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Provider Manual 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 you have any questions or concerns about this Manual, you can reach our Provider Inquiry Department by calling 503-735-2727 or 1-866-441-1221.

5

Billing and Payment

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Kaiser Permanente Provider Manual 3

Table of Contents

PROVIDER MANUAL............................................................................................................... 1

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 .................................................................................................................... 10

5.12 WHERE TO MAIL PAPER CLAIMS .................................................................................................................. 10

5.13 ELECTRONIC DATA INTERCHANGE (EDI) ...................................................................................................... 11

5.14 ELECTRONIC CLAIMS FORMS ........................................................................................................................ 12

5.15 TO INITIATE ELECTRONIC CLAIMS SUBMISSIONS ........................................................................................... 12

5.16 ELECTRONIC SUBMISSION PROCESS ........................................................................................................... 13

5.17 ELECTRONIC FUNDS TRANSFER (EFT) PAYMENT ......................................................................................... 15

5.18 HIPAA REQUIREMENTS ............................................................................................................................... 15

5.19 CLEAN CLAIMS ............................................................................................................................................ 15

5.20 CLAIMS SUBMISSIONTIMEFRAMES…………………………………………………..............................................17

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5.21 CLAIMS PROCESSING TURN-AROUND TIME ................................................................................................... 17

5.22 APPEAL OF TIMELY CLAIMS SUBMISSION....................................................................................................... 17

5.23 PROOF OF TIMELY CLAIMS SUBMISSION ........................................................................................................ 18

5.24 CLAIM ADJUSTMENTS/CORRECTIONS ........................................................................................................... 18

5.25 INCORRECT CLAIMS PAYMENTS ................................................................................................................... 20

5.26 REJECTED CLAIMS DUE TO EDI CLAIMS ERROR ........................................................................................... 20

5.27 FEDERAL TAX ID NUMBER ............................................................................................................................ 20

5.28 CHANGES IN FEDERAL TAX ID NUMBER ........................................................................................................ 21

5.29 NATIONAL PROVIDER IDENTIFICATION (NPI) .................................................................................................. 22

5.30 MEMBER COST SHARE ................................................................................................................................ 22

5.31 MEMBER CLAIMS INQUIRIES ......................................................................................................................... 23

5.32 VISITING MEMBERS ..................................................................................................................................... 23

5.33 CODING FOR CLAIMS ................................................................................................................................... 23

5.34 CODING STANDARDS................................................................................................................................... 23

5.35 MODIFIERS IN CPT AND HCPCS ................................................................................................................. 24

5.36 MODIFIER REVIEW ...................................................................................................................................... 28

5.37 CODING & BILLING VALIDATION .................................................................................................................... 29

5.38 CODING EDIT RULES .................................................................................................................................... 29

5.39 RETROSPECTIVE CLAIM REVIEW .................................................................................................................. 32

5.40 OTHER PARTY LIABILITY (OPL) ................................................................................................................... 34

5.41 WORKERS’ COMPENSATION ........................................................................................................................ 34

5.42 PROVIDER CLAIMS DISPUTES ....................................................................................................................... 34

5.43 CMS-1500 (2/02) FIELD DESCRIPTIONS…………………………………………………………………………..36

5.44 CMS-1450 (UB-04) FIELD DESCRIPTIONS ............................................................................................. 44

5.45 BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES ............................................................ 49

5.45.1 EVALUATION MANAGEMENT (E/M) SERVICES ............................................................................................. 49

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5.45.2 EMERGENCY ROOMS ................................................................................................................................. 50

5.45.3 DURABLE MEDICAL EQUIPMENT ................................................................................................................ 51

5.45.4 INJECTION/ IMMUNIZATIONS ........................................................................................................................ 52

5.45.5 NEWBORN SERVICES ................................................................................................................................. 52

5.45.6 DO NOT BILL EVENTS ............................................................................................................................... 52

5.46 ANESTHESIA ................................................................................................................................................. 54

5.47 COORDINATION OF BENEFITS (COB) ............................................................................................................ 60

5.47.1 HOW TO DETERMINE THE PRIMARY PAYOR ............................................................................................... 59

5.47.2 DESCRIPTION OF COB PAYMENT METHODOLOGIES .................................................................................. 60

5.47.3 COB CLAIMS SUBMISSION REQUIREMENTS AND PROCEDURES .................................................................. 60

5.47.4 MEMBERS ENROLLED IN TWO KAISER PERMANENTE PLANS ...................................................................... 61

5.47.5 COB CLAIMS SUBMISSION TIMEFRAMES ................................................................................................... 61

5.47.6 COB FIELDS ON THE UB-04 CLAIM FORM ......................................................................................... 61

5.48 EXPLANATION OF PAYMENT (EOP) ………………………………………………………………………………...66

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Kaiser Permanente Provider Manual 2015 6

Section 5: Billing and Payment

Introduction At the heart of Kaiser Permanente‘s claim processing operation is the set of policies and procedures that are followed to determine 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 ClaimsXten™ (CXT). On occasion, 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. ClaimsXten™ (CXT) is McKesson’s current solution for applying clinically-based claims

auditing. The software offers flexible rules creation and application and enables payers to process each claim under the specific terms and conditions of individual benefit plans.

ClaimsXten has been contracted nationally as KP’s Enterprise code editing solution to be integrated with Tapestry AP on the KPCC platform.

ClaimsXten combines the strength and flexibility of the McKesson Total Payment™ platform with a comprehensive library of McKesson clinical rule content, and a services team of medical claims experts to provide increased medical and administrative savings opportunities.

– Evaluates codes billed on a claim, and makes coding recommendations in conjunction

with industry guidelines (e.g., AMA, CMS, etc.) – Use of claims history in editing and reporting – Ability to comply with regulatory requirements – ICD 10 capable

In order to help illustrate how this process works, examples have been provided where appropriate. 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 Who 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:

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

CLAIMS INQUIRY

• Benefits/Co-Pay Information • Claim Payment Inquiries * • Claim Status * • Claim Submission • Explanation of Payment (EOP) • Medical Policy Questions • Member Eligibility • Referral Questions • Provider Appeals and Disputes

NOTE: You may be asked to mail or fax a list of the claims in question if the number of claims you are questioning/researching is large.

Local Telephone #: (503) 735-2727 Toll-Free Telephone #: (866) 441-1221

Address: Dates of Service prior to September 14, 2015 Kaiser Permanente Claims Inquiry Unit 500 NE Multnomah Street, Suite 100 Portland, OR 97232-2099 Dates of Service September 14, 2015 and after Kaiser Permanente National Claims Administration PO Box 370050 Denver CO 80237-9998 Fax #: (866)518-3437

PROVIDER CONTRACTING & RELATIONS

• Contracts • Credentialing • Fee Schedule • Participation Request • Participation Status • Practice Demographic Updates • Referral Policy • Orientation

Local Telephone #: (503) 813-3376 and (503) 813-3318 Fax #: (503) 813-2017 Address: Kaiser Permanente

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

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5.2 Methods of Claims Filing

Kaiser Permanente of the Northwest accepts all claims submitted by mail or electronically. Kaiser Permanente’s preferred method is electronically.

5.3 Paper Claim Forms

• CMS-1500 (2/12) 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(2/12) 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 (MM/DD/YYYY).

Example: 01/05/2015

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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

CPT/HCPCS DATE OF SERVICE UNITS 97110 01/05/2015-01/07/2015 3 97110 01/09/2015-01/13/2015 5

Incorrect Way to Bill

CPT/HCPCS DATE OF SERVICE UNITS 97110 01/05/2015-01/13/2015 5

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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 and listed 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-9/10-CM principal procedure and date in Field 80 (Principal Procedure Code and Date) and enter any additional ICD-9/10-CM procedure codes and corresponding dates in Field 81A-E (Other Procedure Codes and Dates). When submitting the UB-04, you should use Field 74A-E (Principal Procedure Code and Date). As ICD-10 implementation approaches, you should be prepared to submit appropriate ICD-10 procedure codes on these claims.

