Provider Manual Section 3: Fully-Insured Member Eligibility
Table of Contents SECTION 3: FULLY-INSURED MEMBER ELIGIBILITY AND BENEFITS VERIFICATION... 4 3.1 MEMBER ELIGIBILITY VERIFICATION... 4 3.1.1 Newborn Eligibility... 5 3.2 AFTER HOURS ELIGIBILITY REQUEST... 5 3.2.1 Patient Financial Responsibility Form... 6 3.3 RETROACTIVE ELIGIBILITY CHANGES... 8 3.4 MEMBER BENEFIT VERIFICATION... 8 3.5 FULLY-INSURED PRODUCTS AND IDENTIFICATION (ID) CARDS... 8 3.5.1 Health Maintenance Organization (HMO) Product... 10 3.5.1.1 Deductible/Coinsurance Plans (Cost Sharing Health Maintenance Organization [HMO]). 10 3.5.1.2 Health Savings Account (HSA-Qualified Deductible Health Maintenance Organization [HMO])... 11 3.5.1.3 Medicare Enrolled Non-Medicare Plus Members (MENPM) with Kaiser Permanente Health Maintenance Organization (HMO) Coverage... 12 3.5.2 Kaiser Permanente Added Choice Point-of-Service (POS) Product... 13 3.5.2.1 Tier One - Kaiser Permanente Health Maintenance Organization (HMO) Network (In-Plan)... 13 3.5.2.2 Tier Two Preferred Provider Organization (PPO) (In-Network)... 14 3.5.2.3 Tier Three Out-of-Network... 15 3.5.2.4 Member Identification (ID) Card for Kaiser Permanente Added Choice Point of Service (POS)... 16 3.5.2.5 Medicare Enrolled Non-Medicare Plus Members (MENPM) with Kaiser Permanente Added Choice Point-of-Service (POS) Coverage... 16 3.5.2.6 Process Flow: Physician Office Visits for Kaiser Permanente Added Choice Point-of- Service (POS) Members... 18 3.5.2.7 Coordinating Care for the Kaiser Permanente Added Choice Point-of-Service (POS) Member... 19 3.5.2.8 Continuity of Care for the Kaiser Permanente Added Choice Point-of-Service (POS) Member... 20 3.5.2.9 Frequently Asked Questions about the Kaiser Permanente Added Choice Point-of- Service (POS) Plan... 21 3.5.3 Out-of-Area Preferred Provider Organization (PPO) Product... 22 3.5.3.1 Member Identification Card (ID) for Out-of-Area PPO... 23 3.5.4 Medicare Cost Product... 24 3.5.4.1 Member Identification (ID) Card for Medicare Cost Product... 25 Revised June 2013 2
3.5.5 Health Savings Account (HSA)... 25 3.5.6 High Deductible Health Plan (HDHP)... 25 3.5.7 Self-Funded (SF) Products... 25 3.5.8 Drug Plans... 25 3.6 EXCLUSIONS... 26 3.7 VISITING MEMBERS... 28 Revised June 2013 3
and Benefits Verification See Section 11 of this Manual for information regarding Self-Funded plans. 3.1 Member Eligibility Verification Plan Providers and their staff are responsible for verifying a Member s Eligibility; otherwise, you provide Services at your own financial risk. Each time a Member presents at a Plan Provider s office for Services, the Member s current Eligibility status must be verified. Do not assume that coverage is in effect because a person has a Kaiser Permanente Member identification (ID) card. Check a form of photo identification to verify the identity of the Member. To confirm a Member s current Primary Care Physician (PCP) or to verify Eligibility and Covered Benefits, choose one of the options below. Option Description #1 Customer Relations Department: Call 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. tollfree at 1-800-441-9742, option 1. Provide the Member s name and Medical Record Number (MRN). #2 Primary Care Physicians (PCP) Roster: Available on KP Online-Affiliate at providers.kaiserpermanente.org/oh or via paper from your Network Associate (see Section 6.1.1 of this Manual for more information). #3 KP Online-Affiliate: New Member Eligibility, PCP selection and Covered Services are available online via KP Online-Affiliate (see Section 6.17.2 of this Manual for more information). There is no charge for this service. #4 Websites such as Availity.com or EMDEON.com. If a Member is not assigned to a Plan PCP s panel, or a Plan Provider is unable to confirm Eligibility and/or the necessary Authorization for Services and the Member insists on being treated, the Member must be informed that he/she will have 100 percent financial responsibility for the Services rendered. The Member should sign an acknowledgement to document the Member s understanding of his/her financial responsibility in writing. If your office does not have an internal form, there is a sample Patient Financial Responsibility Form in Section 3.2.1 of this Manual that may be used for this purpose. Plan Providers can also download a Patient Financial Responsibility Form in the Forms section of the Kaiser Permanente s Community Provider s website at providers.kaiserpermanente.org/oh. If a Plan Provider treats a Member without verifying Eligibility or Authorization, the Plan Provider will not be compensated by Kaiser Permanente for any care delivered to the Member. If the Member is not properly informed of his/her financial responsibility (as Revised June 2013 4
