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Provider Manual

(2)

Billing and

Payment

This

 

section

 

of

 

the

 

Manual

 

was

 

created

 

to

 

help

 

guide

 

you

 

and

 

your

 

staff

 

in

 

working

 

with

 

Kaiser

 

Permanente’s

 

billing

 

and

 

payment

 

policies

 

and

 

procedures.

  

It

 

provides

 

a

 

quick

 

and

 

easy

 

resource

 

with

 

contact

 

phone

 

numbers,

 

detailed

 

processes

 

and

 

site

 

lists

 

for

 

services.

   

 

If,

 

at

 

any

 

time,

 

you

 

have

 

a

 

question

 

or

 

concern

 

about

 

the

 

information

 

in

 

this

 

Manual,

 

you

 

can

 

reach

 

our

 

Provider

 

Inquiry

 

Department

 

by

 

calling

 

503

813

2700

 

or

 

1

800

813

2700.

    

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Kaiser Permanente Provider Manual

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INTRODUCTION... 6

SECTION 5: BILLING AND PAYMENT ... 6

5.1.  WHOM TO CONTACT WITH QUESTIONS... 6

5.2   METHODS OF CLAIMS FILING... 8

5.3   PAPER CLAIM FORMS... 8

5.4  RECORD AUTHORIZATION NUMBER... 8

5.5 ONE MEMBER/ PROVIDER PER CLAIM FORM... 8

5.6  NO FAULT/ WORKERS’  COMPENSATION/OTHER ACCIDENT... 8 

5.7   ENTERING DATES... 8

5.8   MULTIPLE DATES OF SERVICES AND PLACE OF SERVICES... 10

5.9   SURGICAL AND/OR OBSTETRICAL PROCEDURES... 10

5.10  BILLING INPATIENT CLAIMS THAT SPAN DIFFERENT YEARS... 10

5.11  SUPPORTING DOCUMENTATION FOR PAPER CLAIMS(REQUIRED)... 10

5.12   WHERE TO MAIL/FAX PAPER CLAIMS... 11

5.13   ELECTRONIC DATA INTERCHANGE (EDI)... 11

5.14 ELECTRONIC CLAIMS FORMS... 12

5.15  SUPPORTING DOCUMENTATION FOR EDI CLAIMS(REQUIRED)... 12

5.16   TO INITIATE ELECTRONIC CLAIMS SUBMISSIONS... 12

5.17    ELECTRONIC SUBMISSION PROCESS... 14

5.18   KP Contracted Clearinghouses………. 5.19  HIPAA REQUIREMENTS... 16

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5.22  CLAIMS PROCESSING TURN‐AROUND TIME(REQUIRED)... 17

 5.23  Appeal of Timely Claims Submission………  5.24    PROOF OF TIMELY CLAIMS SUBMISSION (REQUIRED)... 18

       5.25  Claim Adjustments/Corrections………. 5.26  Incorrect Claims Payments (Required)... 20 

5.27   REJECTED CLAIMS DUE TO EDI CLAIMS ERROR(REQUIRED)... 22

5.28  FEDERAL TAX ID NUMBER(REQUIRED)... 22

5.29  CHANGES IN FEDERAL TAX ID NUMBER(REQUIRED)... 23

5.30  NATIONAL PROVIDER IDENTIFICATION (NPI)(REQUIRED)... 23

5.31  Member Cost Share………. 5.32 Member Claims Inquiries... 24

5.33 Visiting Members (Required)... 24

5.34  Coding for Claims (Required)... 24

5.35 Coding Standards... 24

5.36 Modifiers in CPT and HCPCS (Required)... 25

5.37 Modifier Review... 29

5.38  CODING & BILLING VALIDATION(REQUIRED)... 29

5.39 Coding Edit Rules (Required)... 29

5.40 Medical Claims Review (Required)... 30

Major Categories of Claim Coding Errors/Inconsistencies ... 30

Incidental Procedures ...31

Mutually Exclusive Procedures...31

Age and Gender (Sex) Conflicts ...32

Obsolete/Deleted Codes ...32

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5.43   PROVIDER CLAIMS APPEALS(REQUIRED)... 34

5.44   CMS‐1500 (08/05) FIELD DESCRIPTIONS ... 36

5.45   CMS‐1450 (UB‐04) FIELD DESCRIPTIONS... 45

5.46   BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES... 51

5.46.1  Evaluation Management (E/M) Services... 51

5.46.2 Emergency Rooms... 52

5.46.3  Durable Medical Equipment……… 5.46.4 Injection/ Immunizations ... 53

5.46.5 Newborn Services... 53

  5.46.6  Expanded Care………  5.47  Anesthesia ... 5.48   COORDINATION OF BENEFITS (COB) ... 58

5.48.1   How to Determine the Primary Payor ... 58

5.48.2   Description of COB Payment Methodologies ... 59

5.48.3   COB Claims Submission Requirements and Procedures ... 59

5.48.4   Members Enrolled in Two Kaiser Permanente Plans... 60

5.48.5   COB Claims Submission Timeframes... 60

5.48.6   COB FIELDS ON THE UB‐92 and UB‐04 CLAIM FORM ... 60

5.48.7   COB FIELDS ON THE CMS‐1500 (HCFA‐1500) CLAIM FORM... 62

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Kaiser Permanente Provider Manual

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Section 5: Billing and Payment

Introduction

At the heart of Kaiser Permanente‘s claim processing operation is the set of policies and procedures followed in determining the appropriate handling and reimbursement of claims received.

Kaiser Permanente uses code editing software from third party vendors to assist in determining the appropriate handling and reimbursement of claims. Currently, Kaiser Permanente has selected IntelliClaim, which in turn uses software from McKesson and Claims Edit System (CES) Knowledgebase. From time to time, Kaiser Permanente may change this coding editor or the specific rules that it uses in analyzing claims submissions. Kaiser Permanente’s goal is to help ensure the accuracy of claims payments.

IntelliClaim is a code editor software application designed to evaluate professional claims data including HCPCS and CPT codes as well as associated modifiers. IntelliClaim is a rule-based application; some of these rules have been chosen to meet Kaiser Permanente’s goals of increased accuracy in claims payment.

IntelliClaim assists Kaiser Permanente in identifying various categories of claims coding and possible inconsistencies. Claims with coding errors/inconsistencies are pended to the Medical Claim Review staff for manual review. Each claim is validated against Kaiser Permanente’s payment criteria, and then is subsequently released for processing. This process has a goal of improving the accuracy of coding and consistency in claims payment procedures.

