Claims

Electronic claim submissions
Kaiser Permanente urges you to submit all claims via Electronic Data Interchange (EDI). You may submit EDI claims Electronic Data Interchange (EDI) is an electronic exchange of information, in a standardized format that adheres to all Health Insurance Portability and Accountability Act (HIPAA) requirements. It is the transfers of structured data, by agreed message standards, from one computer system to another without human intervention.

Benefits of Electronic Data Interchange (EDI) transmission include:

• Reduced Overhead Expenses
• Improved Data Accuracy
• Reduced Turnaround Time for Claims Processing
• Bypass U.S. Mail Delivery
• Go Green! Reduce paper, mail time and postal mail costs

Electronic Submission of Claims Types

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.

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 Northwest region,

Click here to enter a secure portal.
Activation code R3ML96 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 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 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 EDI Support by submitting a Support Case for more
information: https://kpnationalclaims.my.site.com/EDI/s/

If I sign up for EFT in Northwest, 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 EDI Support by submitting a Support Case to: 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 Kaiser Permanente via the Citi Payment Exchange portal.

For detailed instructions and complete information about submitting claims to us, please download our the Billing and Payment Section of our Provider Manual.

Contact EDI Support

If you are interested in enrolling to submit EDI or are having issues related to EDI submissions (EDI claim rejection, missing claim, etc.), please submit a Support Case to EDI Support: https://kpnationalclaims.my.site.com/EDI/s/

Visiting Members Claims

Learn about submitting claims for a Kaiser Permanente member that resides in another Kaiser Permanente region.

Refer to the Visiting Member Guidelines (section 3.4) of the Northwest Provider Manual.

Reimbursement Rates

Providers will be reimbursed for visiting members at the same rates negotiated for all other Kaiser Permanente members.

Reimbursement for Other Services

Kaiser Permanente NW members who have paid for covered services in another service area may apply for reimbursement by submitting the receipts and a claim form to Kaiser Permanente NW Claims Administration.

Provider Claims Inquiry
Access to view detailed information will be available only through OneHealthPort.  Please register if you do not already have a OneHealthPort account!

If you require additional assistance, you may contact the Claims Inquiry Unit at 503-735-2727.

Provider Claim Payment Appeals Process
Please note that all claim payment appeal requests must be filed within 365 days of the date the claim was originally processed or denied, in order to be considered for payment by Kaiser Permanente.

Access to view detailed information will be available only through OneHealthPort.  Please register if you do not already have a OneHealthPort account!

Access to view detailed information will be available only through OneHealthPort.  Please register if you do not already have a OneHealthPort account!

Check the status of submitted claims on our claims guest access site.  No login required but you will need specific details about the claim to view the status.

Kaiser Permanente Policies cover a multitude of topics affecting claims payment. Our current published policies are linked below.

Clinical Review Payment Determination Policy

Intraoperative Neuromonitoring Policy

Acute Care UM Hospital Timely Notification Policy (PDF)

If you have questions about our policies posted here, please contact us with your questions at NWProviderRelations@kp.org.

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”