outlined above), per your Agreement, the Member is to be held harmless; the Plan Provider cannot bill the Member for the Services provided. 3.1.1 Newborn Eligibility Existing Subscribers may add newborn children of the Subscriber or the Subscriber s spouse, effective the date of birth. A newborn child is automatically covered for the first 31 days, subject to Coordination of Benefits and Plan Authorization rules, but must be enrolled within 31 days after birth. Additional premium may be due for membership to continue day 32 and beyond. Note: Children born to an eligible dependent, other than the Subscriber s spouse, are not eligible for coverage unless the Subscriber or the Subscriber s spouse adopts them or becomes their court-appointed guardian, or the group has purchased a sponsored dependent rider. Plan hospitals are provided with Kaiser Permanente Medical Record Numbers (MRNs) to be assigned to newborns at birth. On the day of birth, fax newborn information including date of birth, gender, mother s name, Subscriber s name, newborn s name (if known), and MRN to the Kaiser Permanente Membership Administration Department at 216-362-2116. If Plan hospitals need additional MRNs or have questions about the newborn enrollment procedure, call the Membership Administration Department toll-free at 1-800-524-7372, extension 8863, or 216-265-8863. MRNs should be provided to all newborns born to Eligible dependents even though they may not be Eligible for coverage. 3.2 After Hours Eligibility Request If Members present for medical care after normal business hours, see Section 3.1 of this Manual to review options for online Eligibility verification. If you are unable to verify Eligibility online, do the following: Request that the patient complete a financial responsibility form. If your office does not have a financial responsibility form, the following form may be used for this purpose. Inform the patient that by completing this form, he/she will have 100 percent financial responsibility for Services rendered if he/she is found to be ineligible as a Kaiser Permanente Member or if care provided is not a Covered Service. If the Member is not properly informed of his/her financial responsibility, per your Agreement, the Member is to be held harmless; Plan Providers cannot bill the Member for the Service provided. For more information about holding Members harmless, consult your Agreement. A financial responsibility form is not required for the provision of Emergency Services; however Kaiser Permanente will not pay for Emergency Services or other unauthorized medical care provided if the person is not a Kaiser Permanente Member. Revised June 2013 5
3.2.1 Patient Financial Responsibility Form See the following page. Revised June 2013 6
Revised June 2013 7
3.3 Retroactive Eligibility Changes Member Eligibility may end retroactively if the individual or group policy/benefit contract is terminated in the following conditions: There is a delay in receipt or processing of Eligibility information that an individual is no longer a Member. Termination for non-payment of premium. The Eligibility information received by Kaiser Permanente is later determined to be false. If a Plan Provider has received payment on a Claim(s) that is impacted by a retroactive Eligibility change, a Claim adjustment will be made. The reason for the Claim adjustment will be reflected on the Explanation of Payment (EOP). A sample EOP appears in Section 5 of this Manual, page 74. 3.4 Member Benefit Verification In addition to Eligibility, Plan Providers and their staff are responsible for verifying the Member s benefit coverage. Therefore, you must determine that the Member has coverage for the Service prior to providing such Service to a Member. To determine a Member s benefit coverage, choose one of the options in Section 3.1 of this Manual. 3.5 Fully-Insured Products and Identification (ID) Cards Kaiser Permanente of Ohio offers various Fully-Insured products to individuals and employer groups. The Member s ID card will indicate in which product a Member is enrolled. You have signed an Agreement to treat Members enrolled in Kaiser Permanente's Health Maintenance Organization (HMO), Added Choice Point-of-Service (POS) and Medicare Plus products. The Kaiser Permanente logo appears on each ID card. Logos for other Payors and network managers may also appear. Plan Providers can identify the product in which a Member is enrolled by viewing the Payor code in an active Eligibility screen in KP Online-Affiliate, Kaiser Permanente s web-based application for Eligibility and Covered Benefits verification, Referral submissions and access to the Plan s electronic medical records. See Section 6.17.2 of this Manual for more information regarding KP Online-Affiliate. The following is a list of current Payor codes and their descriptions for Kaiser Permanente of Ohio products: Revised June 2013 8