In order to help illustrate how this process works, examples have been provided where appropriate. If you have questions about the application of these rules, please contact our

Claims Inquiry Unit.

Section 5: Billing and Payment

  

It is your responsibility to submit itemized claims for services provided to Members in a complete and timely manner in accordance with your Agreement, this Manual and applicable law. The Member’s Payor is responsible for payment of claims in accordance with your Agreement

5.1 Whom to Contact with Questions

If you have any questions relating to the submission of claims to Kaiser Permanente for processing, please refer to the table below for the correct department/number to call:

PLEASE CALL: IF YOU HAVE QUESTIONS ABOUT: TELEPHONE NUMBER(S):

CLAIMS

ADMINISTRATION

• Coordination of Benefits (COB

• Third Party Liability (TPL)

COB Local Telephone #: (503) 813-4332

COB Toll-Free Telephone #: (888) 454-4332

TPL Local Telephone #: (503) 813-2703

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Section 5: Billing and Payment

Address: Kaiser Permanente

Claims Administration Department 500 NE Multnomah Street, Suite 100 Portland, OR 97232-2099

CLAIMS INQUIRY Benefits/Co-Pay Information

• Claim Payment Inquiries *

• Claim Status *

• Claim Submission

• Explanation of Payment (EOP)

• Medical Policy Questions

• Member Eligibility

• Referral Questions

For Questions regarding Refunds and Refund Requests

Local Telephone #: (503) 735-2727

Toll-Free Telephone #: (866) 441-1221

Address: Kaiser Permanente Claims Inquiry Unit

500 NE Multnomah Street, Suite 100 Portland, OR 97232-2099

Local Telephone #: (503) 813-1900

Toll-Free Telephone #: (800) 756-2777

Address: Kaiser Permanente Claims Inquiry Unit

500 NE Multnomah Street, Suite 100 Portland, OR 97232-2099 PROVIDER CONTRACTING & RELATIONS • Contracts • Credentialing • Fee Schedule • Participation Request • Participation Status

• Practice Demographic Updates

• Provider Appeals

• Referral Policy

• Orientation

Local Telephone #: (503) 813-3376

Fax #: (503) 813-2017

Address: Kaiser Permanente

Provider Contracting & Relations 500 NE Multnomah Street, Suite 100 Portland, OR 97232-2099

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Section 5: Billing and Payment

5.2 Methods of

Claims Filing

Kaiser Permanente of the Northwest accepts all claims submitted by mail or electronically.

5.3 Paper

Claim Forms

 

• CMS-1500 (8/05) must be used for all professional services and suppliers.

• UB-04 (CMS-1450) must be used by all facilities (e.g., hospitals).

• Any professional services (for example, services rendered by radiologists, ER physicians, etc.) should be billed on CMS-1500 claim forms, unless you are contracted under a GLOBAL rate, in which case “professional services” should not be billed separately.

Please use standard claim forms formatted with RED ink to ensure maximum compatibility with Kaiser Permanente’s optical scanning equipment. Claim forms formatted with black or blue lines will not scan as efficiently as those formatted with RED.

5.4 Record

Authorization

Number

Services that require prior authorization must have an authorization number reflected on the claim form.

CMS 1500(8/05) Form

If applicable, enter the Authorization Number (Field 23) and the Name of the Referring Provider (Field 17) on the claim form, to ensure efficient claims processing and handling.

5.5 One

Member/

Provider per

Claim Form

One Member per Claim Form/One Provider per claim

• Do not bill for different Members on the same claim form • Do not bill for different Providers on the same claim form.

• Separate claim forms must be completed for each Member and for each Provider

5.6 No Fault/

Workers’

Compensation/

Other Accident

Be sure to indicate on the CMS-1500 (HCFA-1500) Claim Form in the “Is Patient’s Condition Related To” fields (Fields 10a -10c), whenever No Fault, Workers’ Compensation, or Other Accident situations apply.

5.7 Entering

Dates

All dates (dates of birth, dates of service, etc.) must be reported in the following format: month, day, and FOUR DIGITS for the year

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Section 5: Billing and Payment

CONSECUTIVE DATES OF SERVICE

• Consecutive dates of service can be billed on one claim line as long as the units entered in Field 24g equal the total number of days billed.

Example:

Correct Way to Bill Æ

CPT/HCPCS DATE OF SERVICE UNITS

97110 01/05/2008-01/07/2008 3 97110 01/09/2008-01/13/2008 5

Incorrect Way to Bill Æ

CPT/HCPCS DATE OF SERVICE UNITS

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Section 5: Billing and Payment

5.8 Multiple

Dates of

Services and

Place of

Services

DIFFERENT PLACES OF SERVICE

When services are rendered in DIFFERENT places of service

(locations), a separate claim form must be submitted for EACH

different place of service. • SAME PLACES OF SERVICE

Whenever services are provided in the SAME place of service, on DIFFERENT dates, these services may be reported andlisted as separate lines on ONE claim form, along with the corresponding date, diagnosis code(s), procedure code(s), and charges.

5.9 Surgical

and/or

Obstetrical

procedures

If any surgical and/or obstetrical procedures were performed, record the ICD-9-CM principal procedure and date in Field 80 (Principal Procedure Code and Date) and enter any additional ICD-9-CM procedure codes and corresponding dates in Field 81A-E (Other Procedure Codes and Dates). When submitting the UB-04, use Field 74a-e (Principal Procedure Code and Date)

5.10 Billing

Inpatient

Claims That

Span Different

Years

When an inpatient claim spans different years (for example, the patient was admitted in December and was discharged in January of the following year), it is NOT necessary to submit two claims for these services. Bill all services for this inpatient stay on one claim form (if possible), reflecting the correct date of admission and the correct date of discharge. Kaiser

Permanente will apply the appropriate/applicable payment methodologies when processing these claims.

5.11

Supporting

Documentation

for Paper

Claims

To expedite claims processing and adjudication, a Practitioner/Provider should submit supporting written documentation (for example, copies of pertinent medical records) with certain types of claims.

Supporting Documentation Submitted WITH a Claim:

• When supporting documentation is submitted WITH the

corresponding paper claim form, attach/secure the documentation to the paper claim with a paper clip (do not staple) and mail to Kaiser Permanente’s mailing address.

