOT enter additional minutes for the Physical Status modifier. If eligible for reimbursement, the additional unit(s) will be calculated by our claims system. The patient cannot be billed for Physical Status modifiers not allowed by Kaiser Permanente. Other CPT Modifiers/Qualifying Circumstances Codes: Other modifiers and qualifying circumstances codes may be used as appropriate. Follow the instructions in the CPT/HCPCS books when reporting these additional modifiers and/or codes.

62 ADDITIONAL SERVICES NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. TOPIC ABORTION SERVICES EXPLANATION/INSTRUCTIONS Description: Abortion is the termination of a pregnancy by the removal or expulsion from the uterus of a fetus or embryo, resulting in or caused by its death. An abortion can occur spontaneously due to complications during pregnancy or can be induced CMS1500 Field 24d CPT codes are required for all professional services. Use CPT Codes to define abortion services BEHAVIORAL HEALTH SERVICES UB-04 Field Include condition codes describing the service for all abortion or abortionrelated services. AA: Abortion Performed due to Rape AB: Abortion Performed due to Incest AC: Abortion Performed due to Serious Fetal Genetic Defect, Deformity, or Abnormality AD: Abortion Performed due to a Life Endangering Physical Condition Caused by, Arising from or Exacerbated by the Pregnancy Itself AE: Abortion Performed due to Physical Health of Mother that is not Life Endangering AF: Abortion Performed due to Emotional/psychological Health of the Mother AG: Abortion Performed due to Social or Economic Reasons AH: Elective Abortion Description: Behavioral health procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors in relation to the prevention, treatment, or management of behavioral health problems. CMS-1500 Field 24d CPT codes are required for all professional services. Record the code for the predominant service only when performing psychiatric health assessment/ intervention on the same date as psychiatric therapeutic procedures. UB-04 Field 14 Required for all inpatient behavioral health claims Field 44 For outpatient services, enter the appropriate HCPCS/CPT code that corresponds to the Revenue Code in Field 42. Supporting Documentation for Behavioral Health Claims: Unlisted Procedure Codes: Any behavioral health claims which contain any unlisted, unclassified, unspecified or miscellaneous CPT or HCPCS procedure codes. Repeated procedures performed on the SAME date of service require supporting documentation. Revised April

63 DURABLE MEDICAL EQUIPMENT (DME) Description: Durable Medical Equipment is medically necessary equipment that is: Appropriate for use at home Primarily and customarily used to service a medical purpose Not useful to a person in absence of an illness Able to withstand repeated use EVALUATION/ MANAGEMENT (E/M) SERVICES CMS-1500 UB-04 Field 24d CPT codes are required for all professional services. Use HCPCS Level II codes to define DME. Use modifiers, if applicable. Field 42 Enter the appropriate revenue code Field 44 HCPCS/Rates required Field 46 Number of rental months Field 54 DME cost sharing amounts collected from the Member Field 80 For DME billing, rental rate costs and anticipated months of usage CMS-1500 Field 19 When covering for another physician, enter the name of the physician you are covering for. NOTE: If a non-participating Practitioner/Provider will be covering for you in your absence, please notify that individual of this requirement. Inpatient E/M Services: If a patient is admitted for observation following the performance of a major/minor surgical package procedure, do not report hospital observation service codes, because all post-operative E/M services are included as part of the global surgical package. Consultations: Kaiser Permanente will reimburse for initial consultations when billed with any surgical procedure done on the same day of service. For office/outpatient: If the consultant assumes patient management responsibilities following the initial consultation, office E/M (established patient) visit codes should be used for all subsequent patient encounters, NOT office consultation codes. For inpatient: If the consultant assumes patient management responsibilities, use subsequent hospital care codes (NOT follow-up inpatient consultation codes) to report all additional E/M encounters with the patient. Surgery and E/M Services: Reimbursement will generally NOT be made for a pre- or post-operative E/M visit provided on the same day as major/minor surgery, or an endoscopic procedure, unless Kaiser Permanente agrees that there was a significant, separately identifiable E/M service provided in addition to the procedure. In these instances, the provider must bill for the E/M visit using the appropriate modifier. If E/M services are performed during the post-operative period for a reason unrelated to the original procedure (such as for other disease or injuries), you may bill for these services using modifier 24 (Unrelated E/M service by the same physician during a post-operative period), and you must list a Revised April