Payor Code KP-OHIO SFOHDHMO SFOHHDHP SFOHHMO SFOHPOSCS SFOHPOSP3 SFKPICOA SFOHSIGDHMO SFOHSIGHDHP SFOHSIGHMO SFOHSIGPOSCS SFOHSIGPOSP3 KPICOA KPOHDHMO KPOHHDHP KPOHMCADV KPOHMEDCOST KPOHPOSCS KPOHPOSP3 KPOHSIGDHMO KPOHSIGHDHP KPOHSIGHMO KPOHSIGPOSCS KPOHSIGPOSP3 MEDICARE Description HMO Self-Funded Deductible HMO Plan Self-Funded High Deductible Health Plan Self-Funded HMO Plan Self-Funded Point-of-Service Cost Sharing Plan Self-Funded Three Tier Point-of-Service Self-Funded Out of Area Self-Funded Signature Deductible HMO Plan Self-Funded Signature High Deductible Health Plan Self-Funded Signature HMO Self-Funded Signature Point-of-Service Cost Sharing Self-Funded Signature Three Tier Point-of-Service Out-of-Area Deductible HMO High Deductible Health Plan Medicare Advantage Medicare Cost (Medicare Plus) Point-of-Service Cost Sharing Three Tier Point-of-Service Signature Deductible HMO Signature High Deductible Health Plan Signature HMO Signature Point-of-Service Cost Sharing Signature Three Tier Point-of-Service HMO/Medicare Primary (MENPM) and Point-of-Service/Medicare Primary (MENPM) The following is a sample Eligibility screen print from KP Online-Affiliate. Note the location of the Payor code in the upper left hand corner of the eligibility screen. Revised June 2013 9
3.5.1 Health Maintenance Organization (HMO) Product This product is offered to both individual Subscribers and employer groups. Covered Benefits and Member costs vary by group. Most Covered Services require a small Copayment at the time of Services. In an HMO Plan, all Covered Services are provided and arranged by the Member s Primary Care Physician (PCP). A PCP is a Family Practice, Internal Medicine or Pediatric Physician. Members enrolled in an HMO product with a Signature Network benefit design must select an Ohio Permanente Medical Group (OPMG) PCP. The Payor code for Signature Members in KP Online-Affiliate is KPOHSIGHMO. Members enrolled in an HMO product with a traditional network benefit design may select either an OPMG PCP or an affiliated PCP within the Ohio Service Area. The Payor code for Traditional HMO Members in KP Online-Affiliate is KP-OHIO. PCP selection is requested from all Members within 30 days of enrollment. Each enrolled family member may designate a different PCP. The Kaiser Permanente Member Support Services Department can help new Members select a PCP. If a new Member does not select a PCP when they enroll, a PCP will be temporarily selected for them. Members can change their temporary PCP for any reason by calling the Member Support Services Department toll-free at 1-800-686-7100, option 3. The PCP coordinates Referrals to Specialists and admissions to the hospital following Kaiser Permanente s protocols for Referrals and Authorizations as described in Section 4 of this Manual. Plan Provider directories for the HMO product are available by calling your Network Associate, 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. toll-free at 1-800-441-9742, option 1, or on Kaiser Permanente s Community Providers website at providers.kaiserpermanente.org/oh. 3.5.1.1 Deductible/Coinsurance Plans (Cost Sharing Health Maintenance Organization [HMO]) These plans are the same as HMO plans (see Section 3.5.1. of this Manual), but with Deductibles and Coinsurance for certain Covered Services. The Payor code for the Deductible HMO product with a Signature Network benefit design in KP Online-Affiliate is KPOHSIGDHMO. The Payor code for the Deductible HMO product with a traditional network benefit design in KP Online-Affiliate is KPOHDHMO. Revised June 2013 10
3.5.1.1.1 Member Identification (ID) Card for Health Maintenance Organization (HMO) Plans Front Back 3.5.1.2 Health Savings Account (HSA-Qualified Deductible Health Maintenance Organization [HMO]) This is a Health Savings Account High Deductible Health Plan. It is the same as HMO plans (see Section 3.5.1 of this Manual), but with Deductibles applying to all health care Services except for certain preventive care Services. After the Deductible is satisfied, a small Copayment or Coinsurance may be applied to additional Covered Services. The Payor code for the High Deductible HMO product with a Signature Network benefit design in KP Online-Affiliate is KPOHSIGHDHP. The Payor code for the High Deductible HMO product with a traditional network in KP Online-Affiliate is KPOHDHP. Revised June 2013 11