Supporting Documentation Submitted SEPARATELY From a Claim:

• When sending supporting documentation SEPARATELY from the claim (for example, when sending in requested medical information for a pended claim)

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Section 5: Billing and Payment

Mail Paper

Claims

Kaiser Permanente Claims Administration 500 NE Multnomah Street, Suite 100

Portland, OR 97232-2099

Note: Faxed Claims are not acceptable

5.13

Electronic Data

Interchange

(EDI)

Electronic Claim Submissions: Kaiser Permanente encourages electronic submission of claims.

EDI is an electronic exchange of information in a standardized format that adheres to all Health Insurance Portability and Accountability Act (HIPAA) requirements. EDI transactions replace the submission of paper claims. Required data elements (for example, claims data elements) are entered into the computer only ONCE - typically at the Provider’s office, or at another location where services were rendered.

Benefits of EDI Submission

1 Reduced Overhead Expenses: Administrative overhead expenses are reduced, because the need for handling paper claims is

eliminated.

2 Improved Data Accuracy: Because the claims data submitted by the Provider is sent electronically to Kaiser Permanente via the

Clearinghouse, data accuracy is improved, as there is no need for re-keying or re-entry of data.

3 Low Error Rate: Additionally, “up-front” edits applied to the claims data while information is being entered at the Provider’s office, and additional payer-specific edits applied to the data by the

Clearinghouse before the data is transmitted to the appropriate payer for processing, increase the percentage of clean claim submissions.

4 Bypass US Mail Delivery: The usage of envelopes and stamps is eliminated. Providers save time by bypassing the U.S. mail delivery system.

5 Standardized Transaction Formats: Industry-accepted standardized medical claim formats may reduce the number of “exceptions” currently required by multiple payers.

NOTICE TO ALL PROVIDERS: Even though you may be reimbursed under a capitated arrangement, periodic interim payments (PIP), or other

reimbursement methodology, you are still required to submit Member Encounter Data to Kaiser Permanente electronically (preferred) or via standard claim forms (CMS-1500/08/05 or UB-04), and to follow all claims completion instructions set forth in this Manual.

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Section 5: Billing and Payment

5.14 Electronic

Claims Forms

Currently, Kaiser Permanente receives and sends the following electronically via the current 4010A1 version through our contracted Clearinghouses

• 837P must be used for all professional services and suppliers. • 837I must be used by all facilities (e.g., hospitals).below

5.15

Supporting

Documentation

for EDI Claims

To expedite claims processing and adjudication, a Practitioner/Provider should submit supporting written documentation (for example, copies of pertinent medical records) with certain types of claims.

Supporting Documentation Submitted SEPARATELY From a Claim:

• When sending supporting documentation SEPARATELY from the claim (for example, when sending in requested medical information for a pended claim)

1) Complete a Supporting Documentation Cover Sheet for each Member for whom you are submitting paper

documentation.

2) Attach the cover sheet to each Member’s paper documentation with a paper clip.

3) Mail the supporting documentation as per the instructions on the form.

5.16 To Initiate

Electronic

Claims

Submissions

A Practitioner/Providermay be contacted by Kaiser Permanente and encouraged to submit claims electronically.

1) Written Request/Call

Alternately, a Practitioner/Providermay initiate the call (or may submit a written request) to our Provider Contracting & Relations Department, asking that they be set up to transmit claims

electronically to Kaiser Permanente. This information will be relayed to the Regional EDI Coordinator.

2) Verifying Connection Is Established

Upon receipt of the EDI request from the Practitioner/Provider, the Regional EDI Coordinator from Kaiser Permanente will contact the Practitioner/Providerto confirm that they have established a

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Section 5: Billing and Payment

Practitioner/Provider in the steps to take.

3) EDI Set-Up

Once the Practitioner’s/Provider’s billing information and verification processes are complete, a representative from either the selected Clearinghouse and/or Kaiser Permanente’s Regional EDI

Coordinator will contact the Practitioner/Provider to work through the technical components of electronic claim testing and

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Section 5: Billing and Payment

5.17

Electronic

Submission

Process

1) Practitioners’/Providers’ EDI Responsibilities:

Once a Practitioner/Providerhas entered all of the required data elements (i.e., all of the required data for a particular claim) into a computer system, the Practitioner/Provider then electronically “sends” all of this information to a Clearinghouse for further data sorting and distribution.

2) Clearinghouse’s EDI Responsibilities:

The Clearinghouse receives information electronically from a

variety of Practitioners and Providers, who have chosen that particular Clearinghouse as their data sorter and distributor. The Clearinghouse “batches” all of the information it has received from the various Practitioners and Providers, sorts the information, and then electronically “sends” the information to the correct payer for processing. Data content required by HIPAA Transaction Implementation Guides is the responsibility of the

Practitioner/Provider and the Clearinghouse. The Clearinghouse should ensure HIPAA Transaction Set Format compliance with HIPAA rules.

In addition, Clearinghouses:

• Frequently supply the requiredPC software to enable direct data entry in the Practitioner’s/Provider’s office.

Edit the data which is electronically submitted to the

Clearinghouse by the Practitioner’s/Provider’s office, so that the data submission will be accepted by the appropriate payer for processing.

Transmit the data to the correct payer in a format easily understood by the payer’s computer system.

• Transmit electronic claim status reports from payers to Practitioners/Providers.

3) Kaiser Permanente’s EDI Responsibilities:

Kaiser Permanente receives EDI information after the

Practitioner/Provider sends it to the Clearinghouse for distribution. The data is loaded into Kaiser Permanente’s computer electronically and is prepared for further processing.

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Section 5: Billing and Payment

claims, Kaiser Permanente EDI Transaction Solution (KPEDITS) prepares a 997electronic acknowledgement which is transmitted back to the Clearinghouse.

NOTE: If you do not receive Kaiser Permanente’s 997 electronic claim acknowledgements from the Clearinghouse, contact your billing service or the Clearinghouse and request that this be routinely forwarded to you.

Additionally, Kaiser Permanente provides a Kaiser Permanente EDI Transaction Solutions (KP EDITS) Reject Detail Report for those claims which were rejected by KP EDITS because of “fatal” front-end errors. Any rejected claims may be re-submitted electronically once the claims have been corrected by the Practitioner/Provider.

