Claims

• Medi-cal DHCS All Plan Letter
• CMS Audit Requirements
• Important Regulatory Compliance Information
• Dual Language for Provider Communications
• Disputes Address Change – Claims Connect Contracted Provider Letter Address Change
• Kaiser Permanente Claims Connect Overview
• Kaiser Permanente Claims Connect Platform
• Kaiser Permanente Claims Connect Provider Impact
• Kaiser Permanente Claims Connect Changes to the EOP (Explanation of Payments – Northern CA New EOP and Southern CA EOP)

Electronic Submission of Claims (HIPAA 837)
HIPAA claims requirements (5010)
Benefits of Using EDI for Claim Submissions
Electronic Submission of Claims Types
Electronic Submission of Claims Types

Electronic Submission of Claims (HIPAA 837)

Kaiser Permanente currently supports electronic submission of claims. Claims can be submitted to Kaiser Permanente through direct claim submissions or, if necessary, through a Kaiser Permanente affiliated clearinghouse.

Please contact Provider Relations Monday through Friday 9:00 a.m. PT to 5:00 p.m. PT.

Durable Medical Equipment/Prosthetics and Orthotics
818-557-6126 and 510-268-5473

HIPAA claims requirements (5010)

The federal government mandated that all covered entities (including providers, clearinghouses and health plans) must transition to the latest version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards and code sets. This affects both electronic and paper claims.

The Centers for Medicare and Medicaid Services (CMS) mandates that all payers, physicians and hospitals exchange key business transactional data by January 1, 2012, using a new HIPAA 5010 format for electronic data interchange (EDI) transactions.

Along with other payers, Kaiser is undertaking preparations to implement these latest standards.

Requires update to version 5010 for HIPAA transactions
- 4010a1 has been around since 2002
– No new HIPAA transactions added at this time
– Some payers voluntarily adding new acknowledgements
Internal development and testing / demonstration of
Ability to send and receive 5010 required by 12/31/2010
External Trading Partner testing / Full Compliance required by 12/31/2011
Effective 1/1/2012 only 5010 transactions will be allowed

For more information on HIPAA 5010 refer to this site.

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.

Cleaner Claim Submissions: "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.

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 US Mail Delivery: Providers save time by bypassing the U.S. mail delivery system.

Reduced Payer-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

Use these forms for Submit electronic claims transactions using the following claims types:

837P Claim/Encounter: For professional services and supplier

837I Claim/Encounter: For facilities and hospitals

Electronic Submission of Claims Types

To receive an electronic provider Explanation of Payment (EOP), providers should already be set up for electronic submission of claims.

Please contact Provider Relations at Monday through Friday 9:00 a.m. PT to 5:00 p.m. PT.

Durable Medical Equipment/Prosthetics and Orthotics
818-557-6126 and 510-268-5473

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Kaiser Permanente is fully compliant with the legal requirements put forth by the Centers for Medicare & Medicaid Services (CMS) in the ICD-10 mandate. As of October 1, 2015, we began processing claims submitted with ICD-10 codes for dates of service (outpatient) or dates of discharge (inpatient) on or after October 1, 2015.

ICD-10 Frequently Asked Questions (FAQs)

For more information about KP’s ICD-10 authorizations policy, please see the KP Authorization and Referrals FAQ.

ICD-10 Claims Submission Rules

Kaiser Permanente has chosen to adopt CMS' EDI guidelines for ICD-10, specifically for claims that span the implementation deadline. Please see MLN Matters® Number: SE1408 Revised for specific instructions.

Important contacts

ICD-10 contacts
If you have questions related to KP’s ICD-10 implementation, please send an e-mail to: ICD10-Information@kp.org.

Useful ICD-10 links

For additional ICD-10 information, you may refer to these useful links from the Centers for Medicare and Medicaid Services (CMS):

CMS ICD-10 Official Information page

CMS Provider Resources