64 EVALUATION/ MANAGEMENT (E/M) SERVICES-con t. corresponding diagnosis code which reflects that the E/M services were for a problem other than the surgical diagnosis. Urgent or Emergency Services Provided in the Office: For urgent or emergency services provided in the office setting, use code Office services provided on an emergency basis in addition to the appropriate E/M office visit code. Because CPT procedure codes series are considered to be adjunct services to the basic services provided, Kaiser Permanente will reimburse providers for BOTH the E/M visit code and emergency services code. Non-Surgical Procedure that Include E/M Services: There are certain instances where Kaiser Permanente will deny medical visits when billed with certain non-surgical procedures, because the codes for these procedures include admission to the hospital and/or daily visits. The non-surgical procedures which fall into this category include: Clinical brachytherapy End stage renal disease services Allergy immunotherapy services Preventive Medicine Services: Preventive medicine codes -- NOT office evaluation/management codes -- should be used to report the routine evaluation and management of adults and children, in the absence of patient complaints. For example, preventive medicine codes should be used for: Well-baby check ups Routine pediatric visits Camp or school physicals Routine, annual gynecological exams EMERGENCY ROOM (ER) SERVICES UB-04 Field 15 Enter the code indicating the source of the admission or outpatient registration Field 44 The emergency department E/M visit codes should ONLY be used if the patient is seen in the emergency department. For urgent or emergency services provided in the office setting, bill code (Office services provided on an emergency basis) in addition to the appropriate E/M office visit code. Emergency department E/M visit codes should be used for E/M services provided in the emergency department, even if these were non-emergency services. The only requirement for using emergency department codes is that the patient must be registered in the emergency department. Office visit E/M codes should be used if the patient is seen in the ER as a convenience to the physician and/or patient, but the patient is not registered in the emergency department. NOTE: If both an emergency department physician and an attending physician are involved in admitting a patient from the ER, the ER physician should bill for his services utilizing the emergency department E/M codes, and the attending physician should bill for his services using the initial hospital visit codes. The two physicians cannot each bill for both the ER services rendered and the hospital admission. INJECTIONS/ IMMUNIZATIONS CPT codes are required for all professional services. Use HCPCS Level II codes to define Injections/ Immunizations. NOTE: If there was no identifiable E/M service rendered by the nurse or the provider, and the patient received only an injection during the encounter, it is permissible to report an injection administration code in lieu of the E/M visit code and the appropriate Revised April

65 INJECTIONS/ IMMUNIZATIONScon t. HCPCS code (specifying the drug administered).unlike injections, immunization procedures include the supply of materials. Additionally, injection administration fees are not eligible for reimbursement when billed with immunization codes. Effective September 1, 2009 HCPCS Code G9142- Influenza A Vaccine and G9141- Influenza A immunization administration should be used to report H1N1 Vaccine and administration. NEWBORN SERVICES CMS-1500 Field 2 Enter the first and last name of the newborn Field 3 Enter the newborn s date of birth OUTPATIENT REHABILITATION The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service was delivered for therapy, even if the code is not recognized by CMS as requiring a therapy modifier; such as or 97545: GN- Services delivered under an outpatient speech-language pathology plan of care GO- Services delivered under an outpatient occupational therapy plan of care GP- Services delivered under an outpatient physical therapy plan of care This is applicable to all claims from physicians, non-physician practitioners, hospitals and skilled nursing facilities. Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech-language pathology services. The inclusion of these modifiers will assist Kaiser Permanente in applying the correct benefits as part of claims adjudication for claims for outpatient rehabilitation services. Revised April

66 COORDINATION OF BENEFITS (COB) NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. Coordination of Benefits (COB) is a way of determining the order in which benefits are paid and the amounts which are payable when a claimant is covered under more than one plan. It prevents duplication of benefits when an individual is covered by multiple plans providing benefits or services for medical, dental or other care and treatment. Kaiser Permanente follows the National Association of Insurance Commissioners (NAIC) model regulations for coordinating benefits, except in those instances where the NAIC model regulations differ from Ohio state law, Ohio state law supersedes the NAIC model regulations. TOPIC DESCRIPTIONS OF COB PAYMENT METHODOLOGIES EXPLANATION / INSTRUCTIONS Kaiser Permanente Ohio Coordination of Benefits allows benefits from multiple carriers to be added on top of each other so that the Member receives the full benefits from their primary carrier and the secondary carrier pays their entire benefit up to 100% of allowed charges. Benefit carve-out calculations are based on whether or not the provider accepts Medicare assignment for the provider contract corresponding to the claim. Medicare assignment means the provider has agreed to accept the Medicare allowed amount as payment. COB QUESTIONS If you have any questions relating to the coordination of benefits, please call our Network Development Department (Option 4) for assistance. HIPAA REQUIREMENTS All electronic claim submissions must adhere to all Health Insurance Portability and Accountability (HIPAA) requirements. The following websites (in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Practitioner/Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at (301) For additional requirements, please contact the Network Development Department (Option #4) to obtain a current list of Clearinghouses, or refer to the Kaiser Permanente EDI Trading Partner Companion document. Revised April

67 TOPIC EOB or MSN STATEMENT EXPLANATION / INSTRUCTIONS Whenever Kaiser Permanente is the SECONDARY payer, claims can be submitted EITHER electronically or on one of the standard paper claim forms: Electronic Claims If Kaiser Permanente is the secondary payer, send the completed electronic claim with the payment fields from the primary insurance carrier entered as follows: 837P claim transaction Enter Amount Paid 837I claim transaction Enter Prior Payments Paper Claims If Kaiser Permanente is the secondary payer, send the completed claim form with a copy of the corresponding Explanation of Benefit (EOB) or Medicare Summary Notice (MSN) from the primary insurance carrier attached to the paper claim to ensure efficient claims processing/adjudication. Kaiser Permanente will deny a claim without an EOB or MSN from the primary insurance carrier. CMS-1500 claim form Complete Field 29 (Amount Paid) UB-04 claim form Complete Field 54 (Prior Payments) MEMBERS ENROLLED IN TWO KAISER PERMANENTE PLANS Some Members may be enrolled under two separate plans offered through Kaiser Permanente (dual coverage). In these situations, standard COB rules still apply. Example: A married couple both work for a company that offers Kaiser Permanente to its employees. Both the husband and wife enroll in Kaiser Permanente as subscribers and each lists the other as a dependent spouse and each lists their children as dependent children. Practitioners/Providers should submit one claim under the primary plan to Kaiser Permanente for processing. After we pay under the primary plan, Practioners/Providers should submit a second claim under the secondary plan. IMPORTANT COB POINTS TO REMEMBER COB ANNUAL UPDATES Kaiser Permanente reviews and updates coordination of benefits information annually (by contacting members as required), in an attempt to maintain up-todate COB records. Revised April BIRTHDAY RULE Kaiser Permanente follows the birthday rule, which states that the insurance carried by the parent/subscriber whose birthday falls earlier in the calendar year will be the primary payer for a dependent child who is covered by two different insurances (for example, when a dependent child is covered BOTH by an insurance carried by the dependent s mother, as well as under a different insurance carried by the dependent s father). Example: Parent A: Date of Birth: 03/06/1948. This coverage is primary. Parent B: Date of Birth: 07/20/1948. This coverage is secondary. NOTE: In rare cases both parents may have the same birth date. In these cases the plan that has been in effect the longest is the primary carrier. DEPENDENT CHILD OF SEPARATED OR DIVORCED PARENTS Divorce Decree/Court Order If specific terms of a court decree state that one of the parents is responsible for the healthcare expenses of a child, and the entity obligated to pay or provide benefits of the plan of that parent has actual knowledge of