NOTE: See the Claims Status Category and Reason Codes at

http://www.wpc-edi.com for a list of common Insurance

Business Process Application error codes that prevent a claim from being accepted by Kaiser Permanente.

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Section 5: Billing and Payment

5.18

KP Contracted

Clearinghouses

Clearinghouse Payer IDs as of 11/07/2006

Clearing House Payer IDs as of 11/07/2006 Cortex EDI 93079

Emdeon (WebMD, Envoy) 93079

Gateway EDI KS007 (837P)

MedAvant (ProxyMed) KS007 (837P) or 93079 (837I) Medisoft KS007 (837P)

NDCHealth 93079 (837P) or 00153 (837I) Office Ally 93079

Payer Connection KS007 (837P) Per Se 93079 (837P)

RelayHealth RH002 (837I and 837P) THIN (Thinedi) KS007 (837P) or 93079 (837I) Zirmed Z1059

Providers should access their Clearinghouses to identify the Payer Id for Kaiser Foundation NW.

PLEASE NOTE: Payer IDs are for both 837I (UB) and 837P (HCFA) transactions unless otherwise noted. Also, these Payer IDs are only for Kaiser Foundation Health Plan of the Northwest. If you wish to submit EDI claims to another Kaiser Permanente region, you must obtain the

appropriate Payer ID from your Clearinghouse or the appropriate region.

5.19 HIPAA

Requirements

All electronic claim submissions must adhere to all HIPAA requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at (301) 949-9740. • www.dhhs.gov • www.wedi.org • www.wpc-edi.com

5.20 Clean

Claims

Kaiser Permanente considers a claim ‘clean’ when the following requirements are met.

Correct Form - Kaiser Permanente requires all professional claims to be submitted using the CMS Form 1500(8/05) and all facility claims (or appropriate ancillary services) to be submitted using the CMS Form CMS 1450 (UB04).

Standard Coding – All fields should be completed using industry standard coding.

Applicable Attachments – Attachments should be included in your submission when circumstances require additional information.

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Section 5: Billing and Payment

Completed Field Elements for CMS Form 1500 (08/05 ) Or CMS 1450 (UB-04) – All applicable data elements of CMS forms should be completed. A claim is not considered to be “Clean” or payable if one or more of the following are missing or are in dispute:

The standards or format used in the completion or submission of the claim The eligibility of a person for coverage

The responsibility of another payor for all or part of the claim

The amount of the claim or the amount currently due under the claim The benefits covered

The manner in which services were accessed or provided The claim was submitted fraudulently

Note: Failure to include all information will result in a delay in claim

processing and payment and it will be returned for any missing information. A claim missing any of the required information will not be considered a clean claim.

5.21 Claims Submission Timeframes

• New Claims: 365 Days from Date of Service(DOS) • COB Claims: 365 Days from date of Primary EOP • Self Funded Claims: 120 Days from DOS

5.22 Claims

Processing

Turn-Around

Time

Clean Claims:

Please allow 30 days for Kaiser Permanente to process and adjudicate your claim(s). Claims requiring additional supporting documentation and/or coordination of benefits may take longer to process.

NOTE: While Kaiser Permanente may require the submission of specific supporting documentation necessary for benefit determination (including medical and/or coordination of benefits information), Kaiser Permanente may have to make a decision on the claim before such information is received.

A "complete” or “clean" claim is defined as a claim that has no defect or impropriety, including lack of required substantiating documentation from providers, suppliers, or Membersor particular circumstances requiring special treatment that prevents timely payments from being made on the claim.

5.23 Appeal of Timely Claims Submission

Resubmitted claims along with proof of initial timely filing received within 365 days of the original date of denial or explanation of payment, will be allowed for reconsideration of claim processing and payment. Any claim

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Section 5: Billing and Payment

resubmissions received for timely filing reconsideration beyond 365 daysof the original date of denial or explanation of payment will be denied as untimely submitted.

5.24 Proof of

Timely Claims

Submission

Claims submitted for consideration or reconsideration of timely filing must be reviewed with information that indicates the claim was initially submitted within the appropriate time frames. Acceptable proof of timely filing may include the following documentation and/or situations:

Proof or Documentation Examples

System generated claim copies, account print-outs, or reports that indicate the original date that claim was submitted, and to which insurance carrier. *Hand-written or typed documentation is not acceptable proof of timely filing. Account ledger posting that includes multiple patient submissions Individual Patient ledger

CMS UB04 or 1500(8/05) with a system generated date or submission. EDI Transmission report Reports from a Provider

Clearinghouse (i.e. WebMD)

Lack of member insurance information. Proof of follow-up with member for lack of insurance or incorrect insurance information.

*Members are responsible for providing current and appropriate insurance information each time services are rendered by a provider. Copies of dated letters requesting information, or requesting correct information from the member.

Original hospital admission sheet or face sheet with incomplete, absent, or incorrect insurance information.

Any type of demographic sheet collected by the provider from the member with incomplete, absent, or incorrect insurance information.

5.25 Claim Adjustments/ Corrections

CMS-1500 (08/05) Claim Forms:

NOTE: Kaiser Permanente prefers corrections to 837P claims which were already accepted by Kaiser Permanente to be submitted on paper

claim forms. Corrections submitted electronically may inadvertently be denied as a duplicate claim. Refer to page Error! Bookmark not defined. within this GUIDE for further information/instructions.

When submitting a corrected CMS-1500 (08/05) paper claim to Kaiser Permanente for processing:

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Section 5: Billing and Payment

1) Write “CORRECTED CLAIM” in the top (blank) portion of the standard claim form.

2) Attach a copy of the corresponding page of Kaiser Permanente’s

Explanation of Payment (EOP) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip.

3) Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address (see page Error! Bookmark not defined. in this section).

UB-04 Claim Forms (837I):

NOTE: 837I corrections may be submitted electronically.

When submitting a corrected UB-04 claim to Kaiser Permanente for processing:

Electronic

Include the appropriate Type of Bill code when electronically submitting a corrected UB-04/837I claim to Kaiser Permanente for processing.

Paper

When submitting a corrected or UB-04 paper claim to Kaiser Permanente for processing:

1) Include the appropriate Type of Bill code in Field 4.

2) Attach a copy of the corresponding page of Kaiser Permanente’s

Explanation of Payment (EOP) to each corrected claim, to prevent these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip.

3) Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address (see page Error! Bookmark not defined. in this section).

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Section 5: Billing and Payment

5.26 Incorrect

Claims

Payments

If you receive an incorrect payment (i.e., either an overpayment or an

underpayment), please do one of the following:

Option 1: Do not cash or deposit the incorrect payment check.

• Mail the incorrect payment check back to Kaiser Permanente, along with a copy of the Explanation of Payment (EOP)and a brief note explaining the payment error to:

Kaiser Permanente Claims Administration 500 Multnomah St, Suite 100

Portland, OR 97232-2099

NOTE: If Kaiser Permanente’s EOP is not available, please record the Member’s Health Record Number and/or Claim Number on the

payment check you are returning.

• Kaiser Permanente will re-issue and mail you a new, corrected payment check within 30 days.

Option 2: Deposit the incorrect Kaiser Permanente payment check in your account.

For an Underpayment Error:

Write or call our Claims Inquiry Unit and explain the error. Upon verification of the error, appropriate corrections will be made to Kaiser Permanente’s accounting system and the underpayment amount owed will be reflected in a Kaiser Permanente reimbursement check within 30 days.

yFor an Overpayment Error: Please do the following:

1) Write a refund check to Kaiser Permanente for the excess amount paid to you by Kaiser Permanente. Attach a copy of Kaiser

Permanente’s Explanation of Payment to your refund check, as well as a brief note explaining the error. Attach with a paper clip.

NOTE: If Kaiser Permanente’s EOP is not available, please record the Member’s Health Record Number on the payment check you are returning.

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Section 5: Billing and Payment

Kaiser Permanente

Claims Administration, Recoveries Unit 500 NE Multnomah St, Suite 100

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Section 5: Billing and Payment

5.27 Rejected

Claims Due to

EDI Claims

Error

Electronic Claim Acknowledgement: Kaiser Permanente sends an electronic claim acknowledgement to the Clearinghouse. This claims acknowledgement will be forwarded to you as confirmation of all claims received by Kaiser Permanente.

NOTE: If you are not receiving Kaiser Permanente’s electronic claim receipt from the Clearinghouse, contact the Clearinghouse and request that this be routinely forwarded to you.

5.28 Federal

Tax ID Number

The Federal Tax ID Number as reported on any and all claim form(s) must match the information filed with the Internal Revenue Service (IRS).

1 When completing IRS Form W-9, please note the following:

• Name: This should be the equivalent of your “entity name,” which you use to file your tax forms with the IRS.

• Sole Provider/Proprietor: List your name, as registered with the IRS.

• Group Practice/Facility: List your “group” or “facility” name, as registered with the IRS.

2 Business Name: Leave this field blank, unless you have registered with the IRS as a “Doing Business As” (DBA) entity. If you are doing business under a different name, enter that name on the IRS Form W-9.

3 Address/City, State, Zip Code: Enter the address where Kaiser Permanente should mail your IRS Form 1099.

4 Taxpayer Identification Number (TIN): The number reported in this field (either the social security number or the employer identification number) MUST be used on all claims submitted to Kaiser

Permanente.

• Sole Provider/Proprietor: Enter your taxpayer identification number, which will usually be your social security number (SSN), unless you have been assigned a unique employer identification number (because you are “doing business as” an entity under a different name).

• Group Practice/Facility: Enter your taxpayer identification number, which will usually be your unique employer identification number (EIN).

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claim forms, please contact the IRS help line in your area or refer to the following website:

http://www.irs.gov/formspubs/

Completed IRS Form W-9 should be mailed to the following address: Kaiser Permanente

<Provider Contracting and Relations 500 NE Multnomah Ste 100

Portland, OR 97232>

5.29 Changes

in Federal Tax

ID Number

If your Federal Tax ID Number should change, please notify us immediately, so that appropriate corrections can be made to Kaiser Permanente’s files.

5.30 National

Provider

Identification

(NPI)

The Health Insurance Portability and Accountability Act of 1996 (HIPPA) mandates that all providers use a standard unique identifier on all electronic transactions. Your National Provider Identifier (NPI) must be used on all HIPPA-standard electronic transactions by May 23, 2007.

For additional information regarding the National Provider Identifier (NPI), how to apply and report please contact the Center for Medicare & Medicaid Services (CMS) or refer to the following website:

http://www.cms.hhs.gov/NationalProvIdentStand/

5.31 Member Cost Share

Depending on the benefit plan, Kaiser Permanente Members may be responsible to share some cost of the services provided. Copayment, co-insurance and deductible (collectively, “Member Cost Share”) are the fees a Member is responsible to pay a Provider for certain covered services. This information varies by plan and all Providers are responsible for collecting Member Cost Share in accordance with Kaiser Permanente Member’s benefits unless explicitly stated otherwise in your Agreement. Please verify applicable Member Cost Share at the time of service. Member Cost Share information can be obtained from:

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5.32 Member

Claims

Inquiries

Please direct Member to call Member Services at 503-813-2000 or 1-800-813-2000

5.33 Visiting

Members

For Visiting Member Claims:

• All non Medicare claims and claims from Medicare Choice Members should be submitted directly to Kaiser Permanente for processing, as per the claims submission instructions set forth in this Manual.

• For Medicare claims from Medicare FFS and Medicare Cost Members, please refer to the section of this Manual that discusses Coordination of Benefits (COB)

Reimbursement Rates:

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

5.34

Coding for

Claims

It is the Provider’s responsibility to ensure that billing codes used on claims forms are current and accurate, that codes reflect the services provided and they are in compliant with Kaiser Permanente’s coding standards. Incorrect and invalid coding may result in delays in payment or denial of payment.

5.35 Coding

Standards

Coding – All fields should be completed using industry standard coding as outlined below.

ICD-9

To code diagnoses and hospital procedures on inpatient claims, use the International Classification of Diseases- 9th Revision-Clinical Modification (ICD-9-CM) developed by the Commission on Professional and Hospital Activities. ICD-9-CM Volumes 1 & 2 codes appear as three-, four- or five-digit codes, depending on the specific disease or injury being described. Volume 3 hospital inpatient procedure codes appear as two-digit codes and require a third and/or fourth digit for coding specificity.

CPT-4

The Physicians' Current Procedural Terminology, Fourth Edition (CPT) code set is a systematic listing and coding of procedures and services performed by Participating Providers. CPT codes are developed by the American Medical Association (AMA). Each procedure code or service is identified with a five-digit code.