3.5.1.2.1 Member Identification (ID) Card for Health Maintenance Organization (HMO) High Deductible Health Plan Front Back 3.5.1.3 Medicare Enrolled Non-Medicare Plus Members (MENPM) with Kaiser Permanente Health Maintenance Organization (HMO) Coverage MENPMs have Medicare as their primary carrier, and secondary coverage through a separate Kaiser Permanente HMO plan. The MENPM identification card (ID) is similar to the Kaiser Permanente HMO ID card; however, the plan code on the ID card is HMO/Medicare Primary. Plan Providers must follow HMO Authorization rules for MENPM Members (see Section 4 of this Manual). Providers should bill Medicare as the primary Payor and Kaiser Permanente as the secondary Payor. The Payor Code in KP Online-Affiliate is Medicare. Revised June 2013 12
3.5.1.3.1 Member Identification (ID) Card for MENPM Front Back 3.5.2 Kaiser Permanente Added Choice Point-of-Service (POS) Product Added Choice is Kaiser Permanente s Point-of-Service product. This product is offered exclusively to employer groups. Kaiser Permanente Added Choice Point-of- Service (POS) is jointly underwritten by Kaiser Foundation Health Plan of Ohio and Kaiser Permanente Insurance Company (KPIC). Members enrolled in this plan have the flexibility to choose where and from whom they receive their health care. The product design includes three tiers or levels of health care options. Covered Benefits and Member costs vary by group. Tier One offers the Member the most comprehensive coverage and convenient and easy access to Services without paper work. 3.5.2.1 Tier One - Kaiser Permanente Health Maintenance Organization (HMO) Network (In-Plan) Members are asked to choose a Tier One Primary Care Physician (PCP). A PCP is a Family Practice, Internal Medicine or Pediatric Physician. Revised June 2013 13
Members enrolled in an Added Choice Point-of-Service (POS) product with a Signature Network benefit design must select an Ohio Permanente Medical Group (OPMG) PCP. The Payor code for these Members in KP Online-Affiliate is KPOHSIGPOSP3. Members enrolled in an Added Choice Point-of-Service (POS) product with a traditional network benefit design may select either an OPMG PCP or an affiliated PCP within the Ohio Service Area. The Payor code for these Members in KP Online-Affiliate is KPOHPOSP3. Tier One PCP selection is requested from all Members within 30 days of enrollment. Each enrolled family member may designate a different PCP. The Kaiser Permanente Member Support Services Department can help new Members select a PCP. If a new Member does not select a PCP when they enroll, a PCP will be temporarily selected for them. Members can change their temporary PCP for any reason by calling the Member Support Services Department toll-free at 1-800-686-7100, option 3 or 216-524-5001. The Tier One PCP coordinates Referrals to Specialists and admissions to the hospital following Kaiser Permanente s protocols for Referrals and Authorizations as described in Section 4 of this Manual. Note: POS Members have direct access to OPMG Specialists. Members may call the Kaiser Permanente Member Service Center at 1-800-524-7377 (toll free) to schedule an appointment with an OPMG Specialist. The hearing/speech impaired may call 1-877-398-3187 (toll free TTY).. Emergency Services rendered at any emergency room are covered at Tier One benefit levels. Emergency room visits that do not meet the Kaiser Permanente definition of Emergency Services may be eligible for coverage through Tier Two or Tier Three benefit levels. Tier One Plan Provider directories for the Added Choice Point-of-Service (POS) product are available by calling your Network Associate, 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. toll-free at 1-800-441-9742, option 1, or on Kaiser Permanente s Community Providers website at providers.kaiserpermanente.org/oh. 3.5.2.2 Tier Two Preferred Provider Organization (PPO) (In-Network) Members may choose a physician or hospital from the Kaiser Permanente Added Choice Point-of-Service (POS) PPO network of providers. Kaiser Permanente Insurance Company (KPIC) has contracted with HealthSmart for the PPO network in Ohio. This network provides access to more than 14,000 providers and 70 hospitals each time a Member seeks Covered Services. A complete listing of HealthSmart Network providers is available by calling toll-free 1-800-346-3141 (Monday through Friday, 8:30 a.m. to 5 p.m.) or online at healthsmart.com and select HealthSmart Preferred. Revised June 2013 14