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

Supporting documentation is only required when requested upon the denial or pending of a claim. The need for this information will be indicated by the remark codes returned on the 835 electronic transaction or paper remittance advice. Your claim will not be reprocessed until this information is received.

When billing with an unlisted CPT code, to expedite claims processing and adjudication, providers should submit supporting written documentation.

5.12 Where to Mail Paper Claims

Dates of service prior to September 14, 2015 Kaiser Permanente Claims Administration 500 NE Multnomah Street, Suite 100 Portland, OR 97232-2099

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Dates of service September 14, 2015 and after Kaiser Permanente National Claims Administration PO Box 370050 Denver CO 80237-9998

A critical requirement to correct claims payment is ensuring that the TIN in Box 25 belongs to the vendor named in Box 33 and the NPI in Box33a belongs to the named vendor in Box 33. Boxes 25, 33 and 33a are all data values that have to represent the same entity. While an organization may take on responsibility for billing for another provider or vendor, Kaiser Permanente will match to the TIN and NPI in boxes 25 and 33a and issue the check /payment to the entity that owns the TIN and NPI regardless of the name appearing in box 33.

5.13 Electronic Data Interchange (EDI)

Electronic Claim Submissions: Kaiser Permanente prefers 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, increases the percentage of clean claim

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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-1500/02/12 or UB-04), and to follow all claims completion instructions set forth in this Manual.

5.14 Electronic Claims Forms

Currently, Kaiser Permanente receives and sends the following electronically via the current 5010 version through our contracted Clearinghouses

• 837P must be used for all professional services and suppliers. A critical requirement to correct claims payment is ensuring that the TIN in Box 25 belongs to the vendor named in Box 33 and the NPI in Box33a belongs to the named vendor in Box 33. Boxes 25, 33 and 33a are all data values that have to represent the same entity. While an organization may take on responsibility for billing for another provider or vendor, Kaiser Permanente will match to the TIN and NPI in boxes 25 and 33a and issue the check /payment to the entity that owns the TIN and NPI regardless of the name appearing in box 33.

• 837I must be used by all facilities (e.g., hospitals).

5.15 To Initiate Electronic Claims Submissions

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

It is not necessary to notify us when you wish to submit electronically. Work with your clearinghouse or billing partner in setting up EDI per the information provided in this manual.

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5.16 Electronic Submission Process

1) Practitioners’/Providers’ EDI Responsibilities:

Once a Practitioner/Provider has 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 required PC 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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On the same business day that Kaiser Permanente receives the EDI claims; Kaiser Permanente EDI Transaction Solution (KPEDITS) prepares a 997 electronic 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 an electronic acknowledgement (277) for each claim received which is transmitted back to the provider via the clearinghouse. For those claims which were rejected because of “fatal” front-end errors, these 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.

Relay Health RH002 SSI SS002 Office Ally NW002 Ingenix NG009 Capario KS007 (Prof only) Emdeon 93079 (no 835) Payer IDs as of 11/07/2006

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.

http://www.wpc-edi.com/

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5.17 Electronic Funds Transfer (EFT) Payment

Electronic Funds Transfer – Kaiser Permanente supports EFT with all contracted vendors. Kaiser Permanente uses CAQH’s service called, “EnrollHub.” This service is free to you and will save you time and money in managing your claim receivables. Please visit www.caqh.org and select any of the prominent links that identify “EnrollHub” or “EFT”.

5.18 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

5.19 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(2/12) 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. Completed Field Elements for CMS Form 1500 (02/12) Or CMS 1450 (UB-04) – All applicable data elements of CMS forms should be completed.

• The format used in the completion or submission of the claim is missing required fields or codes are not active

• The eligibility of a member cannot be verified • The service from and to dates are missing • The rendering physician is missing • The vendor is missing • The diagnosis is missing or invalid • The place of service is missing or invalid • The procedures/services are missing or invalid

http://www.caqh.org/

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• The amount billed is missing or invalid • The number of units/quantity is missing or invalid • The type of bill, when applicable, is missing or invalid • The responsibility of another Payor for all or part of the claim is not

included or sent with the claim Other coverage has not been verified • Additional information is required for processing such as COB

information, operative report or medical notes (these will be requested upon denial or pending of claim)

• 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. Please reference the National Uniform Claim Committee website at www.nucc.org for additional information regarding the elements required for claim submission.

http://www.nucc.org/

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5.20 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

5.21 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 Members or particular circumstances requiring special treatment that prevents timely payments from being made on the claim. Please reference the National Uniform Claim Committee website at www.nucc.org for additional information regarding the elements required for claim submission.

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

http://www.nucc.org/

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5.23 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(2/12) 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.

5.24 Claim Adjustments/ Corrections

CMS-1500 (02/12) Claim Forms: NOTE: Kaiser Permanente prefers corrections to 837P claims which were already accepted by Kaiser Permanente to be submitted via EDI. When submitting a corrected claim via EDI they should be indicated by a "6" or "7" in the Claim Frequency Type Code. The REF01 segment of Loop 2300 should have a value of "F8", and the REF02 segment of Loop 2300 should have the original claim reference number from KP. When submitting a corrected CMS-1500 (02/12) paper claim to Kaiser Permanente for processing:

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

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these claims from being rejected by Kaiser Permanente as duplicate claims. Attach with a paper clip.

Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address. CMS 1450 (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

When submitting a corrected claim via EDI they should be indicated by a "6" or "7" in the Claim Frequency Type Code. The REF01 segment of Loop 2300 should have a value of "F8", and the REF02 segment of Loop 2300 should have the original claim reference number from KP. Paper When submitting a corrected or CMS 1450 (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.

Mail the corrected claim(s) to Kaiser Permanente using the standard claims mailing address.

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5.25 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:

Dates of service prior to September 14,2015 Kaiser Permanente Claims Administration 500 NE Multnomah Street, Suite 100 Portland, OR 97232-2099 Dates of service September 14, 2015 and after Kaiser Permanente National Claims Administration PO Box 370050 Denver CO 80237-9998

5.26 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.

5.27 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.

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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).

If you have any questions regarding the proper completion of IRS Form W-9, or the correct reporting of your Federal Taxpayer ID Number on your 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

5.28 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.

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5.29 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. NPI numbers are required on all claims. If you have already obtained your NPI numbers (both Individual Type 1 and/or Organization/Group Type 2), please notify Kaiser Permanente Provider Contracting & Network Management department.

Individual (Type 1) and Organization/Group (Type 2) NPI applications and instructions can be accessed at: https://nppes.cms.hhs.gov.

5.30 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: http://www.providers.kaiserpermanente.org/nw Member Services at 503-813-2000 or 1-800-813-2000.

http://www.providers.kaiserpermanente.org/nw

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5.31 Member Claims Inquiries

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

5.32 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.

5.33 Coding for Claims

It is the contracted provider’s responsibility to ensure that billing codes used on claims forms are current and accurate, that codes reflect the services provided, that coding is consistent with the encounter documentation and that coding is in compliance with Kaiser Permanente’s coding standards. Individual physician evaluation and management coding statistics are routinely trended and compared with national statistics. Aberrant coding statistics may result in contract termination and investigation by federal regulators.

5.34 Coding Standards

Coding – All fields should be completed using industry standard coding as outlined below. ICD-9/10 To code diagnoses and hospital procedures on inpatient claims, use the International Classification of Diseases- 9th Revision-Clinical Modification (ICD-9-CM/ICD-10-CM) developed by the Commission on Professional and Hospital Activities. ICD-9-CM/ICD-10-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

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Topic Instructions

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: 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

5.35 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 four modifiers per claim line. When submitting claims, use modifiers to:

• Identify distinct or independent services performed on the same day

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Topic Instructions

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

Note: Kaiser Permanente processes up to two (2) modifiers per claim line on CMS-1500 claims forms. Modifiers for Professional and Technical Services Most commonly used modifiers are: 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.

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Topic Instructions

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.

Modifier 51

Multiple Procedures: Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services, or provision of supplies (e.g., 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

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Topic Instructions

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 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.)

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Topic Instructions

Durable Medical Equipment (DME) Modifiers NU= new equipment RP= replacement and repair RR= Rental of DME equipment This list is not all-inclusive.