68 TOPIC IMPORTANT COB POINTS TO REMEMBER-con t. EXPLANATION / INSTRUCTIONS those terms, the benefits of that plan are determined first. The Member may be required to submit a copy of their court order or divorce decree. In the absence of a divorce decree/court order stipulating parental healthcare responsibilities for a dependent child, insurance benefits for that child are applied according to the following order: Insurance carried by the 1) Natural parent with custody pays first 2) Step-parent with custody pays next 3) Natural parent without custody pays next 4) Step-parent without custody pays last If the parents have joint custody of the dependent child, then benefits are applied according to the birthday rule referenced above. Revised April

69 COB FIELDS ON THE CMS-1500 CLAIM FORM The following fields should be completed on the CMS-1500 claim form, to ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB information in these fields may cause claims to be denied or pended and reimbursements delayed. Claims submitted electronically must meet the same data requirements as paper claims. For electronic claim submissions, refer to a HIPAA website for additional information on electronic loops and segments (suggested websites on page 63 in this section). FIELD NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES 9 OTHER INSURED S NAME When additional insurance coverage exists (through a spouse, parent, etc.) enter the LAST NAME, FIRST NAME, and MIDDLE INITIAL of the insured. NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). 9a 9b 9c 9d OTHER INSURED S POLICY OR GROUP NUMBER OTHER INSURED S DATE OF BIRTH/SEX EMPLOYER S NAME or SCHOOL NAME INSURANCE PLAN NAME or PROGRAM NAME Enter the policy and/or group number of the insured individual named in Field 9. If you do not know the policy number, enter the Social Security number of the insured individual. NOTE: Field 9a must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). NOTE: For each entry in this field, there must be a corresponding Entry in 9d (Insurance Plan Name or Program Name). Enter date of birth and sex, of the insured named in Field 9. The date of birth must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/1971 NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). Enter the name of the employer or school name (if a student), of the insured named in Field 9. NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). Enter the name of the insurance plan or program, of the insured individual named in Field 9. NOTE: This field must be completed when there is an entry in Field 11d (Is There Another Health Benefit Plan?). 10 IS PATIENT S CONDITION RELATED TO: a. Employment? b. Auto Accident? c. Other Accident? PLACE (State) Check yes or no to indicate whether employment, auto liability, or other accident involvement applies to one or more of the services described in Field 24. NOTE: If yes, there must be a corresponding entry in Field 14 (Date of Current Illness/ Injury) and in Field 21 (Diagnosis). PLACE (State) Enter the state the Auto Accident occurred in. Revised April

70 FIELD NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES 11d IS THERE ANOTHER HEALTH BENEFIT PLAN? Check yes or no to indicate if there is another health benefit plan. (For example, the patient may be covered under insurance held by a spouse, parent, or some other person). NOTE: If yes, then Field Items 9 and 9a-d must be completed. 14 DATE OF CURRENT Illness (First symptom) Injury (Accident) Pregnancy (LMP) 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Enter the date of the current illness or injury. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2004 Enter the diagnosis and if applicable, enter the Supplementary Classification of External Cause of Injury and Poisoning Code. NOTE: This field must be completed when there is an entry in Field 10 (Is The Patient s Condition Related To). 29 AMOUNT PAID Enter the amount paid by the primary insurance carrier in Field 29. Revised April

71 COB FIELDS ON THE UB-04 CLAIM FORM The following fields should be completed on the UB-04 claim form to ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB information in these fields may cause claims to be denied or pended and reimbursements delayed. For additional information, refer to the current UB-04 National Uniform Billing Data Element Specifications Manual. Claims submitted electronically must meet the same data requirements as paper claims. For electronic claim submissions, refer to a HIPAA website for additional information on electronic loops and segments (suggested websites on page 63 in this section). FIELD NUMBER (UB-04) FIELD NAME OCCURRENCE CODE/DATE INSTRUCTIONS/EXAMPLES Enter the appropriate occurrence code and date defining the specific event(s) relating to the claim billing period. NOTE: If the injuries are a result of an accident, please complete Field 77 (E-Code) on the UB-04. You can include the e- code in Field 81 (Code-Code). 50 PAYER (Payer Identification) 54 PRIOR PAYMENTS (Payers and Patient) Enter the name and number (if known) for each payer organization from whom the provider expects (or has received) payment towards the bill. List payers in the following order on the claim form: A = primary payer B = secondary payer C = tertiary payer Enter the amount(s), if any, that the provider has received toward payment of the bill PRIOR to the billing date, by the indicated payer(s). List prior payments in the following order on the claim form: A = primary payer B = secondary payer C = tertiary payer 58 INSURED S NAME Enter the name (Last Name, First Name) of the individual in whose name insurance is being carried. List entries in the following order on the claim form: A = primary payer B = secondary payer C = tertiary payer NOTE: For each entry in Field 58, there MUST be corresponding entries in Fields 59 through 62 and PATIENT S RELATION TO INSURED 60 INSURED S UNIQUE ID CERT. SSN HIC ID NO. (Certificate/Social Security Number/Health Insurance Claim/Identification Number) Enter the code indicating the relationship of the patient to the insured individual(s) listed in Field 58 (Insured s Name). List entries in the following order: A = primary payer B = secondary payer C = tertiary payer Enter the insured person s (listed in Field 58) unique individual Member identification number (medical/health record number), as assigned by the payer organization. List entries in the following order: A = primary payer B = secondary payer C = tertiary payer Revised April

