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2021Northern CaliforniaHMO Provider ManualKaiser Foundation Health Plan, Inc.

Welcome fromKaiser PermanenteIt is our pleasure to welcome you as a contracted provider (Provider)participating under HMO plans offered by the Kaiser Permanente MedicalCare Program Affiliated Payors. We want this relationship to work well foryou, your medical support staff, and our Members.This Provider Manual was created to help guide you and your staff inworking with Kaiser Permanente’s various systems and proceduresapplicable to our HMO products in Northern California. It is an importantpart of your relationship with Kaiser Permanente, but this Provider Manualdoes not cover all aspects of your relationship with us. Please continue toconsult your Provider agreement with Kaiser Permanente.During the term of such agreement, Providers are responsible for (i)maintaining copies of the Provider Manual and its updates as provided byKaiser Permanente, (ii) providing copies of the Provider Manual to itssubcontractors and (iii) ensuring that Provider and its practitioners andsubcontractors comply with all applicable provisions. The ProviderManual, including but not limited to all updates, shall remain the propertyof Kaiser Permanente and shall be returned to Kaiser Permanente ordestroyed upon termination of the obligations under such agreement.If you have questions or concerns about the information contained in thisHMO Provider Manual, you can reach our Medical Services ContractingDepartment by calling (844) 343-9370.Additional resources can also be found on our Community Provider Portalwebsite at: http://providers.kaiserpermanente.org/nca/

Table of ContentsINTRODUCTION . XI1.KAISER PERMANENTE MEDICAL CARE PROGRAM (KPMCP) . 11.1HISTORY .11.2ORGANIZATIONAL STRUCTURE .11.3KPNC SERVICE AREA .11.4INTEGRATION . 21.5NONDISCRIMINATION . 21.6PREVENTIVE HEALTH CARE . 21.7OTHER PRODUCTS . 21.81.7.1Exclusive Provider Organization (EPO) . 31.7.2Point of Service (POS)—Two-Tier . 31.7.3Point of Service (POS)—Three-Tier . 31.7.4Out of Area Preferred Provider Organization (PPO). 3IDENTIFICATION CARDS AND MEDICAL RECORD NUMBER (MRN) . 42. KEY CONTACTS . 62.1NORTHERN CALIFORNIA REGION KEY CONTACTS. 62.2MEMBER SERVICES INTERACTIVE VOICE RESPONSE SYSTEM (IVR) . 82.3KP OUTSIDE SERVICES . 82.4KP FACILITY LISTING. 82.5NORTHERN CALIFORNIA RESOURCE MANAGEMENT (RM) CONTACTS .133. ELIGIBILITY AND BENEFITS DETERMINATION . 163.1ELIGIBILITY AND BENEFIT VERIFICATION . 163.1.1After Hours Eligibility Requests . 173.1.2Benefit Coverage Determination . 173.2MEMBERSHIP TYPES . 173.3BENEFIT EXCLUSIONS AND LIMITATIONS . 183.4DRUG BENEFITS . 184. UTILIZATION MANAGEMENT (UM) AND RESOURCE MANAGEMENT (RM)19i

4.1OVERVIEW OF UTILIZATION MANAGEMENT AND RESOURCE MANAGEMENT PROGRAM . 194.1.1Data Collection and Surveys . 194.2MEDICAL APPROPRIATENESS. 204.3“REFERRAL” AND “AUTHORIZATION” – GENERAL INFORMATION . 204.4AUTHORIZATION OF SERVICES.214.4.1Hospital Admissions Other Than Emergency Services . 224.4.2Admission to Skilled Nursing Facility (SNF) . 224.4.2.14.4.3Home Health/Hospice Services . 234.4.3.1Home Health Specific Criteria . 234.4.3.2Hospice Care Criteria . 244.4.4Durable Medical Equipment (DME)/ Prosthetics and Orthotics (P&O) . 244.4.5Psychiatric Hospital Services . 244.4.6Non-Emergent Transportation . 244.4.74.4.6.1Non-Emergency Medical Transport (Gurney Van/WheelchairVan) . 244.4.6.2Non-Emergency Ambulance Transportation . 25Transfers to a KP Medical Center . 254.4.7.14.4.84.5Authorization Numbers are Required for Payment . 23Required Information for Transfers to KP . 25Visiting Member Guidelines . 26EMERGENCY ADMISSIONS AND SERVICES; HOSPITAL REPATRIATION POLICY . 274.5.1Emergency Prospective Review Program (EPRP) . 284.5.2Post-Stabilization Care. 294.6CONCURRENT REVIEW . 304.7CASE MANAGEMENT HUB CONTACT INFORMATION .314.8DENIALS AND PROVIDER APPEALS .314.9DISCHARGE PLANNING .314.10 UM INFORMATION . 324.11 CASE MANAGEMENT . 324.12 CLINICAL PRACTICE GUIDELINES (CPGS) . 334.13 PHARMACY SERVICES / DRUG FORMULARY . 334.13.1 Pharmacy Benefits . 33ii

