Transparency in Coverage

Certain services require authorization before you get them. In these cases, your participating provider can help you get authorization for care he or she considers medically necessary. We determine when covered services are medically necessary based upon certain standards that take into account your medical condition as well as generally accepted standards of care.

When you receive covered services for which you do not have prior authorization or that you receive from non-participating providers or from non-Plan facilities that have not been approved by us in advance, we will not pay for them except in an emergency.

Some services need special approval through a utilization review. If you need services that require a review and your participating provider believes they’re medically necessary, he or she may submit a request for a utilization review for you, or you may submit a request. We will respond to your request within 15 calendar days.

If the request is denied, Kaiser Permanente will send you a letter. It will explain the reason for our decision and give instructions for filing an appeal if you don’t agree with the determination.

When you get care from participating providers, you won’t be responsible for paying any amounts except for any cost sharing (deductibles, copayments or coinsurance) amounts that you owe. However, you will need to pay for any noncovered services you receive, whether you get them from a participating or a non-participating provider.

If you get covered services without prior authorization — or if you get them from a non-participating provider we haven’t approved in advance — we won’t pay for them, except in an emergency. Charges for these services will be your financial responsibility, and you may be billed directly by the provider for any balance you owe.

You generally won’t have to file a claim if a Kaiser Permanente provider provides the services. The participating provider will send the bill directly to Kaiser Permanente, and we’ll handle the claim.

However, if you visit a non-participating provider without getting a referral, you may need to send us a claim form with an itemized bill for any services you believe Kaiser Permanente should cover. You’ll need to submit your claim no more than 12 months after you get the service. To get a claim form, contact Member Services or download it here. When you submit the claim, please include a copy of your medical records from the non-participating provider. You can send the completed form and itemized bill to:

Kaiser Permanente
National Claims Administration - Northwest
PO Box 370050
Denver, CO 80237-9998

You may also submit a claim online at the My Coverage & Costs portal. Click here to submit a claim in the online portal.

If you have chosen Kaiser Permanente to receive advance payments of your premium tax credit, your monthly premium payment will be reduced by that amount. You need to pay any part of the premium not covered by the advance payment.

If we don’t receive your portion of the monthly premium by the due date, you’ll have a 3-month grace period to pay the late premium and the premiums owed for the additional 2 months of the grace period. A grace period is a time period during which your plan will not terminate even though you did not pay your premium. If you qualify for a grace period, we’ll send you a notice with details.

During the first month of the 3-month grace period, we’ll pay all appropriate claims for covered services. Claims will be pended for months 2 and 3 until premium payment is made. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full.

You generally won’t have to file a claim if a Kaiser Permanente provider provides the service. A Kaiser Permanente provider will send the bill/claim directly to Kaiser Permanente. We will process the claim unless you don’t pay your premium, and we have indicated to your participating provider that their claim is pending.

In certain cases, a claim may be denied retroactively — for example, if you fail to pay your premium or you get services after your membership ends. In the event of a retroactive denial, you’ll be financially responsible for the covered services you received. To ensure a claim is not retroactively denied, premiums must be paid on time. If you have questions about a claim that’s been denied, please contact Member Services.

If we terminate your membership, we’ll refund any premium payments you made after your membership ended. We’ll also pay you any amounts we owe for claims while you were a member. When making these payments, we may deduct any amounts you owe Kaiser Permanente or any participating providers. Refunds for overpayment of premium are provided based on the method of payment used by the member. If you believe you have overpaid your premium and are due a refund, please contact Member Services.

Sometimes, you may need a prescription drug that is not covered on Kaiser Permanente’s formulary (list of covered drugs). You can request a prescription for a non-formulary drug from your Kaiser Permanente provider. If your provider does not give you the prescription, you may request a non-formulary exception review. You or your Kaiser Permanente provider may submit your request to us along with information on why the non-formulary drug is medically necessary.

If you would like to submit your non-formulary exception request, please contact Member Services. For us to complete our review, you must submit medical information supporting your request.

For most requests, we will respond within 72 hours. If we grant your request, we will cover the non-formulary drug for the duration of the prescription, including refills. If we deny your request, you can appeal the decision.

For requests when exigent circumstances exist (i.e., your life, health, or ability to regain maximum function would be seriously jeopardized without the non-formulary drug or when you are already taking the non-formulary drug), please contact Member Services to request an expedited review, and we will respond within 24 hours of receiving it.  If we approve your request, we will cover the non-formulary drug for the duration of the prescription, including refills. Additionally, we will cover the non-formulary drug for the duration of the exigent circumstance. If we deny your request, you can appeal the decision.

After our internal review, if you feel we have incorrectly denied your request for the non-formulary drug, you may ask us to submit the case for external review. You, your authorized representative, or the prescribing provider may request this external review from an independent review organization.

Within 180 days after the date of an internal appeal denial letter, you must mail, call, or fax your request for an external review to Member Relations at:

Kaiser Foundation Health Plan of the Northwest
Member Relations Department
500 NE Multnomah St., Suite 100
Portland, OR 97232-2099
Phone: 503-813-4480
Fax: 1-855-347-7239

For most requests, the external review will be completed within 72 hours. If the independent review organization approves your non-formulary drug, we will cover it for the duration of the prescription.

For requests when exigent circumstances exist (i.e., your life, health, or ability to regain maximum function would be seriously jeopardized without the non-formulary drug or when you already take the non-formulary drug), please request an expedited review when you contact Member Relations and the external review request will be completed within 24 hours. If the independent review organization approves your non-formulary drug, we will cover it for the duration of the exigent circumstance.

An Explanation of Benefits (EOB) is a summary of services you’ve received during a specific period. It shows the charges, the date of your visit, and the name of the provider you visited. An EOB is not a bill. It’s available to help you understand the payments made for your covered services and to help you keep track of your expenses. EOBs are sent at least once a month after the Member receives services and the claim is received by Kaiser Permanente to be processed.

If you have health coverage under more than one plan, the Coordination of Benefits process helps you make the most of your coverages to make sure you get the care you need. It determines the order in which different plans pay for services, which can make it easier to get and pay for care.

The plan that pays first is the primary plan. It’s responsible for paying first regardless of whether another plan covers some expenses so long as the care is covered. The secondary plan pays next. Based on how much the primary plan pays, it may reduce what it pays so the amounts from both plans don’t total more than the allowable expense for specific services.

If you have any questions or want more information about any of the topics covered here, please contact Member Services. One of our representatives will be happy to help.