5.36 Modifier Review

Kaiser Permanente reserves the right to review use of modifiers to ensure accuracy and appropriateness using industry standard guidelines. Invalid or ineligible modifiers may be corrected if possible or rejected if it is not possible to determine correct code modifier. Our code editing process will assist in evaluating the accuracy of the coding of the procedure(s) not their medical necessity and will identify inappropriate use of modifiers. Improper use of modifiers may cause claims to pend and/or the return of claims for correction.

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5.37 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 ClaimsXten™ (CXT). 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. ClaimsXten™ (CXT) is McKesson’s current solution for applying

clinically-based claims auditing. The software offers flexible rules creation and application - and enables payers to process each claim under the specific terms and conditions of individual benefit plans.

ClaimsXten has been contracted nationally as KP’s Enterprise code editing solution to be integrated with Tapestry AP on the KPCC platform.

ClaimsXten combines the strength and flexibility of the McKesson

Total Payment™ platform with a comprehensive library of McKesson clinical rule content, and a services team of medical claims experts to provide increased medical and administrative savings opportunities.

– Evaluates codes billed on a claim, and makes coding recommendations in conjunction with industry guidelines (e.g., AMA, CMS, etc.)

– Use of claims history in editing and reporting – Ability to comply with regulatory requirements – ICD 10 capable

In order to help illustrate how this process works, examples have been provided where appropriate.

5.38 Coding Edit Rules

Kaiser Permanente applies coding edit rules to all claims submitted. The following descriptions outline some of the major categories of our coding edit rules, some of which ClaimsXten® applies automatically as part of coding and billing validation. These rules are subject to change and may be edited from time to time. There may be situations where your contract supersedes these rules. Should you have any questions regarding your contract and code editing, please contact your Contract manager or Provider Relations.

Major Categories of Claim Coding Errors/Inconsistencies: AMA, CMS Guidelines and ClaimsXten® will identify input codes without valid modifiers and flag potential errors while accepting coding practices judged to be conventional by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS). The CPT and HCPCS manuals

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explicitly detail and outline many of the rules included in ClaimsXten®. HCPCS codes related to CPT codes: ClaimsXten® also evaluates the combination of HCPCS codes and CPT codes. These codes are cross walked to identify where a HCPCS code is related to one or many CPT codes, and are evaluated based on the existing CPT rules. Unnecessary or disallowed codes are then rejected. Example: HCPCS code D7872 is defined as “diagnostic arthroscopy of the temporomandibular joint, with or without biopsy”. D7872 is related to the CPT code 29800 “diagnostic arthroscopy of temporomandibular joint.” Since both codes have the same narrative, the CPT code should be used. If both codes are submitted for the same date of service, ClaimsXten® denies the HCPCS code as part of the CPT code. In addition, additional rules regarding CPT and HCPCS codes will be applied, so in this example, if 90781 (IV infusion) were also on the claim, they would be denied as part of the global services.

HCPCS codes not related to CPT codes: ClaimsXten® also detects situations where HCPCS codes are not related to CPT codes. Rules developed as appropriate that are the result of the review of non-CPT related HCPCS codes are part of the knowledge base supporting ClaimsXten® and do not conflict with the Correct Coding Initiative (CCI) and National Correct Coding Initiative (NCCI).

Example: E1050 is denied in conjunction with E1060. The description for E1050 is “fully reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests”. The description for E1060 is “fully reclining wheelchair, detachable arms, swing away detachable elevating leg rests.”

Procedure Unbundling: 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.

Example 1: Laboratory unbundling occurs when certain laboratory tests are 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 two 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.

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Incidental Procedures: 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. Separate 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 does 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.

Mutually Exclusive Procedures: Mutually exclusive procedures are two or more procedures that are usually not performed at the same operative session on the same member 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.

Age and Gender (Sex) Conflicts: An age conflict occurs when the contracted provider bills an age-specific procedure code for a member outside of the designated age range. Similarly, a gender conflict occurs when a gender-specific procedure is assigned to a member of the opposite gender.

Example 1: The contracted provider assigns the code for surgical opening of the stomach, for newborns (43831), to a 45-year-old member. Example 2: Code 58150 Total abdominal hysterectomy is submitted for a male member. 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 (ages 1-17 years old) Maternity (ages 12-55 years old) Adult (ages over 14 years old)

Obsolete/Deleted Codes: If obsolete or deleted codes cannot be cross-walked to current or updated codes, claims submitted may be denied. Obsolete or deleted codes are updated each calendar year and are not accepted past the end date specified by CMS. Medicare claims with outdated codes will be subject to denial as per CMS guidelines. Multiple/ Duplicate Component Billing: When procedures are billable for professional and technical components (i.e., with Modifiers 26 and TC),

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Kaiser Permanente monitors 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. ClaimsXten® assists the claims examiner and UM staff (Medical Nurse Auditors, Kaiser Permanente physicians) in evaluating the accuracy of the coding of the procedure(s) not their medical necessity.

5.39 Retrospective Claim Review

Retrospective reviews occur after the member has received care and after he/she or their provider has submitted a claim for payment. Staff in the Claims Department review and make benefit decisions on claims. Staff in the Resource Stewardship department support the Claims Department in reviewing claims without a referral or authorization if there is an issue of medical necessity. This same staff review claims for appropriate coding and billing in which clinical expertise is necessary. Issues such as unbundling, up coding, undocumented services are reviewed in the Post Service area. All issues related to medical necessity decisions are reviewed by physician reviewers prior to issuing a denial. The following resources are used during the Post Service Review process. Associated review rules for a particular claim are based on thorough reviews of a variety of sources including, but not limited to:

• Centers for Medicare and Medicaid Services (CMS) policies • Kaiser Permanente medical policy • American Medical Association (AMA) guidelines (i.e., Current

Procedural Terminology, CPT®) • Professional specialty organizations (e.g., American College of

Surgeons, American Academy of Orthopaedic Surgeons, American Society of Anesthesiology)

• State and/or federal mandates • Subscriber benefit contracts • Provider contracts • Specialty expert consultants

Therefore, our policies and review rules are developed through a compilation of information gleaned from a variety of sources, not one single source. Our review rules are designed to verify the clinical accuracy of procedure code relationships to claims. It is important to note that while all codes may be acceptable to report, separate reimbursement may not be made. Reimbursement is based upon

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a multitude of factors such as the member’s coverage, coding rules outlined by CMS, CPT and other nationally recognized entities such as those listed above as well as federal and state mandates and regulations. This ensures that our members receive the right care at the right time at the appropriate level. In order to accurately adjudicate claims and administer subscriber benefits, it is often necessary to request medical records. The following is a list of claims categories from which we may routinely require submission of clinical information, before or after adjudication of a claim. Some of these (e.g., specific modifiers) are discussed in more detail throughout this manual.

• Procedures or services that require precertification/ preauthorization but did not go through the normal process prior to services being rendered.

• Procedures or services involving determination of medical necessity, including but not limited to those outlined in medical policies/criteria

• Procedures or services that are or may be considered cosmetic or experimental/ investigational

• Claims for which we cannot determine from the claim submitted if it involves a covered service and thus a benefit determination cannot be made without reviewing medical records

• Procedures or services reported with “unlisted,” “not otherwise classified,” or “miscellaneous” codes

• Procedures or services reported with CPT® modifiers 22, 62, 66, and 78

• Quality of care and/or quality improvement activities (e.g., data collection as required by accrediting agencies, such as NCQA)

• Claims involving coordination of benefits • Claims that are being appealed • Claims that are being investigated for fraud and abuse or potential

inappropriate billing practices • Claims for which services reported appear to have been unbundled

This list is not intended to limit the ability of Kaiser Foundation Health Plan of the Northwest to request clinical records. There may be additional individual circumstances when these records may be requested.

Services which are classified under the Humanitarian Device Exemption (HDE) must have an authorization prior to usage. Once authorized, the reimbursement would be based upon invoice unless otherwise contracted. Medical Necessity Review does monitor claims for usage and

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reimbursement of such devices.

