Claims

After visiting a Non-Participating Provider:

• When you receive care from a Non-Participating Provider, you will likely need to submit a claim for reimbursement. You are also responsible for paying amounts that are greater than the maximum allowable charge. You may be required to pay the full amount you are billed when you receive care. If so, you will need to submit a Choice Products Medical Claim Form with an itemized bill for reimbursement.

If your plan has an annual deductible:

• Reimbursement is based on how much you have already paid toward your deductible and any remaining charges for which you are responsible, such as coinsurance.

Filing claims for emergency care services:

• If you receive emergency care services and need to submit claims for reimbursement, you must submit itemized bills for claims related to these services within 180 days, or as soon as reasonably possible.

What you’ll receive from Kaiser Permanente when you file:

• Within 30 days, you will receive an Explanation of Benefits (EOB) that will detail what you need to pay and what the health plan will pay. An EOB statement is not a bill from your medical insurance plan administrator, it is an informational statement to keep you informed of any claims processed under your insurance plan.

If you file a claim:

• You have up to 180 days from the date you received care to submit your claim.
• Kaiser Permanente will review the claim and decide what payment or reimbursement may be owed to you.
• Care must be medically necessary. Refer to your Evidence of Coverage and Certificate of Insurance for more information.
• You’ll need specific information from your service provider. Your Choice Products Reference Guide has the steps to take to file a claim.

Claim Submission Address:

National Claims Administration – Colorado
P.O. Box 373150
Denver, CO 80237-9998

Electronic Payer ID #: 91617

What if my claim is denied?

It is your right to file an appeal if you disagree with a decision not to pay for a claim. We are committed to providing you with quality care, in a timely response to your concerns. If we have denied coverage for certain services or supplies, in whole or in part, then you may request that we review this decision, also referred to as an “adverse benefit determination”. In addition, you may request that we review our determination of any cost shares (copayments, deductibles or coinsurance) or other amounts that you may owe. You have the right to appeal our decision by sending your request for review to the following address or by calling 1-877-847-7572:

Kaiser Permanente Insurance Company
Grievance and Appeals Coordinator
P.O. Box 378066
Denver, CO 80237
Phone: 1-855-364-3184
Fax: 1-855-414-2318

We must receive your First Level Appeal request within one hundred eighty (180) calendar days of your receiving this notice of our initial adverse decision. Please note that we will count the one hundred eighty (180) calendar starting five (5) business days from the date of the initial decision notice to allow for delivery time unless you can prove that you received the notice after that 5-business day period.

In your request, please include:

(1) your name and your Medical Record Number;
(2) your medical condition or relevant symptom(s);
(3) the specific treatment, service or supply that you are requesting;
(4) the specific reason(s) for your request that we review our initial decision; and
(5) all supporting documents. Your request and the supporting documents constitute your appeal.

• Our review will take into account all comments, documents, records and other information submitted that relates to the appeal. This includes both previously submitted information and any new information that you may choose to provide. We will consider any materials that you submit to us when we conduct our review.
• If we previously requested information that we never received, it is important that you make sure that we are provided with that information for your appeal. Without it, we may not be able to thoroughly evaluate your appeal.
• We will fully, fairly, and completely review all available information relevant to your request without deferring to any prior decisions.
• A board certified physician, who has the same or like specialty with the medical condition, procedure, or treatment, under review, will conduct the appeal.

Appointment of a Representative

If you would like to have someone act on your behalf during your First Level Appeal, you may appoint an authorized representative.  You must make this appointment in writing.  Please send or fax your representative’s name, address and telephone contact information to:

Kaiser Permanente Insurance Company
Grievance and Appeals Coordinator
P.O. Box 378066
Denver, CO 80237
Phone: 1-855-364-3184
Fax: 1-855-414-2318

Your Rights You are entitled to:

• Submit written comments, documents, records and other material relating to the benefit request for consideration during the review of your First Level Appeal.
• Provide evidence from a medical professional that there is a reasonable medical basis that the exclusion does not apply if our denial decision is due to a contractual exclusion,
• Receive from us, upon request and free of charge, reasonable access to and copies of all documents, records and other information relevant to your benefit request.
• Separately, you have the right to request any diagnostic and treatment codes and their meanings that may be the subject of your claim. To make a request, you should contact:  800-632-9700.

If you disagree with our decision on your first level appeal, your adverse benefit determination notice will tell you how to submit a voluntary second level appeal. We must receive your Second Level Appeal request within thirty (30) days of your receiving the notice of our adverse decision on your First Level Appeal.

You may send us additional information at each level of review including comments, documents, or additional medical records which you believe supports your claim.  If we had asked for additional information before and you did not provide it, we would still like to have that additional information for our review.  Please send or fax all your additional First Level Appeal information to:

Kaiser Permanente Insurance Company
Grievance and Appeals Coordinator
P.O. Box 378066
Denver, CO 80237
Phone: 1-855-364-3184
Fax: 1-855-414-2318

In addition, you may give testimony in writing or by telephone.  Please send or fax your written testimony to the address set forth above. To arrange to give testimony by telephone, you should contact:  1-855-364-3184.

We will add all of the new information to your request file and we will review it without regard to whether this information was submitted and/or considered in our initial decision.

We will share any additional information that we collect in the course of our review, and we will send it to you.  If we believe that your request should not be granted, before we issue our final First Level Appeal decision, we will also share with you any new or additional reasons for that decision.  We will send you a letter explaining the new or additional information and/or reasons.  Our letters will tell you how you can respond to the information provided if you choose to do so.  If you do not respond before we must make our final First Level Appeal decision, that decision will be based on the information already in your claim file.

Should you have questions about your appeal rights please contact us at 1-855-364-3184.