For providers outside of Ohio, KPIC contracts with Private Healthcare Systems (PHCS) Network, which is owned by MultiPlan, Inc. A complete listing of PHCS Network providers is available by calling toll-free 1-888-507-7427 or online at multiplan.com/kaiser. Tier Two offers convenient Services with a slightly higher out-of-pocket expense than Tier One as well as Deductibles and Coinsurance. In addition, certain Services are excluded at Tier Two. To receive full plan benefits at Tier Two, Precertification is required for some Services. Any practitioner or provider who is not contracted with Kaiser Permanente in the Health Maintenance Organization (HMO) network (i.e. Tier One) should call the Precertification Line toll-free at 1-866-433-1333 for Precertification and verification of Covered Benefits. 3.5.2.3 Tier Three Out-of-Network Tier Three benefits offer Kaiser Permanente Added Choice Point-of-Service (POS) Members the most freedom with provider selection. Members may seek medical care from any licensed physician or hospital, even if the provider is not part of the Kaiser Permanente or HealthSmart Networks. Although Tier Three offers the most flexibility, it does have the highest out-of-pocket expenses, including Deductibles and Coinsurance. In addition, certain Services are excluded at Tier Three. To receive full plan benefits at Tier Three, Precertification is required for some Services. Any practitioner or provider who is not contracted with Kaiser Permanente in the Health Maintenance Organization (HMO) network (i.e. Tier One) should call the Precertification Line toll-free at 1-866-433-1333 for Precertification and verification of Covered Benefits. Revised June 2013 15
3.5.2.4 Member Identification (ID) Card for Kaiser Permanente Added Choice Point of Service (POS) Front Back 3.5.2.5 Medicare Enrolled Non-Medicare Plus Members (MENPM) with Kaiser Permanente Added Choice Point-of-Service (POS) Coverage MENPMs have Medicare as their primary carrier, and secondary coverage through a separate Kaiser Permanente Added Choice POS plan. The MENPM identification card (ID) is similar to the Kaiser Permanente Added Choice ID card; however, the plan code is POS/Medicare Primary. Plan Providers must follow Tier One Authorization rules for MENPM Members (see Section 4 of this Manual). Providers should bill Medicare as the primary Payor and Kaiser Permanente as the secondary Payor. The Payor code in KP Online-Affiliate is, Medicare. Revised June 2013 16
3.5.2.5.1 Kaiser Permanente Member Identification Card for MENPM Front Back Revised June 2013 17
3.5.2.6 Process Flow: Physician Office Visits for Kaiser Permanente Added Choice Point-of-Service (POS) Members Point of Service Member Chooses Medical Services Tier One Kaiser Permanente Facilities OPMG/Plan Provider Network Tier Two HealthSmart Network providers Tier Three Non HMO or PPO provider Tier One benefits apply Tier Two benefits apply Tier Three benefits apply Member visits Primary Care Physician of record Member visits a HealthSmart Network provider Member visits a non network provider Member pays office visit Copayment with Deductible waived Member pays office visit Copayment Provider submits bill to address on ID card for reimbursement OR Member pays 100% of charges and submits bill for reimbursement All care is managed through the PCP, including Referrals Provider submits Bill to Kaiser Permanente Claims Department for all related charges Member is responsible for the Deductible & Coinsurance on all applicable charges Member may be responsible for the Deductible & Coinsurance on all applicable charges Revised June 2013 18
3.5.2.7 Coordinating Care for the Kaiser Permanente Added Choice Point-of-Service (POS) Member Consultation Kaiser Permanente Medical Facility Member will have lower out of pocket expenses Member s PCP is a HeathSmart Network provider or non network provider PCP Orders Lab / Radiology Diagnostic Testing Member has a choice Consultation Routine Out of Plan Ancillary Provider Member will have higher out of pocket expenses, Deductible & Coinsurance levels Revised June 2013 19
3.5.2.8 Continuity of Care for the Kaiser Permanente Added Choice Point-of-Service (POS) Member Consultation Kaiser Permanente Medical Facility Member will have lower out of pocket expenses Members PCP is a HealthSmart Network provider or non network provider PCP Orders Specialist consultation Member has a choice Consultation Routine Out of Plan Specialist Provider Member will have higher out of pocket expenses, Deductible & Coinsurance levels Revised June 2013 20
3.5.2.9 Frequently Asked Questions about the Kaiser Permanente Added Choice Point-of-Service (POS) Plan 3.5.2.9.1 Do Members select a Primary Care Physician (PCP) or is one assigned to them? Tier One: PCP selection is requested from all Members within 30 days of enrollment. Either a Signature or a traditional Network Provider directory is provided to Members prior to enrollment to assist with PCP selection. The Kaiser Permanente Plan Provider directory offers a list of Family Practice, Internal Medicine, and Pediatric Physicians to choose from. Each enrolled dependent may designate a different PCP. The Kaiser Permanente Member Support Services Department can help new Members select a PCP. If a new Member does not select a PCP when they enroll, one will be temporarily