Claims

Before your visit to an out-of-network provider:

• Find out if you’ll need to submit a claim.
• When making your appointment, be sure to ask your provider if they intend to submit a claim to Kaiser Permanente on your behalf.
• Please print and take the “Kaiser Permanente Plus/Deductible Kaiser Permanente Plus Information for Physicians” flyer with you to the appointment. This flyer will help them take care of you, while keeping your costs more affordable.

At your provider’s office:

• Collect the necessary documentation.
• On the day of the visit, take the “Kaiser Permanente Plus/Deductible Kaiser Permanente Plus Information for Physicians” flyer with you and give it to your provider.
• If they will be submitting the claim for your visit, please ask them to follow the instructions on the flyer. The claims address is also on the back of your ID card.
• If they confirm that you should submit the claim, be sure to collect and keep copies of:
  • Itemized bill(s) showing the amount charged, the amount you paid, and diagnosis or treatment codes.
  • Receipts for any charges you paid that show a zero balance.

After your visit to an out-of-network provider:

• Make copies of your itemized bills and receipts for your records.
• Write “process under the out-of-network” at the top of the bill. This will ensure that the claim gets processed as quickly as possible.
• Submit your itemized bills and receipts to the address below with your Medical Claim Form.

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 has paid. 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 member reimbursement claim:

• You have up to 365 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 to you. We’ll keep track of your visits and provide a summary, which will be mailed to you after claims for out-of-network services have been processed.

What if my claim is denied?

• It is your right to file an appeal if you disagree with a decision not to pay for a claim. Read your Evidence of Coverage (EOC) for more information.

Send your itemized bill and receipts to the following address:

Kaiser Foundation Health Plan of the Mid-Atlantic States Inc.
P.O. Box 371860, Denver, CO 80237-9998

Pharmacy claims:

For information on pharmacy claims with non-participating pharmacies, please see the Pharmacy section.