5.40 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), and 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) 813-2700 Worker’s Compensation, TRICARE & Medicare Primary Toll-Free Telephone #: (800) 756-2777

5.41 Workers’ Compensation

If you have questions, please call 503-813-2700 or 1-800-756-2777.

5.42 Provider Claims Disputes

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 503-813-2700. 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

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instructed as follows: Provider Claim Payment Appeals Process: If your concern is determined to be a claim payment appeals issue, you will be advised to submit your concern in writing to: For Dates of Service prior to September 14, 2015 Kaiser Permanente Provider Appeals Provider Contracting and Relations 500 NE Multnomah Blvd Ste 100 Portland, OR 97232 503-813-3376 503-813-2017 Fax For Dates of Service on or after September 14, 2015 Kaiser Permanente National Claims Administration PO Box 370050 Denver CO 80237-9998 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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5.43 CMS-1500 (02/12) FIELD DESCRIPTIONS The fields identified in the table below as “Required” must be completed when submitting a CMS-1500 (02/12) 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. 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 STUDENT.

9

OTHER INSURED'S NAME


When additional insurance coverage exists, enter the last name, first name and middle initial of the insured.

9a OTHER INSURED’S POLICY OR GROUP NUMBER


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


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

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FIELD NUMBER FIELD NAME

REQUIRED FIELDS FOR CLAIM

SUBMISSIONS INSTRUCTIONS/EXAMPLES

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


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 another health benefit plan. For example, 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


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).

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Example: 01/05/2008

17

NAME OF REFERRING PHYSICIAN OR OTHER SOURCE


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 1H - CHAMPUS Identification Number 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


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/ICD-10-CM code number. Enter up to 4 diagnostic codes, in PRIORITY order (primary, secondary condition).

22

MEDICAID RESUBMISSION Not Required

23

PRIOR AUTHORIZATION NUMBER


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

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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 enter a space, hyphen, or other separator between the qualifier and the number/code/information. The following qualifiers are to be used when reporting these services. 7 - Anesthesia information ZZ - Narrative description of unspecified code N4 - National Drug Codes (NDC) VP - Vendor Product Number Health Industry Business Communications Council (HIBCC) Labeling Standard OZ - Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN) CTR - Contract rate

24a

DATE(S) OF SERVICE Required Enter the month, day, and year (MM/DD/YY) for each procedure, service, or supply. Services must be entered chronologically (starting with the oldest date first). For each service date listed/billed, the following fields must also be entered: Units, Charges/Amount/Fee, Place of Service, Procedure Code, and corresponding Diagnosis Code. IMPORTANT: Do not submit a claim with a future date of service. Claims can only be submitted once the service has been rendered (for example: durable medical equipment).

24b

PLACE OF SERVICE

Required Enter the place of service code for each item used or service performed.

24c

EMG

Not Required Enter Y for "YES" or leave blank if "NO" to indicate an EMERGENCY as defined in the electronic 837 Professional 4010A1 implementation guide.

24d PROCEDURES, SERVICES, OR SUPPLIES: CPT/HCPCS, MODIFIER

Required Enter the CPT/HCPCS codes and MODIFIERS (if applicable) reflecting the procedures performed, services rendered, or supplies used. IMPORTANT: Enter the anesthesia time, reported as the “beginning” and “end” times of anesthesia in military time above the appropriate procedure code.

24e

DIAGNOSIS POINTER

Required Enter the diagnosis code reference number (pointer) as it relates the date of service and the procedures shown in Field 21, When multiple services are performed, the primary reference number for each service should be listed first, and other applicable services should follow. The reference number(s) should be a 1, or a 2, or a 3, or a 4; or multiple numbers as explained.

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IMPORTANT: (ICD-9-CM/ICD-10-CM diagnosis codes must be entered in Item Number 21 only. Do not enter them in 24E.)

24f

$ CHARGES Required Enter the FULL CHARGE for each listed service. Any necessary payment reductions will be made during claims adjudication (for example, multiple surgery reductions, maximum allowable limitations, co-pays etc.). Do not use commas when reporting dollar amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Enter 00 in the cents area if the amount is a whole number.

24g

DAYS OR UNITS Required Enter the number of days or units in this block. (For example: units of supplies, etc.) When entering the NDC units in addition to the HCPCS units, enter the applicable NDC ‘units’ qualifier and related units in the shaded line. The following qualifiers are to be used: F2 - International Unit ML - Milliliter GR - Gram UN Unit

24h

EPSDT FAMILY PLAN Not Required

24i ID. QUAL Required Enter in the shaded area of 24I the qualifier identifying if the number is a non-NPI. The Other ID# of the rendering provider is reported in 24J in the shaded area. 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 1H - CHAMPUS Identification Number EI - Employer’s Identification Number G2 - Provider Commercial Number LU - Location Number N5 - Provider Plan Network Identification Number SY - Social Security Number (The social security number may not be used for Medicare.) X5 - State Industrial Accident Provider Number ZZ - Provider Taxonomy

24j RENDERING PROVIDER ID # Required Enter the non-NPI ID number in the shaded area of the field. Enter the NPI number in the non-shaded area of the field. Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.

25

FEDERAL TAX ID NUMBER

Required Enter the physician/supplier federal tax I.D. number or Social Security number. Enter an X in the appropriate box to indicate which number is being reported. Only one

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box can be marked. IMPORTANT: The Federal Tax ID Number in this field must match the information on file with the IRS.

26

PATIENT'S ACCOUNT NO.

Required Enter the Members account number assigned by the Provider’s/provider’s accounting system. IMPORTANT: This field aids in patient identification by the Provider/Provider.

27

ACCEPT ASSIGNMENT

Not Required

28

TOTAL CHARGE Required Enter the total charges for the services rendered (total of all the charges listed in Field 24f).

29

AMOUNT PAID Required if Applicable

Enter the amount paid (i.e., Member copayments or other insurance payments) to date in this field for the services billed.

30

BALANCE DUE Not Required Enter the balance due (total charges less amount paid).

31

SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

Required Enter the signature of the physician/supplier or his/her representative, and the date the form was signed. For claims submitted electronically, include a computer printed name as the signature of the health care Provider or person entitled to reimbursement.

32

SERVICE FACILITY LOCATION INFORMATION


The name and address of the facility where services were rendered (if other than patient’s home or physician’s office). Enter the name and address information in the following format: 1st Line – Name 2nd Line – Address 3rd Line – City, State and Zip Code Do not use commas, periods, or other punctuation in the address (e.g., “123 N Main Street 101” instead of “123 N. Main Street, #101”). Enter a space between town name and state code; do not include a comma. When entering a 9 digit zip code, include the hyphen.

32a NPI # Required Enter the NPI number of the service facility.

32b OTHER ID # Required Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

33

BILLING PROVIDER INFO & PH #

Required Enter the name, address and phone number of the billing entity. This information MUST coincide with the data in box 25. The billing provider and TIN in box 25 must represent the same entity.

33a NPI # Required Enter the NPI number of the billing provider.

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33b OTHER ID # Required Enter the two digit qualifier identifying the non-NPI

number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.

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Kaiser Permanente Provider Manual Spring 2008 44


5.44 CMS-1450 (UB-04) FIELD DESCRIPTIONS The fields identified in the table below as “Required” must be completed when submitting a CMS-1450 (UB-04) claim form to Kaiser Permanente for processing: Please Note: The fields required for submission below are required by Kaiser Permanente but not necessarily by CMS or other payers. For Medicare members, please refer to Medicare’s billing requirements for appropriate field requirements and instructions or examples.




1 PROVIDER NAME and ADDRESS

Required Enter the name and address of the hospital or person who rendered the services being billed.

2 PAY-TO NAME, ADDRESS, CITY/STATE, ID #

Required Enter the name and address of the hospital or person to receive the reimbursement. The pay to name must coincide with the TIN being supplied in field 5.

3a PATIENT CONTROL NUMBER

Required Enter the member’s control number. IMPORTANT: This field aids in patient identification by the Provider/Provider.

3b MEDICAL RECORD NUMBER

Not Required Enter the number assigned to the patient’s medical/health record by the provider.