72 61 GROUP NAME (Insured Group Name) Enter the name of the group or plan through which the insurance is being provided to the insured individual (listed in Field 58). Record entries in the following order: A = primary payer B = secondary payer C = tertiary payer 62 INSURANCE GROUP NO. Enter the identification number, control number, or code assigned by the carrier or administrator to identify the GROUP under which the individual (listed in Field 58) is covered. List entries in the following order: A = primary payer B = secondary payer C = tertiary payer 64 ESC (Employment Status Code of the Insured) Note: This field has been deleted from the UB EMPLOYER NAME (Employer Name of the Insured) Enter the code used to define the employment status of the insured individual (listed in Field 58). Record entries in the following order: A = primary payer B = secondary payer C = tertiary payer Enter the name of the employer who provides health care coverage for the insured individual (listed in Field 58). Record entries in the following order: A = primary payer B = secondary payer C = tertiary payer 67 A-Q (UB-04) DIAGNOSIS CODE The primary diagnosis code should be reported in Field 67. Additional diagnosis code can be entered in Field (UB-04) EXTERNAL CAUSE OF INJURY CODE (E-CODE) If applicable, enter an ICD-9-CM E-code in this field. Revised April

73 EXPLANATION OF PAYMENT (EOP) NOTICE TO ALL PRACTITIONERS/PROVIDERS: Regardless of the methodology by which you may be reimbursed, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500 or UB-04 as applicable), and to follow all claims completion instructions set forth in this GUIDE. Number in Screenprint Field Name Explanation 1 Vendor Name/ Address Name and address of the vendor. 2 Check Number/Date/Amount The check number issued to the provider, the check date and the net amount of the check. 3 Vendor ID The Vendor ID number. 4 Service Dates The dates on which the services were provided. 5 Service The procedure code denoting the medical services or procedures provided. 6 Billed Amount The amount billed by the Provider for a specific service. 7 Other Insurance Amount Amounts paid by another insurance carrier under coordination of benefits, third party liability or workers compensation. 8 Allowed Amount This is the allowed amount for a specific service. 9 Not Covered Amount This is the amount billed by a Provider for a specific service that is not covered due to limitations or exclusions from a Member s benefit plan or Provider reductions. 10 Deductible/Inpatient Copay The portion of the Allowed Amount applied to the Members benefit plan deductible, if any, or as the Member s responsibility to pay towards an inpatient stay. 11 Copay/Coinsurance A specific dollar amount or percentage of the Allowed Amount that is the Member s responsibility to pay towards a specific service. 12 Plan Pays The total amount paid by the Health Plan for all services on the claim. 13 Remark Code Codes describing how the claim was processed. 14 Insured The subscriber who applied for coverage and agrees to be responsible for payment. 15 Claim Number The unique number assigned to this claim. 16 Provider Name The Provider of services associated with this claim. 17 Provider NPI and ID Provider s NPI and ID number. 18 Patient This is the name of the patient to whom the services were provided on this claim. 19 Patient ID Kaiser Permanente Medical Record Number (MRN) of the patient. Revised April

