Claims

Benefits of Using EDI for Claim Submissions

• Reduced Overhead Expenses – Administrative overhead expenses are reduced, because the need for handling paper claims is eliminated.
• Improved Data Accuracy – Because the claims data submitted by the provider is loaded directly into Kaiser Permanente’s computer by the clearinghouse, data accuracy is improved, as there is no need for re-keying or re-entry of data.
• Additionally, “up-front” edits applied to the claims data while information is being entered at the provider’s office, and additional payer-specific edits applied to the data by the clearinghouse before the data is transmitted to the appropriate payer for processing, increase the percentage of clean claim submissions.
• Reduced Turnaround Time – EDI claims bypass manual processes and paper handling at Kaiser Permanente; therefore, the turnaround time for processing EDI claims is substantially reduced (as compared to processing paper claims).
• Bypass U.S. Mail Delivery – Providers save time by bypassing the U.S. mail delivery system.
• Reduced Payer-Specific specific “Exceptions” – Industry-accepted standardized medical claim formats will tend to reduce the number of “exceptions” currently required by multiple payers.

Electronic Submission of Claims Types

Listed below is the electronic submission of claims transactions:

• 837P Claim/Encounter – This is used for professional services and suppliers.
• 837I Claim/Encounter – This is used for facilities and hospitals.
  

Please note: Payer IDs are for both 837I (UB) and 837P (CMS1500) transactions.

EDI Trading Partners

Claims submission through Office Ally for bulk claims submissions and for direct entry claim submissions to Kaiser Permanente. Claims submissions to KP are FREE for providers.

• Learn about submitting via Office Ally
• Submit claims electronically and receive confirmation immediately
• Convenient, secure, and HIPAA compliant
  
• 24/7 access from anywhere with an internet connection

Sign up for Office Ally here.
Instructions: Under Practice Software section, select “Clearinghouse”, “Start for Free”, and “Signup”

Electronic Payment and Remittance Advice Online Enrollment

Kaiser Permanente has partnered with Citi Payment Exchange to provide a portal for enrolling in Electronic Fund Transfer (EFT) and Electronic Remittance Advice (ERA). With this partnership, Kaiser Permanente requests that all vendors pursuing EFT/ERA enrollments utilize the Payment Exchange portal for enrollment and changes to existing EFT/ERA. The portal is open 24 hours a day and 7 days a week for new enrollments or changes.

Reduce turn-around-time for receipt of payments and remove overhead costs associated with handling paper correspondence by signing up for EFT/ERA today.

It’s easy to get started now!
Each Kaiser Permanente region requires a separate enrollment.

If you wish to create a new enrollment for EFT/ERA in the Colorado region,
Click here to enter a secure portal.
Activation code YJRWT6 is required at login.

Frequently Asked Questions

What if I already have EFT/ERA set up with Kaiser Permanente? Will I need to re-enroll through Citi Payment Exchange?

No, vendors with EFT/ERA already in place at Kaiser Permanente will have their account set up on their behalf. You will receive an invitation from Citi Payment Exchange to sign in and make changes or additions to your existing account. If you do nothing, your current EFT/ERA arrangements will remain as they are today.

If I’ve submitted a change or an enrollment request, what will be the turnaround time to complete the request?

Continue to check Citi Payment Exchange for status updates. Once approved in the portal, Kaiser Permanente will require 7-10 business days to update the system. If you continue to receive paper checks, contact EDIsupport@kp.org.

Can I remove a bank account from my profile in Citi Payment Exchange?

Yes, you can also unshare a bank account with a region/payer under Settings.

The provider may have more than one bank account set up per region (sub designations are made by adding an NPI) and UNSHARE is the appropriate action if you want to keep one account in play but remove another one.

Can I change my demographic information through Citi Payment Exchange?

No, any demographic information changes need to be handled through Kaiser Permanente. Contact EDIsupport@kp.org for more information.

If I sign up for EFT in Colorado, will my California claim payments be automatically included?

No, you’ll need to request each region if not autoloaded in the initial set up of Payment Exchange.

Go to NEW region URL – sign in with activation code - using the specific activation code notifies the specific region of a new request. If the activation code is not used, the region isn’t notified of a new enrollment.

When Citi automation sees the provider information already exists, a message will pop up and direct the billing provider to log into their existing account. Once logged in and the established password is entered, the request for the new region will pop up in the “established accounts” list and the provider will be asked to link it to the existing account.

There is no limit to the number of regions a provider can be registered to bill. Providers who have multiple regions registered will all show in the “established accounts”. If you do not see your preferred region on this list, please contact EDIsupport@kp.org.

Can I cancel my EFT/ERA setup?

Yes, you can revoke the link between your account and the EFT/ERA vendor.
Within the Payment Exchange portal, provider will select Payers > click the Payer > then select Revoke. That will cancel the enrollment altogether with that payer (region).

Important Note: If you are a provider retrieving ERAs from a clearinghouse, you must remember to complete the ERA setup with your clearinghouse as well as with Kaiser Permanente via the Citi Payment Exchange portal.

