Help with Claims

A claim is an official request to your coverage provider for payment or reimbursement for services you’ve received. Claims can be submitted by you, your doctors, or other health care providers. As a Kaiser Permanente member, claims for your care services would be submitted to Kaiser Permanente according to the requirements of the health plan you chose.

A claim is not the same as a bill or your Explanation of Benefits. It can, however, help you understand how your health plan benefits were applied to bills to determine what costs you’re personally responsible for. You fulfill your costs through copayments, deductibles, and out-of-pocket expenses.

The visit cost summary is an at-a-glance report of medical services and prescriptions claims that are pending (in progress) or completed.

On this summary, those claims that are completed will show you what share of the costs is your responsibility after the claim has been resolved. Those items that are pending will not yet have your share calculated.

A single visit may result in several separate claims being sent to your health plan by those who provided services for that visit.

For example, if your child has an X-ray:

• The hospital may send a claim for use of the equipment and clinical staff time.
• A radiologist may send a claim for interpreting the X-ray. 
• Your doctor may send a claim for developing a treatment plan for your child based on the X-ray.

So, this example could have at least 3 claims associated with it.

Remember, claims are not bills. However, after all claims are resolved, whatever claims or portions of claims aren’t covered by your health care plan may result in medical bills being sent to you by those who took care of your child. The outstanding bills will be your responsibility to pay, and then those dollar amounts will be added toward meeting your annual deductible and out-of-pocket maximums

In addition to the claim from the hospital, you may see a claim from medical professionals who were involved in your care, such as your surgeon, anesthesiologist, radiologist, or pathologist. If you were taken to the hospital by ambulance, you may also see a claim for that.

Yes. Even if you don't see all your claims, all out-of-pocket expenses that count toward your deductible and out-of-pocket maximum are accounted for.

This is the dollar amount typically considered payment-in-full as agreed to by your insurance company and the health care providers serving you. Often, the amount “your plan covers” is lower than the actual charge claimed and submitted by the health care provider.

For example, let's say the total charge for a doctor visit is $100. Doctors in your plan's network of providers have agreed to accept as payment-in-full for that visit whatever amount your health plan has agreed to cover.

So, if your health plan will only cover $80 of the $100 (minus any copayment or deductible you’ve agreed to pay), the remaining $20 is considered a write-off by the doctor. You can’t be billed for the amount the provider has agreed to write off, so in this case, you would owe nothing for the visit.

However, if the doctor is not a network provider, you may owe whatever amount your health insurance company will not cover, up to the full charge of $100 for the visit.

To get this number, we first calculate the “your plan covered” amount based on the coverage plan you’ve chosen. From that amount, we subtract the copayment and deductible you’re responsible for (if these charges apply based on your chosen coverage plan).

What’s left is the amount “your plan paid”; that is, what Kaiser Permanente actually paid the doctor or other health care provider for their claim.

You have the right to appeal your health care plan’s payment decision regarding any claim you personally submit.

To submit an appeal, you must ask that your health care plan (Kaiser Permanente) review the claim and decision. Please refer to your Explanation of Benefits or Statement of Accumulation for steps to submitting an appeal. You can also contact Member Services to speak with a representative.