74 Revised April

75 Revised April

76 UNDERSTANDING YOUR PROVIDER EXPLANATION OF PAYMENT (EOP) Allowed Amount This is the allowed amount for a specific service. Applied to Deductible The portion of the Allowed Amount applied to the Members benefit plan deductible if any. Billed Amount The amount billed by the Provider for a specific service. Check Number/Date/Amount- The check number issued to the Provider, the check date and the net amount of the check. Claim Number The unique number assigned to this claim. Copay/Coinsurance A specific dollar amount or percentage of the Allowed Amount that is the Member s responsibility to pay towards a specific service. Deductible A specified dollar amount that the Member must pay for covered services before the Health Plan will pay any amount. Insured The subscriber who applied for coverage and agrees to be responsible for payment. Not Covered Amount This is the amount billed by a Provider for a specific service that is not covered due to limitations or exclusions from a Member s benefit plan or provider reductions. Other Insurance Amount Amounts paid by another insurance carrier under coordination of benefits, third party liability or workers compensation. Patient- This is the name of the patient to whom the services were provided on this claim. Patient Account # - The patient s account number assigned by the practitioner s/provider s accounting system. Patient ID Kaiser Permanente Medical Record Number (MRN) of the patient. Patient Responsibility This may include a portion of the amount listed in the Not Covered Amount column and any amount listed in the Applied to Deductible and the Copay/Coinsurance columns. Plan Pays The total amount paid by the Health Plan for all services on the claim. Provider Name- The provider of services associated with this claim. Provider ID- Provider s ID number. Remark Code Codes describing how the claim was processed. Service Dates- The dates on which the services were provided. Service Description- The description of the medical services or procedures provided. Vendor Name/Address- Name and address of the vendor. Vendor ID - The Vendor ID number. DENIALS DUE TO MISSING INFORMATION If a claim was denied due to missing information, you may resubmit the claim with the complete information. The information needed to complete this claim is described in the Explanation of Payment (EOP) remarks section. Please submit the claim in writing with comments, documents, records and other supporting information for review. Submit in writing to: Kaiser Permanente P.O. Box 5316 Cleveland, OH ADDITIONAL INFORMATION AVAILABLE You are entitled to receive, upon request and free of charge: An explanation of the scientific or clinical judgment used for determining medical necessity, experimental or investigative treatment or similar exclusions/limits. A copy of any internal rule, guideline, protocol or similar criterion relied upon in making the determination. You may contact our Network Development Department for assistance. PROVIDER CLAIM PAYMENT APPEALS PROCEDURE Please review your EOP carefully. If your office has questions or concerns about the way a particular claim was processed by Kaiser Permanente, please contact our Network Development Department (Option #4). Many questions and issues regarding claim payments, coding, and submission policies can be resolved quickly over the phone or via fax. If your issue cannot be resolved through this initial contact, you will be instructed as follows: If you don t agree with this decision in whole or in part you may submit a signed written appeal within 180 days from the date of this notice to: Kaiser Foundation Health Plan of Ohio Attn: Appeals Unit P.O. Box Cleveland, OH or Fax #: (216) Revised April

77 GLOSSARY TERM ACRONYM DEFINITION Allowed Amount American Medical Association Appeal Authorization Balance Billing Billed Amount Bundling Capitation Centers for Medicare & Medicaid Services Clean Claim Clearinghouse Coinsurance Coordination of Benefits Copayment AMA CMS COB The maximum allowable benefits available under the plan. The Allowed Amount may be established in accordance with an agreement between the Practitioner/Provider and Kaiser Permanente. Professional organization for medical professions. Written request for a review of a prospective or retrospective adverse determination. A grant of approval to provide specified Covered Services. Practice of a Provider billing a patient for all charges not paid by the health plan. The amount billed by the Provider for a specific service. Occurs when two or more CPT-4 procedures are used to describe a procedure performed, when a single -- more comprehensive -- CPT-4 procedure code exists that accurately describes the entire procedure performed. A per Member, monthly payment to a Provider that covers contracted services and is paid in advance of its delivery. A Provider agrees to provide specified services to Members for this fixed, pre-determined payment, regardless of how many times the Member uses the service. The rate can be fixed for all Members or it can be adjusted for the age and sex of the Member. The federal agency responsible for administering Medicare and oversight of state s management of Medicaid. Formerly known as Health Care Financing Administration (HCFA). A clean or complete claim is a claim that has no defect or impropriety, including lack of required substantiating documentation from providers, suppliers, or Members or particular circumstances requiring special treatment that prevents timely payments from being made on the claim. A service bureau that handles electronic information routing. A form of cost-sharing whereby an insured individual pays a set percentage of the cost of covered health care services. The most common Coinsurance involves the individual paying a fixed percentage (e.g., 20%) of the cost of a service. Coordination of Benefits (COB) is a way of determining the order in which benefits are paid and the amounts which are payable when a claimant is covered under more than one plan (individual or group). It is intended to prevent duplication of benefits when an individual is covered by multiple plans providing benefits or services for medical, dental or other care and treatment. The dollar amount, if any, the Member must pay at the time of service for covered services that have not been fully prepaid by membership dues. Revised April

78 TERM ACRONYM DEFINITION Covered Services Current Procedural Terminology CPT Services covered under the terms of the contract between a carrier and a contract holder. A list of medical services and procedures performed by physicians and other providers. CPT has become the health care industry s standard for reporting physician procedures and services, thereby providing an effective method of nationwide communication. CPT procedure codes are sometimes reviewed in conjunction with the reported ICD-9 diagnosis codes, to ensure that the procedures rendered are consistent and appropriate to the medical condition or diagnosis. Customer Relations Department Deductible Diagnosis Related Groups Durable Medical Equipment Electronic Data Interchange Encounter Data Evidence of Coverage DRG DME EDI EOC Kaiser Permanente staff who serve as a liaison between Members and the rest of Kaiser Permanente. This department addresses questions relating to benefits and claims, and resolves Members various issues and concerns. The dollar amount in Tiers Two and Three that must be incurred by an individual or family, per calendar year, before benefits will be paid at the allowed amount. The individual or family is financially responsible for 100% of all deductibles. A fixed amount of health care dollars of which a Member must pay 100% before his or her health benefits begin. Statistical system of classifying any inpatient stays into groups for purpose of payment. DRGs may be primary or secondary. This is the form of reimbursement that CMS uses to pay hospitals for Medicare recipients. Also used by a few states for all payers and by many private health plans (usually non-hmo) for contracting purposes. Equipment which can stand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use at home. Examples of durable medical equipment include hospital beds, wheelchairs, and oxygen equipment. A term that refers to the exchange of data through electronic means rather than by using paper or the telephone. Report submitted to Kaiser Permanente on either a CMS-1500 (HCFA-1500) or CMS of capitated services rendered to Members. The document issued to the Subscriber that sets out the coverage and other rights to which the Subscriber and his or her dependents are entitled. Explanation of Benefits Explanation of Payment EOB EOP Revised April A written statement from an insurance company or third party payer which lists the amounts paid (or not paid/denied), based upon the Member s benefit contract. The Medicare version is called an EOMB/MSN. A written statement sent to the Provider which lists the amounts paid (or not paid/denied), based upon the Member s benefit contract.