selected for them. Members can change their temporary PCP for any reason by calling the Member Support Services Department toll-free at 1-800-686-7100, option 3. Tier Two: With Tier Two benefit coverage, Members may see a primary care physician in the HealthSmart Network. This primary care physician is not the Tier One PCP of record. Members may need to meet Precertification requirements for some Services. See Appendix A (Precertification Guidelines) of this Manual for a complete description of Precertification requirements. Tier Three: With Tier Three benefit coverage, Members may receive Services from any licensed primary care physician even if the physician is not affiliated with Kaiser Permanente or the HealthSmart Network. Members may need to meet Precertification requirements for some Services. See Appendix A (Precertification Guidelines) of this Manual for a complete description of Precertification requirements. 3.5.2.9.2 Do Members need a Referral to see a Specialist? Tier One Members can self-refer to Tier One Behavioral Health, Optometry, and Obstetrics/Gynecology Plan Providers. A Referral from the Members PCP is needed for all other medical specialties, unless the Member elects to see an Ohio Permanente Medical Group (OPMG) Specialist. A Member may schedule an appointment with an OPMG Specialist by calling the Kaiser Permanente Member Service Center at 1-800-524-7377 (toll free). The hearing/speech impaired may call 1-877-398-3187 (toll free TTY). Tier Two: Members don t need a Referral to see a specialist if they are using their Tier Two Preferred Provider Organization (PPO) benefit coverage. They are free to visit any Revised June 2013 21
HealthSmart Network primary care or specialty provider without a Referral. They may need to meet Precertification requirements for some Services. See Appendix A (Precertification Guidelines) of this Manual for a complete description of Precertification requirements. Tier Three: Members don t need a Referral to receive care from any licensed provider when using their Tier Three benefit coverage. They may need to meet Precertification requirements for some Services. See Appendix A (Precertification Guidelines) of this Manual for a complete description of Precertification requirements. 3.5.2.9.3 What Services need Precertification? Tier One: See Appendix A (Precertification Guidelines) of this Manual for a complete description of Precertification requirements. Tiers Two and Three: To receive full plan benefits at Tier Two or Tier Three, Precertification is required for some Services. See Appendix A (Precertification Guidelines) of this Manual for a complete description of Precertification requirements. If Precertification is not obtained, payment for Covered Benefits will be reduced even if the treatment or Service is deemed Medically Necessary. If a hospital confinement is extended beyond the number of days first Precertified, benefits for the extra days similarly will be reduced, or will not be covered if not deemed Medically Necessary. 3.5.2.9.4 Where should Claims for Kaiser Permanente Added Choice Point-of- Service (POS) Members be mailed? All Claims (Tiers One, Two and Three) are mailed to: Kaiser Permanente Claims Department P.O. Box 5316 Cleveland, OH 44101-9774 3.5.3 Out-of-Area Preferred Provider Organization (PPO) Product This product is designed for group employees that are living outside the Health Maintenance Organization (HMO) Service Area. It is offered alongside other Kaiser Permanente products, only. Inside Ohio, Members may receive care either from HealthSmart Network practitioners/providers or from any licensed community practitioner or provider. Outside of Ohio, Members may access the Private Healthcare Systems Network (PHCS) owned by MultiPlan, Inc. Members also have an out-ofnetwork tier in which they can access care from any licensed provider. Out-of-Area Revised June 2013 22
Members have no HMO benefits. Precertification is required for some Services. See Appendix A (Precertification Guidelines) of this Manual for a complete description of Precertification requirements. Claims for Out-of-Area Members should be forwarded to the address on the back of their Member identification cards. 3.5.3.1 Member Identification Card (ID) for Out-of-Area PPO Front Back Revised June 2013 23