If the claim is normally submitted via EDI, the corrected claim can be submitted via EDI as long the claim is identified as a corrected claim and includes the original claim # in the EDI transaction. If the original claim number is not included, the claim will be rejected before it gets to the claims processing system, as the original claim # is a required data element in the EDI transaction.

If claim is submitted via paper CMS 1500-- corrected claims need to be submitted on preprinted red claim forms, in box 22 the resubmission code is 7 (replacement claim) and the original reference # would be the original claim # that this claim is replacing. Do not stamp or note “Corrected Claim” on the form as it interferes with the OCR process causing delays in processing.

If claim is submitted via paper UB 04-- corrected claims need to be submitted on preprinted red claim forms the right most number in the type of bill field needs to be a 7 (example: 137). Please note the original claim # in box 64 of the corresponding line (A,B,or C) to which Kaiser Permanente is identified as the payor in block 50. Example Kaiser Permanente is identified as the payor in box 50A. The original claim number would be provided in box 64A. Do not stamp or note "Corrected Claim" on the form as it interferes with OCR process causing delays in processing.

We encourage you to submit your claims electronically.

Kaiser Permanente’s payor ID number is 91617. Complete claims will be paid or denied within the time frames required by applicable federal or state law.

All claims must include the member’s Health/Medical Record number. Kaiser Permanente does not recognize Social Security numbers as policy numbers. All claims must be submitted on a CMS 1500 form for professional charges or CMS 1450 form (UB-40) for facility charges. NPI numbers are required. Unless otherwise specified in your contractual agreement, charges should be submitted concurrently, but no later than 90 days from the date of service.

Additional information about claims procedures may be found in Section 5: Billing and Payment of the Fully-insured Provider Manual.

Email the EDI team

If you are interested in enrolling to submit EDI or are having issues related to EDI submissions (EDI claim rejection, missing claim, etc.), click send email to EDI Support:

Send email to EDI Support

Please mail paper claims and correspondence to:

Kaiser Permanente of Colorado
Claims Administration
P.O. Box 373150
Denver, CO 80237
1-303-338-3600

For additional information about claims procedures, refer to Section 5: Billing and Payment section of the Affiliated Provider Manual.

Self-funded claims

For self-funded claims, the payor ID is 94320. Complete claims will be paid or denied within the time frames required by applicable federal or state law.

Paper claims and correspondence should be mailed to:

KPIC – SF Claims Administration
P.O. Box 30547
Salt Lake City, UT 84130-0547
1-877-883-6698

All claims must include the member’s Health/Medical Record number. Kaiser Permanente does not recognize Social Security numbers as policy numbers. All claims must be submitted on a CMS 1500 form for professional charges or CMS 1450 form (UB-40) for facility charges. NPI numbers are required. Unless otherwise specified in your contractual agreement, charges should be submitted concurrently, but no later than 90 days from the date of service.

Fully-funded claims

You may now submit disputes or appeals online via the Online Affiliate portal. Sign on or register to access KP Online Affiliate and start using this feature today.

Self-funded claims

For information on Self Funded claims, call 1-877-883-6698.

For further information, please refer to Section 6 Provider Rights and Responsibilities of the appropriate provider manual:

Fully-insured Provider Manual, Section 6 Provider Rights and Responsibilities.
 

View claim information for Fully-funded members

Online Affiliate is Kaiser Permanente’s self-service portal, which allows providers access to many claims features, such as:

• Check the status of submitted claims and view claim details (service date, billed amount, allowed amount, patient responsibility)
• Confirm payment information (check number, payment date, amount)

Perform the following "Take Action" on a claim

• Submit a claim inquiry related to 'denied', or 'in progress' claims
• Submit an inquiry related to a check payment, request a copy of a check or report a change of address for a specific claim.
• Submit appeals or disputes - request a reconsideration of a payment
• Respond to KP request for information

View claim information for Self-funded members

You will be asked to sign on to view claim information for Self-funded members. A new page will open in your browser window.

view claim information for Self-funded members
 

EOP/835 Verbiage

Allowed amount is the qualifying payment amount for each item or service. The qualifying payment amount applies for purposes of the recognized amount. The qualifying payment amount was determined in compliance with this regulation. If you wish to initiate a 30-day open negotiation period for purposes of determining the amount of the total payment, as applicable, visit provider.multiplan.com, or contact MultiPlan at NSAService@multiplan.com or 888-593-7427. If the 30-day negotiation period does not result in a determination, you may initiate the independent dispute resolution process within 4 days after the end of the open negotiation period.

For Air ambulance services, please send your request to air-ambulance-appeals@kp.org

Additional Information

• The qualifying payment amount for all items or services was determined based on an underlying fee schedule or derived amount.
• If you wish for more information about how the qualifying payment amount for items or services provided, then please refer to the contact info on your EOP or 835.
• We can provide the detailed payment information for the new items or services based on the existing code(s) for items and services, if requested.

“IDR Initiation” and “Open Negotiation Notice”