If you would like to request a new code or suggest deleting or revising an existing code, obtain and complete a form from the AMA's Web site at www.ama-assn.org/ama/pub/category/3112.html or submit your request and supporting documentation to:

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CPT Editorial Research and Development American Medical Association

515 North State Street Chicago IL 60610 HCPCS

The Healthcare Common Procedure Coding System (HCPCS) Level 2 identifies services and supplies. HCPCS Level 2 begin with letters A–V and are used to bill services such as, home medical equipment, ambulance, orthotics and prosthetics, drug codes and injections.

Revenue Code

Approved by the Health Services Cost Review Commission for a hospital located in the State of Maryland, or of the national or state uniform billing data elements specifications for a hospital not located in that State. NDC (National Drug Codes)

Prescribed drugs, maintained and distributed by the U.S. Department of Health and Human Services

ASA (American Society of Anesthesiologists)

Anesthesia services, the codes maintained and distributed by the American Society of Anesthesiologists

DSM-IV (American Psychiatric Services)

For psychiatric services, codes distributed by the American Psychiatric Association

5.36 Modifiers

in CPT and

HCPCS

Modifiers submitted with an appropriate procedure code further define and/or explain a service provided. Valid modifiers and their descriptions can be found in the most current CPT or HCPCS coding book. Note CMS-1500 Submitters: Kaiser Permanente processes up to fourmodifiers per claim line.

When submitting claims, use modifiers to:

• Identify distinct or independent services performed on the same day

• Reflect services provided and documented in a patient's medical record

Modifiers for Professional and Technical Services Most commonly used modifiers are:

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Modifier -25

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Modifier -26

Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier '-26' to the usual procedure number.

Modifier -TC

Technical Component - The modifier TC is submitted with a CPT procedure code to bill for equipment and facility charges, to indicate the technical component.

• Use with diagnostic tests; e.g. radiation therapy, radiology, and pulmonary function tests.

• Indicates the Provider performed only the technical component portion of the service.]

Modifier 50

Bilateral Procedure: Add Modifier 50 to the service line of a unilateral 5-digit CPT procedure code to indicate that a bilateral procedure was

performed. Modifier 50 may be used to bill surgical procedures at the same operative session, or to bill diagnostic and therapeutic procedures that were performed bilaterally on the same day.

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Multiple Procedures: Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or

provision of supplies (eg, vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by

appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated "add-on" codes.

Modifier 52

Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier '-52', signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled

procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers '-73' and '-74' (see modifiers approved for ASC hospital outpatient use). Modifier 57

Decision for Surgery: An evaluation and management service that

resulted in the initial decision to perform the surgery may be identified by adding the modifier '-57' to the appropriate level of E/M service.

Modifier 59

Distinct Procedural Service: Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services

performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported

together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the

circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see

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Section 5: Billing and Payment

modifier 25. Modifier 62

Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding the modifier '-62' to the

procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same

procedure code. If additional procedure(s) (including add-on

procedure(s) are performed during the same surgical session, separate code(s) may also be reported with the modifier '-62' added. Note: If a co-surgeon acts as an assistant in the performance of additional

procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier '-80' or modifier '-82' added, as appropriate.

Modifier 76

Repeat Procedure or Service by Same Physician: Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service

Modifier 78

Return to the Operating Room for a Related Procedure During the Postoperative Period: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76.)

This list is not all-inclusive.

Durable Medical Equipment (DME) Modifiers

NU= new equipment

RP= replacement and repair RR= Rental of DME equipment

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Section 5: Billing and Payment

Review

accuracy and appropriateness, to include review of supporting

documentation. Improper use of modifiers may cause claims to pend and/or be returned for correction. Documentation may be requested from various units within the claims department.

5.38 Coding &

Billing

Validation

Kaiser Permanente uses code editing software from third party vendors to assist in determining the appropriate handling and reimbursement of claims. Currently, Kaiser Permanente has selected IntelliClaim as our claim editing source, which in turn uses software from McKesson and McKesson Knowledgebase. From time to time, Kaiser Permanente may change this coding editor or the specific rules that it uses in analyzing claims submissions. Kaiser Permanente’s goal is to help ensure the accuracy of claims payments.

IntelliClaim is a code editor software application designed to evaluate professional claims data including HCPCS and CPT codes as well as associated modifiers. IntelliClaim is a rule-based application; some of these rules have been chosen to meet Kaiser Permanente’s goals of increased accuracy in claims payment.

IntelliClaim assists Kaiser Permanente in identifying various categories of claims coding and possible inconsistencies. Claims with coding errors/inconsistencies are pended to the Claim Review staff for manual review. Each claim is validated against Kaiser Permanente’s payment criteria, and then is subsequently released for processing. This process has a goal of improving the accuracy of coding and consistency in claims payment procedures.

In order to help illustrate how this process works, examples have been provided where appropriate. If you have questions about the application of these rules, please contact our Claims Inquiry Unit.

5.39 Coding

Edit Rules

An example of the Coding Edit Rules is provided below. Please see Appendix A for entire listing of Rules.

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5.40 Medical

Claims Review

Major Categories of Claim Coding Errors/Inconsistencies

Procedure Unbundling

Definition: Procedure unbundling occurs when two or more procedure codes are used to describe a procedure performed, when a single – more comprehensive –procedure code exists that accurately describes the entire procedure performed.

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Section 5: Billing and Payment

billed separately when a pre-defined panel exists that contains all of the individual tests billed. These tests should NOT be billed separately, but should be billed using ONE panel code.

Example 2: Billing the following 2 codes together is considered “unbundling.”

93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report

93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

When 93005 and 93010 are performed on the same day the appropriate comprehensive procedure code would be 93000.] Incidental Procedures

Definition: An incidental procedure is typically performed at the same time as a more complex primary procedure. However, the incidental procedure requires little additional physician resources, and/or is clinically integral to the performance of the primary procedure. Therefore, incidental procedures are NOT reimbursed separately.

Appendectomy with other abdominal procedures is not billable when the appendix was removed solely for incidental reasons, in other words, since the surgeon was in the abdominal cavity he removed the appendix.

Separate Procedures

Definition: Procedures designated as a “separate procedure” in the CPT code book are commonly performed as an integral part of a total, larger procedure, and normally do NOT warrant separate identification. Therefore, these services are typically included as part of the “global” charges

submitted for the related, larger procedure.

