Claims

Kaiser Permanente urges you to submit all claims via Electronic Data Interchange (EDI). You may submit EDI claims via 837I (Institutional) or 837P (Professional) transaction format, following all HIPAA standards and appropriate coding and regulatory requirements.

Benefits of using EDI for claim submissions

For complete information on claims filing requirements or processing, please refer to your agreement or contact the administrator for the applicable product.

Institutional providers may also refer to the applicable institutional provider manual.

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.

KPIC Self-Funded EPO/Self-Funded Product members
For instructions on how to submit EDI claims for KPIC Self-Funded EPO/Self-Funded Product members, please refer to the Self-Funded Provider Manual for Contracted Institutional Providers. You may contact 866-921-5310 (toll free) for any additional questions.

KPIC Fully Insured EPO/KPIC Deductible for Individuals Product members
For KPIC Fully Insured EPO/KPIC Deductible for Individuals Product members, please contact 866-921-5310 (toll free) for instructions on submitting EDI.

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 Southern California region,
Click here to enter a secure portal.
Activation code MN4WX2 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 Georgia, 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.
 

Member Claims Inquiries

If you are presented with a Health Plan member complaint or inquiry regarding any billing for cost share or other financial liability, you should direct the member to call the phone number on the back of his/her membership card for assistance.

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/

Submitting Paper Claims to Kaiser Permanente

If cost is an issue with your clearinghouse, Kaiser Permanente is now partnering with Office Ally to offer electronic claim submission tools to you for free. Office Ally Direct Data Entry is a full-service clearinghouse offering a web-based service where providers can submit to Kaiser Permanente. For more information and to determine your eligibility, please visit Office Ally.

HMO/DHMO/Senior Advantage members

For HMO/DHMO/Senior Advantage members, claims for services must be sent to the following:

By U.S mail:
Kaiser Foundation Health Plan, Inc.
Claims Administration Department
P.O. Box 7004
Downey, California 90242-7004

For claims filing requirements:
Contact 800-390-3510.

KPIC Self-Funded EPO/Self-Funded Product members

For KPIC Self-Funded EPO/Self-Funded Product members, claims for services must be sent to the following:

By electronic delivery:
For instructions on how to submit EDI claims for KPIC Self-Funded EPO/Self-Funded members, please refer to the Self-Funded Provider Manual for Contracted Institutional Providers. You may contact 866-921-5310 (toll free) for any additional questions.

By U.S. mail:
KPIC Claims Administrator
P.O. Box 30547
Salt Lake City, UT 84130-0547

For claims filing requirements or status:
Contact 800-533-1833.

KPIC Fully Insured EPO/KPIC Deductible for Individuals Product member
For KPIC Fully Insured EPO/KPIC Deductible for Individuals Product members, claims for services must be sent to the following:

By electronic delivery:
Contact 866-921-5310 (toll free) for instructions on submitting electronic claims.

By U.S. mail:
KPIC Claims Administrator
P.O. Box 30547
Salt Lake City, UT 84130-0547

For claims filing requirements:
Contact 866-213-3065

You may now submit appeals online via the Online Affiliate portal.

Sign on or Register to access KP Online Affiliate and start using this feature today.

Health Plan provides all providers with a fast, fair, and cost-effective dispute resolution mechanism under which you may submit all disputes regarding invoices, billing determinations, or other contract issues. We will handle disputes and this dispute resolution mechanism in accordance with applicable law. Please make sure that you review your agreement and the applicable law for a complete description of the dispute resolution process.

For more information on the provider appeals processes, call:

HMO/DHMO/Senior Advantage
800-464-4000

KPIC Self-Funded EPO or Self-Funded Product
800-533-1833

KPIC Deductible for Individuals Product or Fully Insured EPO
866-213-3065

Institutional providers may also refer to the applicable institutional provider manual.

View claim information for fully-funded members

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

View claim information for Self-funded members

You will be asked to sign on to view claim information for Self-funded members. A new page will open in your browser window.

view claim information for Self-funded members

Overview

The claims communication information found here is in addition to the annual communication Affiliate providers receive to meet compliance and regulatory requirements. The information below includes tools and other materials we want you to share to make your partnership with KP the best!

Online Affiliate

Did you know that you have access to claim status online? The days of waiting on hold to check claim status are over! Learn more about what Online Affiliate can offer to you and your staff.

Electronic Data Interchange (EDI), Electronic Fund Transfers (EFT), and Electronic Remittance Advice (ERA)

Go paperless and get connected with Electronic Data Interchange (EDI) and Electronic Fund Transfers (EFT)! You can also view Electronic Remittance Advice (ERA). For more information and our EDI payer IDs, refer to the Electronic Claim Submission, Payments (EFT) and Remits tab.

The NCA Provider Notification is a reminder that Kaiser Permanente only accepts completed claims as defined by California legal and regulatory requirements. The letter outlines the minimum acceptable submission and suggests using EDI to submit claims. If you are unable to use Electronic Data Interchange to submit claims, you can use the CMS 1500 form and be sure to include all required information as outlined in the NCA Provider Notification letter.

Claims Settlement Practices Provider Dispute Resolution Mechanism

As a reminder, you can find a summary of our claims submission requirements and settlement practices as well as a description of our provider dispute resolution mechanisms.

Claims Frequently Asked Questions (FAQs)

Kaiser Permanente’s National Claims Administration has developed FAQs to address common and frequent questions from a limited number of our specialty provider groups. These FAQs are intended to supplement and not replace the provider’s contract and supporting documents or state and federal regulations. If your specialty is not listed here, please reference the Provider Manual for Institutional providers, or the Annual Mailings for Professional Providers for more information.

• Mental Health providers FAQ
• Electrolysis providers FAQ
• LTSS providers FAQ

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”