79 TERM ACRONYM DEFINITION Fatal Error Federal Tax ID Number Full Component Global Codes/ Fees Health Care Financing Administration Health Care Financing Administration Common Procedure Coding System Health Insurance Portability and Accountability Act of 1996 International Classification of Diseases, 9th Edition Incidental Procedures IntelliClaim Medical Policy Medicare Summary Notice Medical Record Number Member TIN HCFA HCPCS HIPAA ICD-9-CM MSN MRN Revised April An electronic claim that contains one of the following: syntax errors, missing required loops & segments, invalid or incorrect qualifiers or invalid medical code sets. A federally issued identification number given to medical service providers. The identification number is given to organizations (i.e.: insurance companies) paying providers for services rendered. Physician performs both the professional and technical component of either the radiology or laboratory/pathology procedure. A global code includes all fees related to the procedure performed. This may include a pre-operative visit/service on the day of, or the day prior to surgery, all intra-operative procedures, medical or surgical services for complications which do not require a return trip to the operating room, and all related post-operative care/visits. Please see Centers for Medicare & Medicaid Services (CMS). A uniform coding method for health care Providers and medical suppliers to report professional services, procedures, and supplies. A federal law dealing with a variety of issues, including standardizing electronic health care transactions and the privacy and security of protected health information (PHI). This coding system is used by providers and the insurance industry to succinctly describe a patient s medical condition/diagnosis. These codes are also used in claims payment and medical management activities to review the appropriateness of treatment provided for a specific diagnosis. An incidental procedure is a procedure carried out at the same time as a more complex primary procedure. However, the incidental procedure requires little additional physician resources and/or is clinically integral to the performance of the primary procedure. For these reasons, an incidental procedure will not be reimbursed separately by Kaiser Permanente. IntelliClaim is a code editor software application designed to evaluate professional and facility outpatient claims data including HCPCS and CPT codes as well as associated modifiers. Refers to the policies of a health plan regarding what will be paid for as medical benefits. A written statement from Medicare which lists the amounts paid (or not paid/denied), based upon the Member s benefit contract. Also known as Explanation of Medicare Benefits (EOMB). Unique six or seven digit identification number assigned to each enrolled Member of Kaiser Foundation Health Plan. A person who meets all of the eligibility requirements of the applicable Kaiser Foundation Health Plan, who is enrolled in the plan, and for whom all required membership dues have been paid. Members include Subscribers and their dependents as defined in the Evidence of Coverage (EOC).

80 TERM ACRONYM DEFINITION National Drug Code National Provider Identifier Network Development Department Not Covered Amount Patient- Controlled Analgesia Patient Responsibility Physical Status Modifiers Practitioner Pre-Authorization Primary Care Provider Primary Insured Professional Component Provider Prudent Layperson NDC NPI PCA PCP A medical code set that identifies prescription drugs and some over the counter products, and that has been selected for use in the HIPAA transactions. A standard unique 10-digit numeric identifier for all health care providers. The NPI was mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Effective May 23, 2005 covered providers began applying for NPIs. The current date for mandated adoption and usage of NPI is May 23, A department, consisting of internal and external representatives dedicated to serving Kaiser Permanente s Provider networks. Responsibilities include provider contracting, reimbursement, provider office visits, training of office staff, communication of Kaiser Permanente administrative policies and procedures, and general problem resolution on behalf of providers. This is the amount billed by a Provider for a specific service that is not covered due to limitations or exclusions from a Member s benefit plan or provider reductions. PCA is the self administration of a predetermined dose of pain medication via IV catheter by a programmed pump. This may include a portion of the amount listed in the Not Covered Amount column and any amount listed in the Applied to Deductible and the Copay/Coinsurance columns on the Explanation of Payment. Physical status modifiers that should be appended to the CPT anesthesia code to distinguish between the various levels of complexity of the anesthesia service(s) provided. The professional who provides health care services. Practitioners are usually required to be licensed as defined by law. Prospective review and approval of specialty consults and/or treatment, covered inpatient or outpatient technical services, equipment and/or supplies. A Provider (for example, a pediatrician, internist, family practitioner) whom the Member selects (or who is selected on behalf of the Member) as the provider/coordinator of his/her primary health care. The name of the subscriber covered by the benefit plan. A component (modifier 26) that identifies the diagnostic interpretation or reading of a radiology or laboratory service. An institution or organization that provides services for managed care organization s Members. Examples of providers include hospitals and home health agencies. Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; (2) Serious impairment to bodily functions; or (3) Serious dysfunction of any bodily organ or part. Revised April

81 TERM ACRONYM DEFINITION Radiology Services Radiology services include tests and procedures performed in a Provider s office, a hospital radiology department, and ambulatory care center or a free standing imaging center. Billing for radiology services may be for the professional, technical or full component. Referral Relative Value Guide Subscriber Technical Component Unbundling Visiting Member RVG TC A prospective, written recommendation by a plan Practitioner for specialty care. The RVG considers anesthesia services to be independent to an actual surgical procedure, allowing an anesthesiologist to calculate his/her fee on the basis of difficulty/time. The person who applied for coverage and agrees to be responsible for payment. A component (TC) that identifies the performance of a radiology or laboratory procedure. The practice of a Provider billing for multiple components of service that were previously included in a single fee. A Member from another Kaiser Permanente Region who is temporarily away from their home Service Area and in the Ohio Service Area for less than 90 days. Revised April