4 TYPE OF BILL

Required Enter the appropriate code to identify the specific type of bill being submitted. This code is required for the correct identification of inpatient vs. outpatient claims, voids, etc.

5 FEDERAL TAX NUMBER

Required Enter the federal tax ID of the hospital or person entitled to reimbursement.

6 STATEMENT COVERS PERIOD

Required Enter the beginning and ending date of service included in the claim.

7 BLANK Not Required Leave blank.

8 PATIENT NAME Required Enter the member’s name.

9 PATIENT ADDRESS Required Enter the member’s address.

10 PATIENT BIRTH DATE Required Enter the member’s birth date.

11 PATIENT SEX Required Enter the member’s gender.

12 ADMISSION DATE Required For inpatient claims only, enter the date of admission.

13 ADMISSION HOUR Required For either inpatient OR outpatient care, enter the 2-digit code for the hour during which the member was admitted or seen.

14 ADMISSION TYPE Required Indicate the type of admission (e.g. emergency, urgent, elective, and newborn).

15 ADMISSION SOURCE Required Enter the source of the admission type code.

16 DISCHARGE HOUR (DHR)


Enter the two-digit code for the hour during which the member was discharged.

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17 PATIENT STATUS Required Enter the discharge status code.

18-28

CONDITION CODES Required if Applicable

Enter any applicable codes which identify conditions relating to the claim that may affect claims processing.

29 ACCIDENT (ACDT) STATE

Not Required Enter the two-character code indicating the state in which the accident occurred which necessitated medical treatment.


31-34

OCCURRENCE CODES AND DATES


Enter the code and the associated date defining a significant event relating to this bill that may affect claims processing.

35-36

OCCURRENCE SPAN CODES AND DATES


Enter the occurrence span code and associated dates defining a significant event relating to this bill that may affect claims processing.


38 RESPONSIBLE PARTY Not Required Enter the responsible party name and address.

39-41

VALUE CODES and AMOUNT


Enter the code and related amount/value which is necessary to process the claim.

42 REVENUE CODE Required Identify the specific accommodation, ancillary service, or billing calculation, by assigning an appropriate revenue code.

43

REVENUE DESCRIPTION

Not Required Enter the revenue description.

44 PROCEDURE CODE AND MODIFIER

Required For ALL outpatient claims, enter BOTH a revenue code in Field 42 (Rev. CD.), and the corresponding CPT/HCPCS procedure code in this field.

45

SERVICE DATE

Required

Outpatient Series Bills: A service date must be entered for all outpatient series bills whenever the “from” and “through” dates in Field 6 (Statement Covers Period: From/Through) are not the same. Submissions that are received without the required service date(s) will be rejected with a request for itemization. Multiple/Different Dates of Service: Multiple/different dates of service can be listed on ONE claim form. List each date on a separate line on the form, along with the corresponding revenue code (Field 42), procedure code (Field 44), and total charges (Field 47).

46 UNITS OF SERVICE Required The units of service.

47 TOTAL CHARGES Required Indicate the total charges pertaining to the related revenue code for the current billing period, as listed in Field 6.


48 NON COVERED CHARGES

Not Required Enter any non-covered charges.

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50

PAYER NAME

Required Enter (in appropriate ORDER on lines A, B, and C) the NAME and NUMBER of each payer organization from whom you are expecting payment towards the claim.

51 HEALTH PLAN ID Required Enter the provider number.

52

RELEASE OF INFORMATION (RLS INFO)

Not Required Enter the release of information certification number

53

ASSIGNMENT OF BENEFITS (ASG BEN)


Enter the assignment of benefits certification number.

54a-c

PRIOR PAYMENTS Required if Applicable

If payment has already been received toward the claim by one of the payers listed in Field 50 (Payer) prior to the billing date, enter the amounts here.

55 ESTIMATED AMOUNT DUE

Not Required Enter the estimated amount due.

56

NATIONAL PROVIDER IDENTIFIER (NPI)

Required Enter the service provider’s National Provider Identifier (NPI).

57 OTHER PROVIDER ID Required Enter the service provider’s Kaiser-assigned provider ID.

58

INSURED’S NAME

Required Enter the subscriber’s name.

59

PATIENT’S RELATION TO INSURED


Enter the member’s relationship to the subscriber.

60 INSURED’S UNIQUE ID Required Enter the insured person’s unique individual member identification number (medical/health record number), as assigned by Kaiser.

61

INSURED’S GROUP NAME


Enter the insured’s group name.

62

INSURED’S GROUP NUMBER


Enter the insured’s group number as shown on the identification card. For Prepaid Services claims enter "PPS".

63

TREATMENT AUTHORIZATION CODE


For ALL inpatient and outpatient claims, enter the referral number.

64 DOCUMENT CONTROL NUMBER

Not Required Enter the document control number related to the member or the claim.

65

EMPLOYER NAME Required if Applicable

Enter the employer’s name.

66 DX VERSION QUALIFIER

Not Required Indicate the type of diagnosis codes being reported. Note: At the time of printing, Kaiser only accepts ICD-9-CM/ICD-10-CM diagnosis codes on the UB-04.

67

PRINCIPAL DIAGNOSIS CODE

Required Enter the principal diagnosis code, on all inpatient and outpatient claims.

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67 A-Q

OTHER DIAGNOSES CODES


Enter other diagnoses codes corresponding to additional conditions. Diagnosis codes must be carried to their highest degree of detail.


69

ADMITTING DIAGNOSIS

Required Enter the admitting diagnosis code on all inpatient claims.

70 (a-c)

REASON FOR VISIT (PATIENT REASON DX)

Not Required Enter the diagnosis codes indicating the patient’s reason for outpatient visit at the time of registration.

71 PPS CODE Required if Applicable

Enter the DRG number which the procedures group, even if you are being reimbursed under a different payment methodology.

72

EXTERNAL CAUSE OF INJURY CODE (ECI)


Enter an ICD-9-CM/ICD-10-CM “E-code” in this field (if applicable).

73 BLANK Not required Leave blank.

74

PRINCIPAL PROCEDURE CODE AND DATE


Enter the ICD-9-CM/ICD-10-CM procedure CODE and DATE on all inpatient AND outpatient claims for the principal surgical and/or obstetrical procedure which was performed (if applicable).

74 (a–e)

OTHER PROCEDURE CODES AND DATES


Enter other ICD-9-CM/ICD-10-CM procedure CODE(S) and DATE(S) on all inpatient AND outpatient claims (in fields “A” through “E”) for any additional surgical and/or obstetrical procedures which were performed (if applicable).

75 BLANK Not required Leave blank.

76

ATTENDING PHYSICIAN / NPI / QUAL / ID

Required Enter the National Provider Identifier (NPI) and the name of the attending physician for inpatient bills or the physician that requested the outpatient services. Inpatient Claims—Attending Physician Enter the full name (first and last name) of the physician who is responsible for the care of the patient. Outpatient Claims—Referring Physician For ALL outpatient claims, enter the full name (first and last name) of the physician who referred the Member for the outpatient services billed on the claim.

77

OPERATING PHYSICIAN / NPI/ QUAL/ ID

Required If Applicable

Enter the National Provider Identifier (NPI) and the name of the lead surgeon who performed the surgical procedure.

78-79

OTHER PHYSICIAN/ NPI/ QUAL/ ID


Enter the National Provider Identifier (NPI) and name of any other physicians.

80 REMARKS

Not Required Special annotations may be entered in this field.

81 CODE-CODE Not required Enter the code qualifier and additional code, such as marital status, taxonomy, or ethnicity codes, as may be appropriate.

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5.45 Billing Requirements and Instruction for Specific Services

Topic Instructions

5.45.1 Evaluation Management (E/M) Services

CMS-1500 (2/12) • Field 19 When “covering” for another physician, enter the name of

the physician you are covering for.

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

Inpatient E/M Services:

• If a patient is admitted for observation following the performance of a major/minor “surgical package” procedure, do not report hospital observation service codes, because all post-operative E/M services are included as part of the global surgical package.

Consultations:

• Kaiser Permanente will reimburse for initial consultations when billed with any surgical procedure done on the same day of service.

