Provider Information

Provider Manual for HMO Members

The Provider Manual for HMO members may be viewed one section at a time. Click on the link below to open the PDF in a new window.

• Introduction and Table of Content
• Section 1: Kaiser Permanente Medical Care Program
• Section 2: Key Contacts
• Section 3: Eligibility and Benefits Determination
• Section 4: Utilization Management (UM) and Resource Management (RM)
• Section 5: Billing and Payment
• Section 6: Provider Dispute Resolution Process
• Section 7: Member Rights and Responsibilities
• Section 8: Provider Rights and Responsibilities
• Section 9: Quality Assurance and Improvement
• Section 10: Compliance
• Section 11: Additional Information
• Section 12: Additional Service Specific Information
• Appendix A

 

Provider Manual for Self-Funded Members

The Provider Manual for Self-Funded Members may be viewed one section at a time. Click on the link below to open the PDF in a new window.

• Introduction and Table of Contents
• Section 1: Self-Funded Program Overview
• Section 2: Key Contacts
• Section 3: Eligibility and Benefits Determination
• Section 4: Utilization Management (UM)/Resource Management (RM)
• Section 5: Billing and Payment
• Section 6: Member Rights and Responsibilities
• Section 7: Provider Rights and Responsibilities
• Section 8: Quality Assurance and Improvement (QA &I)
• Section 9: Compliance
• Section 10: Additional Information
• Section 11: Additional Service Specific Information

 

Annual notices

View annual notifications Kaiser Permanente makes available to its contracted providers.

Annual Fee Schedule Confirmation
Claims Settlement Practices and Provider Dispute Mechanisms Annual Notice
Annual NCQA Update
Clinical Practice Guidelines
EDI ERA EFT Flyer
NDC Claim Submission Reminder
Ownership and Control Change Notification Reminder
Practitioner Roster Maintenance
Completion of Billing Forms
SB 133 and Continuity of Care
Visiting Member Guidelines

2024 Northern California Medi-Cal Provider Manual Supplement
ICF DD Authorization and Billing Provider Manual Supplement
Coordination of Benefits and Medi-Cal Cost Avoidance
Reporting Requirements Related to Provider Preventable Conditions
SNF Provider Guidance re CalAIM
KP NCAL LTC SNF Billing Instructions
Northern California SNF LTC FAQ
KP NCAL Long Term Care Authorization Guidance

Enhanced Care Management (ECM): A Medi-Cal managed care benefit addresses clinical and non-clinical needs of high-need, high-cost individuals through coordinated services and comprehensive care management. ECM services are interdisciplinary, team-based, high-touch and person-centered.

Community Supports (CS): KP provides these services as a substitute to avoid utilization of other services such as hospital or skilled nursing facility admissions, discharge delays, or emergency department use.

Community Health Workers (CHW): CHWs are non-licensed frontline workers based in the member’s community and provide non-clinical support to members to help them reach a health-related goal. As an extension of the KP care team, they bring support services out of care facilities to meet members where they are in their own community.

For more information about ECM and CS, including information about how to refer members, click here: ECM, CS & CHW Information and Reference Guide.

• To download the ECM and CS referral form, click here: ECM, CS, & CHW Referral Form.

For information on how to contract with KP to become an ECM or Community Supports provider, click here: Kaiser Permanente, Network Lead Entity FAQ.

Kaiser Permanente’s Justice Involved Liaison (JIL) supports our members as they transition from incarceration into the community. The JIL coordinates care between correctional facilities, pre-release care management providers, and ECM providers. To contact our Justice Involved Liaison, email Ji-Liaison@kp.org or call 626-405-5386.

In accordance with Medi-Cal requirements, Kaiser Foundation Health Plan, Inc. (KFHP) may make Proposition (Prop) 56 payments based on eligible services provided to KFHP Medi-Cal members. Please see below communications which include information on the various Prop 56 programs and eligibility requirements for payments to non KP providers.

• Adverse Childhood Experience 
• Developmental Screening
• Family Planning Services
• Hyde Payments
• Physician Services
• Value-Based Payments

 

The Department of Health Care Services (DHCS) posts All Plan Letters (APLs) informing Medi-Cal Managed Care Plans (MCPs) of new guidelines and standards required by the state of California for Medi-Cal Services. Click below for a summary of the most recent APLs released by DHCS.

DHCS All Plan Letters

The Department of Health Care Services (DHCS) requires providers who see members under age 21 to be trained on Medi-Cal for Kids and Teens, also referred to as Early and Periodic, Diagnostic, and Treatment Services (EPSDT), at least every 2 years. The document linked below is a comprehensive training on EPSDT services provided by DHCS.

DHCS-EPSDT Provider Training

The Department of Health Care Services (DHCS) requires that KP, as a Medi-Cal Managed Care Plan, provide cultural competency, sensitivity, or diversity training for its contracted providers at key points of contact with KP members, such as reception staff and direct caregivers. This training helps reinforce KP’s commitment to effectively deliver health care services in a culturally competent manner that meets the social, cultural, and linguistic needs of our members. To promote access and the delivery of services in a culturally competent manner to all members, we are requesting you attest to having reviewed the Diversity, Cultural Competency, and Cultural Sensitivity Training.

If an attestation form has already been provided or you opt to utilize the electronically editable form below, please fill out the form or allow an authorized designee to respond on behalf of your practice/organization, sign and return it to KP by scanning and emailing it to the following email address: Medicaid-PROV-Team@kp.org

• Kaiser Permanente Diversity, Cultural Competency, and Cultural Sensitivity Training
• Kaiser Permanente Diversity, Cultural Competency, and Cultural Sensitivity Training Attestation Form

Consistent with state guidance, KP will utilize the attestations to Diversity, Cultural Competency, and Cultural Sensitivity training to modify provider listings to indicate providers have completed the training.

Any questions about this request can be directed to the email noted above. Please be sure to include your question(s) and phone contact information so we can respond quickly to your question(s).

The Provider Profile Information Form (PPIF) is a Kaiser Permanente document used to collect demographic information.

The PPIF should be completed for new contractors or existing contractors that have demographic changes. (e.g., to add, remove, or update locations, billing information, participating practitioners).

Click on link below to download PPIF.

• Provider Profile Information Form (PPIF)

Once the PPIF is downloaded to your PC /MAC it should be electronically completed fully for each submission. If you are a prospective contractor, please email the PPIF to your assigned Contract Manager. If you are an existing contractor, please email the PPIF to TPMG-MSC-ProvSvcs@kp.org.

Please attach PPIF in email in below format:
Subject Line: Your Legal Entity name – PPIF/W9

Hover-over options are now available on the PPIF to help guide you as you’re filling out the form.

Along with all practice information cited (Pg # Sec #), only the information for the practitioner to be added/updated is required for submission within the PPIF. 

Please consult your Contracts Manager for advice, especially if there is any change to your legal entity. Sometimes a Tax ID change requires a contractual change and sometimes it does not. If you are unable to reach your Contracts Manager, please email TPMG-MSC-ProvSvcs@kp.org to find out how to contact your Contracts Manager.

Please complete page 1 and page 3 of the PPIF and send it to TPMG-MSC-ProvSvcs@kp.org.

Note: If you need more facility care locations than the form allows on page 3, please complete the PPIF Bulk Submission Form instead and submit it along with page 1 of the PPIF.

For the best user experience, we recommend using the free desktop version of Adobe Acrobat Reader on your computer.