However, when the procedure is performed as a separate, independent service not in conjunction with any normally related procedure it may be billed as a “separate procedure.” If the procedure is performed alone for a specific purpose, it may be eligible for separate reimbursement.

Tracheotomy performed in an emergent situation is warranted for separate reimbursement. Yet, tracheotomy performed to create a permanent

tracheostomy is part of the larger procedure. Mutually Exclusive Procedures

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Section 5: Billing and Payment

are usually NOT performed at the same operative session on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of

procedure(s), for which the physician should be submitting only ONE of the procedure codes.

An example of a mutually exclusive situation is when the repair of an organ can be performed by two different methods. One repair method must be chosen to repair the organ and must be reported.

A second example is the reporting of an “initial” service and a “subsequent” service. It is contradictory for a service to be classified as an initial and a subsequent service at the same time.

CPT codes that are mutually exclusive of one another based either on the CPT definition or the medical impossibility/improbability that the procedures could be performed at the same session can be identified as code pairs. Age and Gender (Sex) Conflicts

Definition: An age conflict occurs when the Provider bills an age-specific procedure code for a patient outside of the designated age range. Similarly, a gender conflict occurs when a gender-specific procedure is assigned to a patient of the opposite gender.

[Example 1: The Provider assigns the code for surgical opening of the stomach, for newborns (43831), to a 45-year-old patient.

Example 2: Code 58150 Total abdominal hysterectomy is submitted for a male patient. Exception: Initial Newborn Care (99431, 99432, 99435) are payable under the mother’s contract and are excluded from the age processing rules.

The following age categories are examined for conflicts: • Newborn (age less than 1 year old)

• Pediatric (age 1-17 years old) • Maternity (age 12-55 years old) • Adult (age over 14 years old)] Obsolete/Deleted Codes

Claims submitted with obsolete or deleted codes may be denied. Obsolete or deleted codes are updated each calendar year and will be end dated as specified by CMS. Kaiser Permanente does not pay against deleted codes following the end date.

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Section 5: Billing and Payment

code is in effect on 01/01/2008. If the provider bills with the deleted code in 2008, that procedure will be denied.

Multiple/ Duplicate Component Billing

When procedures are billable for professional and technical components (i.e. with modifiers 26 and TC), Kaiser Permanentemonitors that the total amount paid for the service does not exceed what would have been paid if the procedure had been billed without the modifier(s). Kaiser Permanente reserves the right to adjust claims that are paid in excess of the total. Example: 71020-26 (Interpretation and report of chest x-ray) billed by provider A and 71020 billed by provider B for the same patient same day. Since 71020 encompasses both the technical and the professional

component of the chest x-ray, claim from provider A could be denied as a partial duplicate unless supported by documentation or another supporting modifier

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5.41 Other

Party Liability

(OPL)

Other Party Liability (OPL) is a way of determining the order in which benefits are paid and the amounts which are payable when a claimant is covered under more than one plan (individual or group). It is intended to prevent duplication of benefits when an individual is covered by multiple plans or payers providing benefits or services for medical, dental or other care and treatment. Other Party Liability includes Coordination of Benefits (COB), Third Party Liability (TPL), Worker’s Compensation (WC), TRICARE (also known as Champus), Medicare Primary and dual coverage.

Kaiser Permanente follows the National Association of Insurance

Commissioners (NAIC) model regulations for coordinating benefits, except in those instances where the NAIC model regulations differ from Oregon or Washington state law, state law supersedes the NAIC model regulations. If you have any questions relating to the coordination of benefits, please call the appropriate number listed below for assistance.

COB Local Telephone #: (503) 813-4332

COB Toll-Free Telephone #: (888) 454-4332

TPL Local Telephone #: (503) 813-2703

TPL Toll-Free Telephone #: (866) 374-0929

Worker’s Compensation, TRICARE & Medicare Primary Local Telephone #:

(503) 735-2727

Worker’s Compensation, TRICARE & Medicare Primary Toll-Free Telephone #:

(866) 441-1221

5.42 Workers’

Compensation

If you have questions, please call 503-735-2727 or 1-866-441-1221

5.43 Provider

Claims Appeals

If your office/facility has questions or concerns about the way a particular claim was processed by Kaiser Permanente, please contact our Claims Inquiry Unit at 503-732-2727. Many questions and issues regarding claim payments, coding, and submission policies can be resolved quickly over the phone or via fax.

If your issue cannot be resolved through this initial contact, you will be instructed as follows:

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Section 5: Billing and Payment

If your concern is determined to be a claim payment appeals issue, you will be advised to submit your concern in writing to:

Kaiser Permanente Provider Appeals Provider Contracting and Relations

500 NE Multnomah Blvd Ste 100 Portland, OR 97232

503-813-3376 503-813-2017 Fax

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.

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The fields identified in the table below as “Required” must be completed when submitting a CMS-1500 (08/05) claim form to Kaiser Permanente for processing:

Note: The required fields for submission shown below are required by Kaiser Permanente but not necessarily required by CMS or other payers. For Medicare Members, please refer to Medicare Billing Requirements for appropriate field requirements and instructions/examples. Note: The new CMS-1500 (08/05) form is revised to accommodate National Provider

Identifiers (NPI). Kaiser currently accepts both forms.

FIELD

NUMBER FIELD NAME

REQUIRED FIELDS FOR CLAIM SUBMISSIONS INSTRUCTIONS/EXAMPLES 1 MEDICARE/ MEDICAID/ TRICARE CHAMPUS/ CHAMPVA/ GROUP HEALTH PLAN/FECA BLK LUNG/OTHER

Not Required Check the type of health insurance coverage applicable to this claim by checking the appropriate box.

1a INSURED’S I.D. NUMBER Required Enter the subscriber’s plan identification

number.

2 PATIENT’S NAME Required Enter the patient’s name. When submitting

newborn claims, enter the newborn’s first and last name.

3 PATIENT'S BIRTH DATE AND

SEX Required

Enter the patient’s date of birth and gender. The date of birth must include the month, day and FOUR DIGITS for the year (MM/DD/YYYY). Example:01/05/2008 4 INSURED'S NAME Required Enter the name of the insured (Last Name, First Name,

and Middle Initial), unless the insured and the patient are the same—then the word “SAME” may be entered. 5 PATIENT'S ADDRESS Required Enter the patient’s mailing address and telephone

number. On the first line, enter the STREET ADDRESS; the second line is for the CITY and STATE; the third line is for the ZIP CODE and PHONE NUMBER.