• For office/outpatient: If the consultant assumes patient management

responsibilities following the initial consultation, office E/M (established patient) visit codes should be used for all subsequent patient encounters, NOT office consultation codes.

• For inpatient: If the consultant assumes patient management

responsibilities, use subsequent hospital care codes (NOT follow-up inpatient consultation codes) to report all additional E/M encounters with the patient.

Surgery and E/M Services:

• Reimbursement will generally NOT be made for a pre- or post-operative E/M visit provided on the same day as major/minor surgery, or an endoscopic procedure, unless Kaiser Permanente agrees that there was a significant, separately identifiable E/M

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Topic Instructions

service provided in addition to the procedure. In these instances, the provider must bill for the E/M visit using the appropriate modifier.

• If E/M services are performed during the post-operative period for a reason unrelated to the original procedure (such as for other disease or injuries), you may bill for these services using modifier 24 (Unrelated E/M service by the same physician during a post-operative period), and you must list a corresponding diagnosis code which reflects that the E/M services were for a problem other than the surgical diagnosis.

Urgent or Emergency Services Provided in the Office:

• For urgent or emergency services provided in the office setting, use code Office services provided on an emergency basis in addition to the appropriate E/M office visit code.

Non-Surgical Procedure that Include E/M Services:

• There are certain instances where Kaiser Permanente will deny medical visits when billed with certain non-surgical procedures, because the codes for these procedures include admission to the hospital and/or daily visits. The non-surgical procedures which fall into this category include:

• Clinical brachytherapy • End stage renal disease services • Allergy immunotherapy services

Preventive Medicine Services:

• Preventive medicine codes -- NOT office evaluation/management codes -- should be used to report the routine evaluation and management of adults and children, in the absence of patient complaints. For example, preventive medicine codes should be used for:

• Well-baby check ups • Routine pediatric visits • Camp or school physicals • Routine, annual gynecological exams

5.45.2 Emergency Rooms

UB-04

• Field 15 (UB-04) Enter the code indicating the source of the

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Topic Instructions

admission or outpatient registration • Field 44 The emergency department E/M visit codes should ONLY

be used if the patient is seen in the emergency department.

Emergency department E/M visit codes should be used for E/M services provided in the emergency department, even if these were “non-emergency” services. The only requirement for using “emergency department” codes is that the patient must be registered in the emergency department. Office visit E/M codes should be used if the patient is seen in the ER as a convenience to the physician and/or patient, but the patient is not registered in the emergency department.

5.45.3 Durable Medical Equipment

Description:

Durable Medical Equipment is medically necessary equipment that is:

• Appropriate for use at home • Primarily and customarily used to service a medical purpose • Not useful to a person in absence of an illness • Able to withstand repeated use

CMS-1500 (2/12)

• Field 24d CPT codes are required for all professional services. Use HCPCS Level II codes to define DME. Use modifiers, if applicable.

UB-92 or UB-04

• Field 42 Enter the appropriate revenue code

• Field 44 HCPCS/Rates required

• Field 46 Number of rental months

• Field 54 DME cost sharing amounts collected from the Member are reported in this field.

• Field 84 (UB-92) or Field 80 (UB-04) For DME billing, rental rate

costs and anticipated months of usage should be inserted in this field.

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Topic Instructions

5.45.4 Injection/ Immunizations

CPT codes are required for all professional services. Use HCPCS Level II codes to define Injections/ Immunizations.

NOTE: If there was no identifiable E/M service rendered by the nurse or the provider, and the patient received only an injection during the encounter, it is permissible to report an injection administration code in lieu of the E/M visit code and the appropriate HCPCS code (specifying the drug administered).

Unlike injections, immunization procedures include the supply of materials. Additionally, injection administration fees are not eligible for reimbursement when billed with immunization codes.

5.45.5 Newborn Services

CMS-1500 (2/12)

• Field 2 Enter the first and last name of the newborn • Field 3 Enter the newborn’s date of birth

UB-04

• Field 8 (UB-04) Enter the first and last name of the newborn • Field 10 (UB-04) Enter the newborn’s date of birth

NOTE: If the Health Record Number is not established, contact the Membership Services Department at 800-813-2000 or (503) 813-2000.

5.45.6 Do Not Bill Events

Do Not Bill Events (DNBEs) are occurrences for which the fees for all or part of the health care services directly related to the occurrences may be waived. Please see Section 8.3 of this Manual for further definitions of DNBEs. The Sections of this manual that address DNBE are solely for the purpose of determining compensation to Provider and shall not constitute or imply any admission of liability. DNBE Claims Submission If you submit claims on a CMS 1450 (UB-04) form, you should (i) include on all inpatient claims the present on admission (“POA”) indicators in the manner required by CMS for Medicare fee-for-service claims and (ii) for any DNBEs recognized prior to submitting a

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Topic Instructions

claim, include on all claims, the applicable International Classification of Diseases (“ICD”) codes and all applicable standard modifiers (including CMS National Coverage Determination (“NCD”) modifiers for SEs) in the manner required by CMS for Medicare fee-for-services claims.

If you submit claims on a CMS 1500 (2/12) form and recognize that a DNBE has occurred prior to submitting a claim, you should include on all claims, the applicable ICD codes and all applicable standard modifiers (including CMS NCD modifiers for SEs) for any DNBE in the manner required by CMS for Medicare fee-for-service claims.

If you recognize that a DNBE has occurred prior to submitting a claim, the claim should reflect all services provided (including those related to the DNBE) and all associated fees (including those related to the DNBE), with an adjustment in fees to reflect the waiver of fees directly related to the DNBE.

For example, when billing for inpatient stays, you must submit a no-pay claim (Type of Bill 110) to report all charges associated with a DNBE. More specifically, if services or procedures unrelated to the DNBE are provided during the same stay as the DNBE, Providers billing for inpatient stays are required to submit two claims, one claim with services or procedures unrelated to the DNBE and the other claim with the services or procedures related to the DNBE as a no-pay claim. Non-covered Type of Bill 110 must have one of the diagnosis codes listed below in the diagnosis position 2-9 on the UB-04 form to identify the type of DNBE performed. You should not transmit via the External Cause of Injury (E-code) located on the UB-04 form. E876.5 - Performance of wrong operation (surgical procedure) on correct patient (existing code) E876.6 – Performance of operation (surgical procedure) on patient not scheduled for surgery E876.7 – Performance of correct operation (surgical procedure) on wrong side/body part. Present on Admission (POA) field is required on all primary and secondary diagnosis for inpatient discharges for all applicable bill types.

Providers billing for hospital outpatient encounters, ambulatory surgery centers or other health care professionals must utilize one of the following HCPCS modifier(s) when the associated charges on all lines related to a DNBE:

PA: Surgery Wrong Body Part

PB: Surgery Wrong Patient

PC: Wrong Surgery on Patient

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Topic Instructions

Waive or Reimburse Fees You should waive fees otherwise owed by Payors and members (or reimburse any fees that may have already been paid by Payors and members) that are directly related to the DNBE, whether the event has already been reported by you or if it is later discovered by Kaiser Permanente. In addition, you will consider, on a case-by-case basis at your discretion, waiving (or later reimbursing) fees otherwise owed by Payors or members for medically necessary health care services required to treat the DNBE subsequent to the encounter at which the DNBE occurred.

Resolving DNBE Reimbursement Issues We will work collaboratively with you to resolve promptly DNBE determinations and corresponding reimbursement issues. Any disputes related to DNBE reimbursement shall be resolved according to the dispute resolution process set forth in your Agreement.

Reimbursement by you to Payors or members for fees directly related to a DNBE that were already paid to you will be deemed an overpayment subject to the Adjustment to Payment clause of your Agreement and made within thirty (30) days of the parties’ resolution of DNBE determinations and reimbursement issues, unless otherwise required by law.