82 INDEX A Abortion services, 59 Address Mailing claims, 9, 32, 46 Over payments, 13 Payment Disputes, 15 Provider Appeals, 14 Admitting notes, 90 Anesthesia, 27, 40, 41, 56, 90 base units, 56 Crosswalk, 27 EDI, 56 exceptions, 57 global package, 56 modifiers, 58 multiple conscious sedation, 57 multiple surgeries, 56 reimbursement, 56 RVU, 78 time, 41 Appeals process claim payment, 14 Assistance contact/call, 7 Assistant surgeon invalid codes, 29 Authorization Number, 34 Authorizations / Referrals, 11 B Base code Quantity, 31 Behavioral Health Services, 59 Benefit carve-out, 63 Bilateral procedures invalid, 30 valid, 30 Birthday rule COB, 64 Bundling, 26 C Claims clean claim, 13 corrections, 32 CMS 1500, 12 timeframe, 47 UB-04, 49 Submission Timeframes, 12 Supporting Documentation, 11 Clearinghouse, 46 Clearinghouses, 32, 63 CMS-1450 UB-04, 8, 46, 51, 68 Revised April CMS-1500, 8, 32, 37 COB, 66 corrections, 12 Covering Provider, 35 EOB / MSN, 64 Field descriptions, 37 NPI, 32 Patient s Condition, 34 COB fields, 16, 48 Condition codes, 52 conscious sedation, 57 Consultations, 23, 24, 57, 60 Coordination of Benefits additional information, 16 Coordination of Benefits, 16 Coordination of Benefits, 34 Coordination of Benefits, 48 Coordination of Benefits additional information, 48 Coordination of Benefits, 63 Coordination of Benefits, 63 Coordination of Benefits CMS-1500 COB fields, 66 Coordination of Benefits UB-04 fields, 68 Coordination of Benefits, 70 Coordination of Benefits, 73 Coordination of Benefits, 94 Coordination of Benefits (COB) electronic, 16 corrections, 21 Cover Sheet, 21, 82, 89 CPT/HCPCS, 41, 52 D Dates of service, 35, 40, 48, 91 dependent child, 64 Diagnosis codes, 53 DME, 60, 75 special supplies, 9 Documentation supporting, 11, 21, 36, 50, 82, 89, 90 Duplicate Line Items, 28 E E/M codes, 91 EDI, 46, I corrections, 12 Benefits of., 18 Claim errors, 21 Clearing House, 18 clearinghouses, 19 CMS-1500 corrections

83 837P, 21 Corrected claims, 21 KPRequirements, 20 Requirements, 20, 32 Responsibilities, 18 UB-04 corrections 837I, 21 electronic, 46, 68, 75 Electronic Claims, 8 Recieves & Sends, 8 submission, 90 Emergency Room Services, 61 Entering Dates, 35 ER services, 61 Evaluation Management Services, 60 Explanation of Benefit, 16, 32, 48, 64, 75 Explanation of Payment, 12, 15, 73, 75, 82, 94 corrected claim, 35 F federal, 83 Federal Tax, 51 Federal Tax ID Number, 10, 42 questions, 10 Filing Deadlines, 29 Full Charges, 33, 47 G Global Surgery, 25 H HIPAA, 32, 46, 63, 68, 76, 77 COB fields, 66 Requirements, 9 Holidays, 27 I ICD-9, 41, 54 ICD-9 codes, 53 Immunizations, 61 Injections, 61 inpatient services, 57, 90 IntelliClaim, 22, 76 IRS Alert Bulletin, 82 M Medical Claim Review, 22 modifiers, 22, 23, 77 Modifiers, 25, 58, 62, 77 Multiple Procedure Codes, 23 mutually exclusive, 26 N NAIC, 63 National Provider Identifier, 46, 53, 54, 77 paper claims, 8 Revised April NATIONAL PROVIDER IDENTIFIER (NPI), 8 Network Development Department, 7, 10, 77, 94 New Born Services, 62 New Patient Codes, 24 No Fault, 48 not covered, 73, 77, 88, 94 Not covered, 28 not covered amounts, 70 NUBC, 8 O Outpatient Rehabilitation modifiers, 62 P paper claims, 46, 68 Paper Claims, 8, 48, 64 paper documentation, 21, 89 Patient Acknowledgement of Financial Responsibility, 15, 82 patient-controlled analgesia (PCA), 57 Payment disputes, 15 Member, 15 place of service, 28, 40, 91, 92 Place of service, 35 procedure codes, 23, 75 Procedure codes Add-on codes, 30 deleted, 29 not covered, 28 unlisted, 28 Procedure codes surgical, 48 Q questions, 94 R REFERRALS/ AUTHORIZATIONS, 11 Required fields CMS 1500, 37 S submission, 48, 94 submissions, 46 supplies, 25 supporting, 94 supporting documentation, 46 Supporting documentation with claim, 11 Supporting Documentation Cover Sheet, 90 Cover Sheet, 11 separately mailed, 11

84 T table, 37 Tips, 9 U UB-04, 46 EOB / MSN, 64 requirements, 51 unbundling, 26 Unbundling, 78 W W-9 common mistakes, 83 Mail completed form to, 10 Workers Compensation, 48 Revised April