3.5.4 Medicare Cost Product Kaiser Permanente is the secondary Payor to Medicare for the Medicare Cost product if care is coordinated by a Plan Provider. The plan name for the Kaiser Permanente Medicare Cost product is Medicare Plus. All Kaiser Permanente Medicare Plus Members have a plan code of Medicare Primary on their identification (ID) card. The Payor Code in KP Online Affiliate is, KPOHMEDCOST. See the following section of this Manual for a sample ID card. The Centers for Medicare and Medicaid Services (CMS) plan code for the Kaiser Permanente Medicare Plus Plan is H6360. Ask Kaiser Permanente Medicare Plus Members to bring their Medicare card, along with their Kaiser Permanente identification card, to their appointments. Plan Providers will need to reference the Medicare card to record the HIC # as well as Part A and Part B entitlement. A small number of Kaiser Permanente Medicare Plus Members may only have Part B entitlement. Also, a small number of Members not enrolled in the Kaiser Permanente Medicare Plus will have Part A only (Part B Entitlement is required for enrollment in the Kaiser Permanente Medicare Plus Plan, but these Part A Members still have Medicare as the primary Payor for Part A Services). This will not be indicated on the Kaiser Permanente identification card, but will appear on the Member s Medicare card. If a Member has Part A of Medicare only, Kaiser Permanente will be the primary Payor for any Medicare Part B Services incurred and payment will be rendered in accordance with your Agreement. If a Member has Part B of Medicare only, Kaiser Permanente will be the primary Payor for any Medicare Part A Services incurred and payment will be rendered in accordance with your Agreement. Benefits and Copayments under the Kaiser Permanente Medicare Plus plan may vary depending upon whether the Member is enrolled in the plan through an employer group or as direct pay (i.e., non-group). Do not collect Copayments for office visits from Kaiser Permanente Medicare Plus Members. Copayments will be deducted from secondary payments. Kaiser Permanente Medicare Plus Members may elect to use their Medicare card to receive services from non-network practitioners and providers who participate with original Medicare. However, Kaiser Permanente will not pay for any services Members receive from non-plan providers, except for emergency or out-of-area urgently needed care. Original Medicare will pay for its share of charges it approves and Members will be financially responsible for the remaining Coinsurance. Notification is requested for some Services. See Appendix A (Precertification Guidelines) of this Manual for a complete description of Services for which notification is requested. Revised June 2013 24
3.5.4.1 Member Identification (ID) Card for Medicare Cost Product Front Back 3.5.5 Health Savings Account (HSA) Reserved for future use. 3.5.6 High Deductible Health Plan (HDHP) See Section 3.5.1.3 of this Manual. 3.5.7 Self-Funded (SF) Products See Section 11 of this Manual. 3.5.8 Drug Plans Kaiser Permanente offers medication coverage through a variety of benefit plan designs. Prescription drug coverage may vary, based upon the Member s health benefit plan, and not all Kaiser Permanente health plans include prescription drug coverage. To verify a Member s drug coverage, call the Kaiser Permanente Customer Relations Revised June 2013 25
Department, Monday through Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. toll-free at 1-800-441-9742, option 1. Copies of Kaiser Permanente drug Formularies or Plan Pharmacy directories are available by calling your Network Associate, 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. toll-free at 1-800-441-9742, option 1, or on the Kaiser Permanente s Community Providers website at providers.kaiserpermanente.org/oh. For Kaiser Permanente Health Maintenance Organization (HMO) and Medicare Plus Members, prescribed covered drugs and accessories are provided at a single Copayment for each prescription up to a 31-day supply, not to exceed the amount prescribed. If the regular charge is less than the Copayment, Members pay the regular charge. All HMO plans require exclusive use of Kaiser Permanente Plan Pharmacies or Kaiser Permanente Mail Order to receive prescription coverage. Kaiser Permanente Added Choice Point-of-Service (POS) Members have the option to fill prescriptions for covered drugs at: Kaiser Permanente Pharmacies for Tier One drug prescription coverage. Med-Impact participating pharmacies for Tier Two drug prescription coverage. To obtain a list of Tier One or Tier Two pharmacies, call Med-Impact toll-free at 1-800-788-2949. Additional information regarding Kaiser Permanente prescription drug plans is available in Section 10 of this Manual. 3.6 Exclusions Each benefit program has exclusions applied to Covered Services. Plan Providers are responsible for verifying a Member s benefit coverage. To confirm Covered Benefits, choose one of the options in Section 3.1 of this Manual. It is important to inquire about a particular Service that may be excluded under the Member s coverage before rendering the Service so the Member can be informed of potential payment responsibility. The following is a list of common benefit exclusions in base benefit packages: Services that aren t Medically Necessary. Air casts. Alternative medical Services including acupuncture, naturopathy and massage therapy. In vitro fertilization, ovum transplants, gamete intrafallopian transfer, zygote intrafallopian transfer, and all Services related to non-covered methods of artificial conception, including drugs, donor semen, donor eggs and Services related to their procurement and storage. Services to reverse voluntary, surgically induced fertility. Revised June 2013 26