5.46 Anesthesia GLOBAL ANESTHESIA PACKAGE

The “global” anesthesia package includes:

• The performance of a pre-anesthetic examination and evaluation (even if the exam is done on a date different from the date of surgery)

• The administration of the anesthetic • The administration of fluids and/or blood incidental to the

delivery of anesthesia (or the procedure being performed) • The usual monitoring services (ECG, blood pressure, etc.) • The provision of post-operative anesthesia care (post-

operative visit)

OFFICE-BASED SURGICAL PROCEDURES

When an office-based surgical procedure is performed, reimbursement for the procedure includes reimbursement for anesthesia services as part of the global surgical fee, because it is expected that appropriate anesthesia will be administered with

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the office-based procedure.

ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT Cont.

Kaiser Permanente reimburses participating providers for anesthesia services based on nationally recognized criteria for reporting of anesthesia services, including:

• The American Medical Association (AMA) CPT codes (00100 – 01999)

• American Society of Anesthesiologists’ (ASA) Relative Value Guide (RVG)

• Medicare Guidelines BASE UNITS: Providers are NOT to indicate the ASA base unit values in the Days/Units field (Item 24, Box G). Base units are determined as defined by the American Society of Anesthesiologists Relative Value Guide. The base units assigned to a procedure are intended to demonstrate the relative complexity of a specific procedure and include the value of all anesthesia services, except the value of the actual time spent administering the anesthesia. Kaiser Permanente stores the base unit value within our claims system and will calculate the anesthesia payment of the base units according to the information provided on the claim. REPORTING OF ANESTHESIA TIME: Anesthesia time begins when the anesthesiologist starts to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area. Anesthesia time ends when the anesthesiologist is no longer in personal attendance, which is when the patient may be safely placed under postoperative supervision. Time units are calculated by allowing 1 unit for each 15 minute interval or remaining fraction thereof. Providers are to show time as total number of minutes in the Units field (Item 24, Box G). REIMBURSEMENT: Payment for most anesthesia services is based on:

• The base unit value • Plus anesthesia time units • Multiplied by the fee schedule conversion factor, as

appropriate. Other services are reimbursed based upon the CPT code.

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MULTIPLE SURGICAL PROCEDURES: When multiple surgical procedures are performed during a single anesthetic administration, the anesthesia code representing the most complex procedure is reported. The time reported is the combined total of all procedures reported on the primary procedure.

EXCEPTIONS TO BILLING ANESTHESIA CODES EXCEPTIONS TO BILLING ANESTHESIA CODES Cont.

Anesthesiologists should bill using anesthesia codes only, unless one or more of the following services was performed by the anesthesiologist (in which case the appropriate “non-anesthesia” CPT code(s) may be reported and billed in accordance with CMS guidelines):

• Evaluation and management services • Hospital inpatient services • Consultations • Critical care services • Pain management • Nerve blocks • Destruction by neurolytic agents • Services not included in the global anesthesia fee • Other miscellaneous services

QUALIFYING CIRCUMSTANCES: CPT codes 99100, 99116, 99135 and 99140 represent various patient conditions that may impact the anesthesia service provided. Such codes may be billed in addition to the anesthesia being billed. Charges for these codes are to be shown on the same line as the CPT Qualifying Circumstances Code in Item 24, Box F. PATIENT-CONTROLLED ANALGESIA (PCA): Benefits may be available for the administration of patient-controlled analgesia (PCA) following a surgical procedure. PCA billed by a surgeon is covered as part of the global surgical package and is not separately reimbursable. PCA reimbursements are limited to anesthesiologists only. An anesthesiologist’s services for PCA should be submitted as a single line on the claim form as follows:

• Span the dates to include the entire care for the PCA (reimbursement will be made as a global allowance, and will include the entire course of PCA).

• Any “hospital care” provided by the anesthesiologist subsequent to the initial day of PCA will be considered

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covered under the global PCA fee. • Use CPT code 01996 when billing for PCA services.

CONSCIOUS SEDATION: Sedation with or without analgesia (conscious sedation), intravenous, intramuscular or inhalation (CPT code 99143-99145) are considered eligible for reimbursement when billed by an anesthesiologist, pain management or certified registered nurse anesthetist.

ANESTHESIA MODIFIERS

Personally Performed or Medically-Directed/Supervised Anesthesia Services: Use an appropriate HCPCS anesthesia modifier to denote whether the anesthesia services were personally performed, medically directed, or medically supervised: AA - Anesthesia service performed personally by the Anesthesiologist AD - Medical supervision by a physician of more than four concurrent procedures QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals QX - CRNA service with medical direction by a physician QY - Medical direction of one CRNA by the QZ - CRNA service without medical direction by a physician QS - Monitored anesthesia care service (can be billed by a CRNA or a physician) Physical Status Modifiers: As indicated in the CPT book, the following physical status modifiers should be appended to the CPT anesthesia code to distinguish between the various levels of complexity of the anesthesia service(s) provided:

P1 - A normal healthy patient P2 - A patient with mild systemic disease P3 - A patient with severe systemic disease P4 - A patient with severe systemic disease that is a

constant threat to life P5 - A moribund patient who is not expected to survive

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without the operation P6 - A declared brain-dead patient whose organs are being

removed for donor purposes DO NOT enter additional minutes for the Physical Status modifier. If eligible for reimbursement, the additional unit(s) will be calculated by our claims system. The patient cannot be billed for Physical Status modifiers not allowed by Kaiser Permanente. Other CPT Modifiers/Qualifying Circumstances Codes: Other modifiers and “qualifying circumstances” codes may be used as appropriate. Follow the instructions in the CPT/HCPCS books when reporting these additional modifiers and/or codes.

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5.47 Coordination of Benefits (COB) Coordination of Benefits (COB) is a method for determining the order in which benefits are paid and the amounts which are payable when a Member is covered under more than one plan. It is intended to prevent duplication of benefits when an individual is covered by multiple plans providing benefits or services for medical or other care and treatment. Kaiser Permanente Providers are responsible for determining the primary Payor and for billing the appropriate party. If Kaiser Permanente is not the primary carrier, an EOB is required with the claim CMS 1500 (2/12) submission. Topic Instructions

5.47.1 How to Determine the Primary Payor

1 The benefits of the plan that covers an individual as an

employee, Member or subscriber other than as a dependent are determined before those of a plan that covers the individual as a dependent.

2 When both parents cover a child, the “birthday rule”

applies – the Payor for the parent whose birthday falls earlier in the calendar year (month and day) is the primary Payor.

When determining the primary Payor for a child of separated or divorced parents, inquire about the court agreement or decree. In the absence of a divorce decree/court order stipulating parental healthcare responsibilities for a dependent child, insurance benefits for that child are applied according to the following order: Insurance carried by the

1 Natural parent with custody pays first 2 Step-parent with custody pays next 3 Natural parent without custody pays next 4 Step-parent without custody pays last

If the parents have joint custody of the dependent child, then benefits are applied according to the birthday rule referenced above. If this does not apply, call the Member Services Department at 503-813-2000 or 1-800-813-2000.

1 Kaiser Permanente is generally primary for working Medicare-eligible Members when the CMS Working Aged regulation applies.

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Topic Instructions

2 Medicare is generally primary for retired Medicare

Members over age 65, and for employee group health plan (EGHP) Members with End Stage Renal Disease (ESRD) for the first thirty (30) months of dialysis treatment. This does not apply to direct pay Members.

3 In cases of work-related injuries, Workers

Compensation is primary unless coverage for the injury has been denied.

4 In cases of services for injuries sustained in vehicle accidents or other types of accidents, primary Payor status is determined on a jurisdictional basis. If the auto insurance is primary, claims will require an EOB.]

5.47.2 Description of COB Payment Methodologies

Kaiser Permanente Coordination of Benefits allows benefits from multiple carriers to be added on top of each other so that the Member receives the full benefits from their primary carrier and the secondary carrier pays their entire benefit up to 100% of allowed charges. When Kaiser Permanente has been determined as the secondary Payor, Kaiser Permanente pays the difference between the payment by the primary Payor and the amount which would be have been paid if Kaiser Permanente was primary, less any amount for which the Member has financial responsibility. Benefit carve-out calculations are based on whether or not the Provider accepts Medicare assignment for the provider contract corresponding to the claim. Medicare assignment means the provider has agreed to accept the Medicare allowed amount as payment.