85 APPENDIX IRS Alert Bulletin IRS Form W-9 Patient Acknowledgement of Financial Responsibility Form Supporting Documentation Cover Sheet Supporting Documentation Table Billing Same/Different Dates of Service & Places of Service Table Explanation of Payment Revised April

86 Source: Internal Revenue Service IRS ALERT Avoid Problems - Use Your Correct Name and Number IRS Says Medical Service Providers Have High Rate of Errors If you are a medical service provider, double-check the name and taxpayer identification number (TIN) you give to organizations paying you for services (payer). These payers (such as insurance companies) must send your name, TIN, and amount of payment to the Internal Revenue Service. IRS has found that a high rate of Name and Taxpayer Identification Numbers of medical service providers do not match the name and TIN combinations in IRS records. (For individuals, the TIN is the social security number (SSN); for corporations, partnerships and similar entities, the TIN is the employer identification number (EIN). Mistakes May Cause Withholdings From Your Pay When there is a name/number mismatch, IRS alerts the payer and the payer attempts to correct the information. The payer sends you a Form W-9, Request for Taxpayer Identification Number and Certification, or a similar form to verify your correct name and TIN. If you fail to respond or supply the correct information, the payer must withhold federal income tax at a rate of 31 percent ( backup withholding ) from your payments. Avoid Backup Withholding A good way to check the name and TIN you are giving to payers is to look at your medical service invoice. Payers generally use the information on the invoice in their reports to IRS. Make sure you are not making any of these common mistakes: D/B/A Policies You are a sole proprietor using your doing business as (d/b/a) name with your SSN or the EIN of your sole proprietorship. A sole proprietor must always put his/her name first; the d/b/a name may be listed second. SSN Only for Humans You are a partnership, corporation, hospital or clinic and you are using an individual medical provider s SSN. You should use the EIN of the partnership, corporation, hospital or clinic. Only use the SSN with an individual s name. You are an individual medical provider who should be using your SSN, but instead you are using the EIN of the partnership, corporation, hospital or clinic of which you are a member. You should always use your SSN in combination with your name. EIN Mix-ups You are an operating unit of a larger business entity and you are using your name with the EIN of the business entity. For example, you are Meadowview Nursing Home, an operating unit of Healthcare, Inc. You are using your name with the EIN of Healthcare, Inc. This will cause a mismatch with IRS records. You should apply for your own EIN or use the name Healthcare, Inc. You are identifying your business with initials instead of your complete name. For example, you originally obtained your EIN under the business name Immediate Care Clinic, P.C., but lately you ve been using the initials ICC with your EIN. This will cause a mismatch of your name and EIN with IRS records. You should use your complete name. You are a medical specialist group practicing at a hospital and you are using the EIN of the hospital. For example, you are Orthopedic Group of Metropolis practicing at Metropolis General Hospital. You are using your name, Orthopedic Group of Metropolis, with the EIN of the hospital. You should be using your own EIN. Check with your Collection Agency Your collection agency is using its own name and your TIN. The agency should use either its name with its TIN or your name with your TIN. Help is Available If you think you are using an incorrect name and TIN combination, please contact the IRS help line in your area. Name Changes You change your business name and fail to notify IRS. For example, you change your business name Johnson, McCleary and Reed, P.C. to JMC Medical Group, P.C., and forget to notify IRS. Since you are still using the old TIN, your new name will cause a mismatch with IRS records. To notify IRS of your name change, write to the Entity Section of the Service Center handling your federal tax returns. Revised April

87 Revised April

88 Revised April

89 Revised April

90 Revised April

91 Patient Acknowledgement of Financial Responsibility Form I understand and acknowledge that Kaiser Permanente pays only for Covered Services as defined in my Kaiser Permanente Evidence of Coverage. I also understand that Kaiser Permanente has informed (insert the Practitioner/Provider of service) that I am not eligible to receive the services listed below for one of the following reasons: I am not an eligible Member I am not currently assigned to this primary care physician The services requested were denied by Kaiser Permanente as not medically appropriate The requested services are not a Covered Service as defined in my Kaiser Permanente Evidence of Coverage I do not have prior authorization for requested service(s) from Kaiser Permanente. I understand that the following services are not covered by my Kaiser Permanente Health Plan and that I am responsible for paying one hundred percent (100%) of the cost if I choose to receive these services. Patient Signature Date Please refer to your Kaiser Permanente Evidence of Coverage for specific information regarding your health care benefits. If you have questions about your benefits, or about your right to Appeal, please contact the Kaiser Permanente Customer Relations Department, Monday through Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. at or The deaf, hard of hearing, or speechimpaired may call or (TTY/TDD). Revised April

92 Supporting Documentation Cover Sheet For paper documentation sent in separately from the claim Complete a separate SUPPORTING DOCUMENTATION COVER SHEET for each Member for whom you are submitting paper documentation. Medical Record Number (MRN): Member s Name: Member s DOB Practitioner s/provider s Name Kaiser Permanente Assigned Provider ID#: AND TIN # Date(s) of Service: Kaiser Permanente Assigned Claim Number (if known): Documentation Attached: (check all that apply) Adjustment Request Admitting Notes Appeal Submission Audit Response ER Report EOP/EOMB/MSN Itemized Bill/Invoice Medical Records Office/Physician Notes Operative Report Provider Correspondence Referral Returned Check/Overpayment Other (please specify) Attach this cover sheet to each Member s paper documentation with a paper clip, and mail to the following address: Kaiser Permanente P.O. Box 5316 Cleveland, OH Revised April