Internally implanted, external and injectable contraceptives*. Drugs purchased by Members*. Specialized behavioral modification programs to maximize a person s ability to control pain, obesity, eating disorders, or other chronic conditions. Collection, transportation, storage and processing of donor directed blood or blood products. Procurement and storage of cord blood for a possible future need or for a yet to be determined Member recipient. Chiropractic Services* for Health Maintenance Organization (HMO) and Kaiser Permanente Added Choice Point-of-Service (POS) Members. Comfort or convenience items. Cosmetic Services. Custodial or intermediate care. Dental Services*. Disposable supplies for home use. Experimental or investigational Services. Hypnotherapy and hypnotic anesthesia. Physical exams required: to obtain or maintain employment; for insurance or licensing; by court ordered or required for parole or probation. Routine foot care. Services related to sexual reassignment. Services for military service-connected illness, injury, or conditions when care from the Department of Veterans Affairs is reasonably available. Services that are the financial responsibility of employer or government agencies. Services covered by any workers compensation or employer s liability Law. Transportation by car, taxi, bus, gurney or wheelchair van, or mini-van. Travel and lodging expenses. Inpatient/residential rehabilitation for chemical dependency* including specialized behaviorally programs in a residential facility*. Long-term rehabilitative Services. Services as a condition of probation, parole or an other third party or court order, unless a Plan Physician determines such Services to be Medically Necessary and appropriate. DME*, except for apnea monitors for infants up to a period of 6 months use; oxygen dispensing equipment and oxygen (including pulse oximetry for infants); bilirubin lights for home photo therapy for infants; traction equipment; negative pressure wound dressings. Prosthetic and Orthotic Devices*. Hearing Aids*. Testing for ability, aptitude, intelligence or interest. Cognitive therapy. Recreational therapy, music therapy, diversional therapy, and play therapy. o Therapy Services primarily for vocational training or re-training, including sports physical therapy. Revised June 2013 27
Non-human and artificial organs and their implantation.. Corrective Lenses, eyeglasses, frames and contact lenses*. o Services related to eye surgery for the purpose of correcting refractive defects. *Employer group and Medicare Plus benefit packages may include coverage for some of these items. 3.7 Visiting Members Kaiser Permanente offers a Visiting Member Program to ensure that Members can receive a variety of health care Services when temporarily visiting another Kaiser Permanente region. Visiting Member benefits may not be the same as those they receive in their home Service Area and are subject to certain exclusions. Members are eligible to receive Visiting Member benefits for up to 90 days. If a Member permanently moves into another Kaiser Permanente region, the Member is offered membership in the new region. If a Visiting Member needs medical care while in the Ohio region, he/she should call the Insurance Verification Department toll-free at 1-866-265-8844 to activate Visiting Member status and obtain an Ohio Medical Record Number. The Visiting Member is then directed to seek health care Services at the nearest Kaiser Permanente Medical Office. If an Ohio Permanente Medical Group (OPMG) Physician needs to refer a Visiting Member to another Plan Provider, both the Plan Provider and the Member will receive an Authorization letter explaining the start and end dates of the Referral and a description of the Authorized Services. Claims for scheduled, referred Services should be submitted to the Kaiser Permanente Ohio Claims address: Kaiser Permanente Claims Department P.O. Box 5316 Cleveland, Ohio 44101 Claims for Emergency/urgent care Services should be directed to the address on the back of the Visiting Member s identification card for his/her home region. Do not collect Copayments for office visits from Visiting Members. Payment will be rendered in accordance with your Agreement. Revised June 2013 28