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Claims

Electronic Claims Submissions (EDI), Payments (EFT) and Remits (ERA)

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.

Listed below is the electronic submission of claims transactions:

837P Claim/Encounter - This is used for professional services and supplier.
837I Claim/Encounter - This is used by facilities and hospitals.

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

We encourage you to submit your claims electronically. Our EDI Trading Partners, and Payer ID's are listed below:

Clearing house	Northern CA	Southern CA	Hawaii	Georgia	Northwest	Mid-Atlantic	Colorado
Office Ally	94135	94134	94123	21313	93079	52095	91617
Waystar	N/A	N/A	N/A	21313	N/A	N/A	N/A
Availity (formerly REALMED)	N/A	N/A	N/A	N/A	N/A	52095	N/A
SSI	94135	94134	94123	21313	93079	52095	91617
Optum	94135	94134	94123	21313	93079	52095	91617
Optum Insight/ Ingenix	N/A	N/A	N/A	N/A	N/A	N/A	91617
Trizetto	94135	94134	94123	21313	93079	52095	91617

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

Instructions: Under Practice Software section, select “Clearinghouse”, “Start for Free”, and “Signup”

Kaiser Permanente’s EFT/ERA enrollment process has changed, and we are not extending enrollment to non-contracted vendors at this time. Please check back here periodically for additional process changes. Contracted providers can reach out to their Kaiser Permanente contact to begin the enrollment process.

Current EFT/ERA enrollees will continue to have access to the Citi Portal to make updates to their profile.

Processing time of new enrollments and changes in current enrollments have been slower than typical. We appreciate your patience while we work through these unexpected delays.

Frequently Asked Questions

If I’ve submitted a change or an enrollment request, what should I expect next?
Continue to check Citi Payment Exchange for status updates. Once approved in the portal, Kaiser Permanente will update the system. If you continue to receive paper checks, contact EDI Support by submitting a Support Case to: https://kpnationalclaims.my.site.com/EDI/s/

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 and remove another one.

Can I change my demographic information through Citi Payment Exchange?
You can log into your current Citi account to make most changes. If you need additional support, contact EDI Support by submitting a Support Case for more information: https://kpnationalclaims.my.site.com/EDI/s/

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 your KP contract manager.

Claim disputes

You may now submit online disputes or appeals online via KP Online Affiliate portal. When you submit disputes online, you will receive an acknowledgement letter and resolution letter in your Online Affiliate in-basket. Take advantage of all our claims self-service tools today!

For further information on fully-funded claims, please refer to the Fully-funded provider manual.

For information on self-funded claims, call 1-877-740-4117.

Member appeals

Members have the right to file a grievance or appeal when they disagree with the Health Plan's decision not to authorize necessary medical services or not to pay for a claim.

Download our appeals policy for members, which outlines the appeals process and provides contact information.

For further information on fully-funded appeals, please refer to the Fully-funded provider manual.

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

National Claims Administration Claims Recovery Mailing Addresses By Region
Region		Address	City	State	Zip Code
California - NCAL	Kaiser Permanente Recovery, NCAL	PO Box 742120	Los Angeles	CA	90074-2120
TPMG	KP TPMG Refunds	PO Box 743375	Los Angeles	CA	90074-3375
California - SCAL	Kaiser Permanente Attn: Regional Claims Recovery	PO Box 741639	Los Angeles	CA	90074-1639
Colorado	Kaiser Foundation Health Plan of Colorado	PO Box 740812	Los Angeles	CA	90074-0812
Georgia	Kaiser Foundation Health Plan of Georgia	PO Box 403032	Atlanta	GA	30384-3032
Hawaii	Kaiser Foundation Health Plan of Hawaii	PO Box 745820	Los Angeles	CA	90074-5820
Mid-Atlantic	Kaiser Foundation Health Plan Mid Atlantic	PO Box 740814	Los Angeles	CA	90074-0814
Northwest	Kaiser Foundation Health Plan of Northwest	PO Box 745854	Los Angeles	CA	90074-5854
Washington State	Kaiser Foundation Health Plan of WA	PO Box 748945	Los Angeles	CA	90074-8945

Download the Waiver of Liability Statement form (non-contracted Medicare Advantage providers)

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”

Kaiser Permanente has paid in accordance with the Maryland General Assembly’s guidelines, which utilize Maryland Medical Care Database. If you disagree with this determination, please contact the Life and Health Unit at 410-468-2244 or 800-492-6116.

According to Maryland Code, Health – General §19–710.1(g)(1), providers may file complaints regarding the payment of claims with the Maryland Insurance Administration by fax at 410-468-2270 or by e-mail to agcomplaints.mia@maryland.gov or by mail at:

Maryland Insurance Administration
Attn: Consumer Complaint Investigation (Please specify Property & Casualty or Life/Health)
200 St. Paul Place, Suite 2700
Baltimore, MD 21202.

Kaiser Permanente has paid in accordance with the Virginia state regulation 38.2-3445.01. The law establishes the reimbursement amounts for out-of-network providers who provide services to covered persons at an in-network facility, and for emergency services received at an out-of-network facility. The law also prohibits providers from surprise billing or balance billing consumers. The claim allowable was determined using a “commercially reasonable amount” based on payments for the same or similar services in a similar geographic area and was compared to the Kaiser Permanente Median Geographical Contracted rate.

If you disagree with this determination you can email the Notice of Intent to Arbitrate Form to both BBVA@scc.virginia.gov and to Kaiser Permanente, ClaimServicesIntake@kp.org within 10 days of the end of the good faith negotiation period. Note that the good faith negotiation period must be completed before arbitration can be requested.

Claims Submission Addresses

If you are unable to submit claims electronically, see below for mailing addresses

Note: Claims are to be submitted according to where the membership is held, not where the provider is practicing.

National Claims Administration By Region
Region	Phone	Address	City	State	Zip Code
California - NCAL	800-464-4000	PO Box 8002	Pleasanton	CA	94588-8602
California - SCAL	800-464-4000	PO Box 7004	Downey	CA	90242-8004
Colorado	303-338-3800	PO Box 373150	Denver	CO	80237-3150
Georgia	888-865-5813	PO Box 370010	Denver	CO	80237-0010
Hawaii	800-966-5955	PO Box 378021	Denver	CO	80237-8021
Mid-Atlantic	800-777-7902	PO Box 371860	Denver	CO	80237-9998
Northwest	503-813-2000	PO Box 370050	Denver	CO	80237-9998
Washington State	888-901-4636	PO Box 30766	Salt Lake City	UT	84130-0766
KPIC Self-Funded	800-533-1833	PO Box 30547	Salt Lake City	UT	84130-0547
Ambulance Claims		Relations Insurance - KP Ambulance Claims PO Box 853915	Richardson	TX	78085-3915