6 PATIENT'S RELATIONSHIP TO

INSURED Required

if Applicable

Check the appropriate box for the patient’s relationship to the insured.

7 INSURED'S ADDRESS Required

if Applicable

Enter the insured’s address (STREET ADDRESS, CITY, STATE, and ZIP CODE) and telephone number. When the address is the same as the patient’s—the word “SAME” may be entered.

8 PATIENT STATUS Required

if Applicable

Check the appropriate box for the patient’s MARITAL STATUS, and check whether the patient is EMPLOYED or is a

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Section 5: Billing and Payment

Required

if Applicable last name, first name and middle initial of the insured.

9a OTHER INSURED’S POLICY OR

GROUP NUMBER Required

if Applicable

Enter the policy and/or group number of the insured individual named in Field 9 (Other Insured’s

Name) above. NOTE: For each entry in

Field 9A, there must be a corresponding entry in Field 9d.

9b OTHER INSURED’S DATE OF

BIRTH/SEX Required

if Applicable

Enter the “other” insured’s date of birth and sex. The date of birth must include the month, day, and FOUR DIGITS for year (MM/DD/YYYY). Example:

01/05/2008

9c EMPLOYER”S NAME OR

SCHOOL NAME Required if Applicable

Enter the name of the “other” insured’s EMPLOYER or SCHOOL NAME (if a student).

9d INSURANCE PLAN NAME OR

PROGRAM NAME Required if Applicable Enter the name of the “other” insured’s

INSURANCE PLAN or program.

10a-c IS PATIENT CONDITION

RELATED TO Required

Check “Yes” or “No” to indicate whether

employment, auto liability, or other accident involvement applies to one or more of the services described in field 24.

NOTE: If “yes” there must be a

corresponding entry in Field 14 (Date of Current Illness/Injury).

Place (State) - enter the State postal code.

10d RESERVED FOR LOCAL USE Not Required Leave blank.

11 INSURED’S POLICY NUMBER

OR FECA NUMBER Not Required

If there is insurance primary to Medicare, enter the insured’s policy or group number.

11a INSURED’S DATE OF BIRTH Not Required Enter the insured’s date of birth and sex, if

different from Field 3. The date of birth must include the month, day, and FOUR digits for the year (MM/DD/YYYY). Example: 01/05/2008

11b EMPLOYER’S NAME OR

SCHOOL NAME Not Required Enter the name of the employer or school

(if a student), if applicable.

11c INSURANCE PLAN OR

PROGRAM NAME Not Required Enter the insurance plan or program

name.

11d IS THERE ANOTHER HEALTH

BENEFIT PLAN? Required Check “yes” or “no” to indicate if there is

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NUMBER FIELD NAME FOR CLAIM INSTRUCTIONS/EXAMPLES

SUBMISSIONS

the patient may be covered under insurance held by a spouse, parent, or some other person.

If “yes” then fields 9 and 9a-d must be completed.

12 PATIENT'S OR AUTHORIZED

PERSON'S SIGNATURE Not Required Have the patient or an authorized

representative SIGN and DATE this block, unless the signature is on file. If the

patient’s representative signs, then the relationship to the patient must be indicated.

13 INSURED'S OR AUTHORIZED

PERSON'S SIGNATURE Not Required Have the patient or an authorized

representative SIGN this block, unless the signature is on file.

14 DATE OF CURRENT ILLNESS,

INJURY, PREGNANCY Required

if Applicable

Enter the date of the current illness or injury. If

pregnancy, enter the date of the patient’s last menstrual period. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY).

Example: 01/05/2008 15 IF PATIENT HAS HAD SAME OR

SIMILAR ILLNESS Not Required Enter the previous date the patient had a

similar illness, if applicable. The date must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/2008

16 DATES PATIENT UNABLE TO WORK IN CURRENT

OCCUPATION

Not Required Enter the “from” and “to” dates that the patient is unable to work. The dates must include the month, day, and FOUR

DIGITS for the year (MM/DD/YYYY). Example: 01/05/2008 17 NAME OF REFERRING PHYSICIAN OR OTHER SOURCE Required if Applicable

Enter the FIRST and LAST NAME of the referring or ordering physician.

17a OTHER ID # Not Required In the shaded area, enter the non-NPI ID number of the physician whose name is listed in Field 17. Enter the qualifier identifying the number in the field to the right of 17a. The NUCC defines the following qualifiers: 0B - State License Number

1B - Blue Shield Provider Number 1C - Medicare Provider Number 1D - Medicaid Provider Number 1G - Provider UPIN Number

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Section 5: Billing and Payment EI - Employer’s Identification Number

G2 - Provider Commercial Number LU - Location Number

N5 - Provider Plan Network Identification Number

SY - Social Security Number

X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy

17b NPI NUMBER Required In the non-shaded area enter the NPI

number of the referring provider

18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

Not Required Complete this block when a medical service is furnished as a result of, or subsequent to, a related hospitalization.

19 RESERVED FOR LOCAL USE Required

if Applicable

If you are “covering” for another physician, enter the name of the physician (for whom you are covering) in this field.

If a non-contracting Provider/Provider will be covering for you in your absence, please notify that individual of this requirement.

20 OUTSIDE LAB CHARGES Not Required

21 DIAGNOSIS OR NATURE OF

ILLNESS OR INJURY Required Enter the diagnosis/condition of the

patient, indicated by an ICD-9-CM code number. Enter up to 4 diagnostic codes, in PRIORITY order (primary, secondary condition).

22 MEDICAID RESUBMISSION Not Required

23 PRIOR AUTHORIZATION

NUMBER Required

if Applicable

Enter the prior authorization number for those procedures requiring prior approval.

24a-g SUPPLEMENTAL INFORMATION

SUPPLEMENTAL INFORMATION, con’t.

Required Supplemental information can only be entered with a corresponding, completed service line.

The top area of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 lines of service. When reporting additional anesthesia services information (e.g., begin and end times), narrative description of an unspecified code, NDC, VP – HIBCC codes, OZ – GTIN codes or contract rate, enter the applicable qualifier and number/code/information starting with the first space in the shaded line of this field. Do not

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