Claims

When to submit claim forms.

• When you receive care from a Kaiser Permanente in-network provider (Option 1), there are virtually no claim forms to complete.
• For Option 2, your provider generally completes and submits claim forms. Providers are not allowed to bill any balances.
• For Option 3 out-of-network care, you will likely need to submit a claim for reimbursement. You are also responsible for paying amounts that are greater than the maximum allowable charge.

Filing claims after seeing a non-participating provider.

After visiting an Option 2 provider:

• You usually will not have to file a claim. However, if you receive services from a non-participating provider, you will likely need to file a claim.

After visiting an Option 3 provider:

• You may be required to pay the full amount you are billed when you receive care.
• If so, you will need to submit a Medical Claim Form with an itemized bill for reimbursement.

If your plan has an annual deductible:

• Reimbursement is based on how much you have already paid toward your deductible and any remaining charges for which you are responsible, such as coinsurance.

Filing claims for emergency care services.

If you receive emergency care services and need to submit claims for reimbursement, you must submit itemized bills for claims related to these services within 180 days, or as soon as reasonably possible.

What you’ll receive from Kaiser Permanente when you file.

Within 30 days, you will receive an Explanation of Benefits (EOB) that will detail what you need to pay and what the health plan will pay. An EOB statement is not a bill from your medical insurance plan administrator. It is an informational statement to keep you informed of any claims processed under your insurance plan.

If you file a claim.

• You have up to 180 days from the date you received care to submit your claim.
• Kaiser Permanente will review the claim and decide what payment or reimbursement may be owed you.
• Care must be medically necessary. Refer to your Evidence of Coverage and Certificate of Insurance for more information.
• You’ll need specific information from your service provider. Your Flexible Choice reference guide has the steps to take to file a claim.

What if my claim is denied?

We are committed to providing you with quality care, in a timely response to your concerns. If we have denied coverage for certain services or supplies, in whole or in part, then you may request that we review this decision, also referred to as an “adverse benefit determination”. In addition, you may request that we review our determination of any cost shares (copayments, deductibles or coinsurance) or other amounts that you may owe.

As a member of a group with health coverage insured by Kaiser Permanente Insurance Company (KPIC), your internal review process includes a mandatory appeal. You, or a representative whom you formally appoint in writing, have the right to appeal our decision by asking that we review it. To appeal the decision, please send your request for review to:

Member Relations, Appeals
Nine Piedmont Center
3495 Piedmont Rd NE
Atlanta, GA 30305-1736
Phone: 888-225-7202
Fax: 404-949-5001

In your request, please include:

(1) your name and, your medical record number
(2) your medical condition or symptom
(3) the specific treatment, service or supply that you are requesting,
(4) the specific reason(s) for your request that we review our initial decision, and
(5) all supporting documents. Your request and the supporting documents constitute your appeal.

We must receive your request within 180 days of your receiving the notice of our adverse benefit determination. Please note that we will count the 180 days starting 5 business days from the date of the notice to allow for mail delivery time, unless you can prove that you received the notice after that 5-business day period.

A decision about your appeal will be made within 30 days of receipt of your request for review at each level.

If you disagree with our decision on your appeal, your appeal adverse decision notice will tell you how to respond if you so choose.

Appointment of a Representative

If you would like to have someone act on your behalf during our review, you may appoint an authorized representative. You must make this appointment in writing. Please send the name, address, and telephone contact information to:

Member Relations, Appeals
Nine Piedmont Center
3495 Piedmont Rd NE
Atlanta, GA 30305-1736
Phone: 888-225-7202
Fax: 404-949-5001

You are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents and records relevant to your claim for benefits. In addition, you may give testimony in writing or by telephone. Please send your written testimony to Kaiser Permanente Insurance Company at the address set forth above. To arrange to give testimony by telephone, you should contact (888) 225-7202. We will add all of the new information to your claim file and we will review it without regard to whether this information was submitted and/or considered in our initial adverse benefit determination.

We will share any additional information that we collect in the course of our review by sending it to you in advance of our final decision. If we believe on review that your request should not be granted, before we issue our final decision, we will also share with you in writing any new or additional reasons for that decision. We will send you a letter explaining the new or additional information and/or reasons. Our letters will tell you how you can respond to the information provided if you choose to do so. If you do not respond before we must make our final decision, that decision will be based on the information in your claim file.

For questions about your claim status, benefits, or eligibility call Customer Service at (888) 225-7202 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m., Pacific standard time.

Should you have any questions regarding your appeal rights, please call Kaiser Permanente Insurance Company (888) 225-7202.