5.47.3 COB Claims Submission Requirements and Procedures

Whenever Kaiser Permanente is the SECONDARY payer, claims can be submitted EITHER electronically or on one of the standard paper claim forms:

1 Electronic Claims: If Kaiser Permanente is the secondary payer, send the completed electronic claim with the payment fields from the primary insurance carrier entered as follows: • 837P claim transaction Enter Amount Paid • 837I claim transaction Enter Prior Payments

2 Paper Claims

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Topic Instructions

If Kaiser Permanente is the secondary payer, send the completed claim form with a copy of the corresponding Explanation of Benefit (EOB) or Explanation of Medicare Benefits (EOMB)/Medicare Summary Notice (MSN) from the primary insurance carrier attached to the paper claim to ensure efficient claims processing/adjudication. Kaiser Permanente cannot process a claim without an EOB or EOMB/MSN from the primary insurance carrier. • CMS-1500 (2/12) claim form: Complete Field 29

(Amount Paid) • CMS-1450 (UB04) claim form: Complete Field 54

(Prior Payments)

5.47.4 Members Enrolled in Two Kaiser Permanente Plans

Some Members may be enrolled under two separate plans offered through Kaiser Permanente (dual coverage). In these situations, Providers need only submit ONE claim under the primary plan to Kaiser Permanente for processing.

5.47.5 COB Claims Submission Timeframes

If Kaiser Permanente is the secondary payer, any Coordination of Benefits (COB) claims must be submitted for processing within 45 days of the date of the Explanation of Benefits (EOB) or EOMB/MSN.]

5.47.6 COB FIELDS ON THE CMS 1450 (UB-04) CLAIM FORM The following fields should be completed on the CMS-1450 (UB-04) claim form to ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB information in these fields may cause claims to be denied or pended and reimbursements delayed. For additional information, refer to the current UB-04 National Uniform Billing Data Element Specifications Manual. Claims submitted electronically must meet the same data requirements as paper claims. For electronic claim submissions, refer to a HIPAA website for additional information on electronic loops and segments.

837I LOOP #

FIELD NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES

2300 H1 32-35 (UB-92)

31-36

(UB-04)

OCCURRENCE CODE/DATE Enter the appropriate occurrence code and date defining the specific event(s) relating to the claim billing period. NOTE: If the injuries are a result of an accident, please complete Field 77 (E-Code)

2330B NM

50 PAYER (Payer Identification)

Enter the name and number (if known) for each payer organization from whom the provider expects (or has received) payment towards the bill.

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837I LOOP #


List payers in the following order on the claim form:

A = primary payer B = secondary payer C = tertiary payer

2320 AMT

54 PRIOR PAYMENTS (Payers and Patient)

Enter the amount(s), if any, that the provider has received toward payment of the bill PRIOR to the billing date, by the indicated payer(s). List prior payments in the following order on the claim form:


2330A NM

58 INSURED’S NAME

Enter the name (Last Name, First Name) of the individual in whose name insurance is being carried. List entries in the following order on the claim form:


NOTE: For each entry in Field 58, there MUST be corresponding entries in Fields 59 through 62 (UB-92 and UB-04) AND 64 through 65 (Field 65 only on the UB-04).

2320 SBR

59 Patient’s Relationship To Insured

Enter the code indicating the relationship of the patient to the insured individual(s) listed in Field 58 (Insured’s Name). List entries in the following order:


2330A NM

60 CERT. – SSN – HIC – ID NO. (Certificate/Social Security Number/Health Insurance Claim/Identification Number)

Enter the insured person’s (listed in Field 58) unique individual Member identification number (medical/health record number), as assigned by the payer organization. List entries in the following order:

A = primary payer B = secondary payer C = tertiary paper

2320 SBR

61 GROUP NAME (Insured Group Name)

Enter the name of the group or plan through which the insurance is being provided to the insured individual (listed in Field 58). Record entries in the following order:


2320 SBR

62 INSURANCE GROUP NO. Enter the identification number, control number, or code assigned by the carrier or administrator to identify the GROUP under which the individual (listed in Field 58) is covered. List entries in the following order:

A = primary payer B = secondary payer

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837I LOOP #


C = tertiary paper

2320 SBR

64 ESC (Employment Status Code of the Insured) Note: This field has been deleted from the UB-04.

Enter the code used to define the employment status of the insured individual (listed in Field 58). Record entries in the following order:


2320 SBR

65 EMPLOYER NAME (Employer Name of the Insured)

Enter the name of the employer who provides health care coverage for the insured individual (listed in Field 58). Record entries in the following order:


2300 H1 67-76

(UB-92) 67 A-Q (UB-

04)

DIAGNOSIS CODE The primary diagnosis code should be reported in Field 67. Additional diagnosis code can be entered in Field 68-76.

2300H1 77(UB-92) 72 (UB-04)

EXTERNAL CAUSE OF INJURY CODE (E-CODE)

If applicable, enter an ICD-9-CM/ICD-10-CM “E-code” in this field.

5.47.7 COB FIELDS ON THE CMS-1500 (HCFA-1500 (2/12) CLAIM FORM The following fields should be completed on the CMS-1500 (HCFA-1500) (2/12) claim form, to ensure timely and efficient claims processing. Incomplete, missing, or erroneous COB information in these fields may cause claims to be denied or pended and reimbursements delayed. Claims submitted electronically must meet the same data requirements as paper claims. For electronic claim submissions, refer to a HIPAA website for additional information on electronic loops and segments

837P LOOP # FIELD

NUMBER FIELD NAME INSTRUCTIONS/EXAMPLES

2330A NM 9 OTHER INSURED’S NAME When additional insurance coverage exists (through a spouse, parent, etc.) enter the LAST NAME, FIRST NAME, and MIDDLE INITIAL of the insured.

NOTE: This field must be completed when there is an

entry in Field 11d (Is There Another Health Benefit Plan?).

2330A NM 9a OTHER INSURED’S POLICY Enter the policy and/or group number of the insured

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837P LOOP # FIELD


OR GROUP NUMBER individual named in Field 9. If you do not know the policy number, enter the Social Security number of the insured individual. NOTE: Field 9a must be completed when there is an


NOTE: For each entry in this field, there must be a

corresponding Entry in 9d (Insurance Plan Name or Program Name).

2320 DMG 9b OTHER INSURED’S DATE

OF BIRTH/SEX Enter date of birth and sex, of the insured named in Field 9. The date of birth must include the month, day, and FOUR DIGITS for the year (MM/DD/YYYY). Example: 01/05/1971 NOTE: This field must be completed when there is an


N/A 9c EMPLOYER’S NAME or

SCHOOL NAME

Enter the name of the employer or school name (if a student), of the insured named in Field 9. NOTE: This field must be completed when there is an


2330B NM 9d INSURANCE PLAN NAME or

PROGRAM NAME

Enter the name of the insurance plan or program, of the insured individual named in Field 9. NOTE: This field must be completed when there is an


2300 CLM 10

IS PATIENT’S CONDITION RELATED TO: a. Employment? b. Auto Accident? c. Other Accident? PLACE (State)

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) and in Field 21 (Diagnosis).

PLACE (State) Enter the state the Auto Accident occurred in.

N/A 11d IS THERE ANOTHER HEALTH BENEFIT PLAN?

Check “yes” or “no” to indicate if there is another health benefit plan. (For example, the patient may be covered under insurance held by a spouse, parent, or some other person). NOTE: If “yes,” then Field Items 9 and 9a-d must be

completed.

2300 DTP 14 DATE OF CURRENT

--Illness (First symptom) Enter the date of the current illness or injury. The date must include the month, day, and FOUR DIGITS for the year

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837P LOOP # FIELD


--Injury (Accident) --Pregnancy (LMP)

(MM/DD/YYYY). Example: 01/05/2008

2300 H1 21 DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Enter the diagnosis and if applicable, enter the Supplementary Classification of External Cause of Injury and Poisoning Code. NOTE: This field must be completed when there is an

entry in Field 10 (Is The Patient’s Condition Related To).

2320 AMT 29 AMOUNT PAID Enter the amount paid by the primary insurance carrier in

Field 29.

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5.48 Explanation of Payment

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