4.13.2 Filling Prescriptions . 344.13.2.1 Prescribing Non-Formulary Drugs. 344.13.2.2 Pharmacies . 354.13.2.3 Telephone and Internet Refills . 354.13.2.4 Mail Order . 354.13.2.5 Restricted Use Drugs . 354.13.2.6 Emergency Situations . 365. BILLING AND PAYMENT . 375.1WHOM TO CONTACT WITH QUESTIONS . 375.2METHODS OF CLAIMS SUBMISSION . 375.3CLAIMS FILING REQUIREMENTS . 375.45.3.1Record Authorization Number . 375.3.2One Member and One Provider per Claim Form . 375.3.3Submission of Multiple Page Claim (CMS-1500 Form and UB-04 Form) 385.3.4Billing for Claims That Span Different Years . 385.3.4.1Billing Inpatient Claims That Span Different Years . 385.3.4.2Billing Outpatient Claims That Span Different Years . 385.3.5Interim Inpatient Bills . 385.3.6Psychiatric and Recovery Services Provided to Medi-Cal Members. 385.3.7Services Provided to Medicare Cost Members . 39PAPER CLAIMS . 395.4.1Submission of Paper Claims . 395.4.1.15.4.2Submission of Paper Claims – Emergency Services . 405.4.2.15.5Contacting KP Regarding Referred Services Claims . 39Calling KP Regarding Emergency Claims . 405.4.3Supporting Documentation for Paper Claims . 405.4.4Ambulance Services .41SUBMISSION OF ELECTRONIC CLAIMS . 425.5.1Electronic Data Interchange (EDI) . 425.5.2Where to Submit Electronic Claims . 425.5.3EDI Claims Acknowledgement . 42iii

5.5.4Supporting Documentation for Electronic Claims . 435.5.5HIPAA Requirements . 435.6COMPLETE CLAIM . 435.7CLAIMS SUBMISSION TIMEFRAMES . 445.8PROOF OF TIMELY CLAIMS SUBMISSION. 455.9CLAIMS RECEIPT VERIFICATION AND STATUS . 455.10 CLAIM CORRECTIONS . 455.11 INCORRECT CLAIMS PAYMENTS . 495.11.1Underpayments . 495.11.2 Overpayments . 495.11.2.1 Overpayment Identified by Provider . 495.11.2.2 Overpayment Identified by KP . 505.11.2.3 Contested Notice . 505.11.2.4 No Contest. 505.11.2.5 Offset to Payments . 515.11.3 Inconsistent Payments . 515.12 MEMBER COST SHARE .515.13 BILLING FOR SERVICE PROVIDED TO VISITING MEMBERS . 535.14 CODING FOR CLAIMS . 535.15 CODING STANDARDS . 545.16 MODIFIERS USED IN CONJUNCTION WITH CPT AND HCPCS CODES . 555.17 MODIFIER REVIEW . 555.18 CLAIMS ADJUSTMENTS, CODING & BILLING VALIDATION . 555.18.1 Claims Review . 555.18.2 Code Review and Editing . 565.18.3 Coding Edit Rules. 575.18.4 Clinical Review . 575.18.5 Do Not Bill Events (DNBE) . 585.18.6 Claims for Do Not Bill Events . 605.19 CMS-1500 (02/12) FIELD DESCRIPTIONS . 615.20 UB-04 (CMS-1450) FIELD DESCRIPTIONS . 725.21 COORDINATION OF BENEFITS (COB) . 79iv

5.21.1 How to Determine the Primary Payor . 795.21.2 Description of COB Payment Methodology. 805.21.3 COB Claims Submission Requirements and Procedures . 805.21.4 Direct Patient Billing . 805.22 THIRD PARTY LIABILITY (TPL) . 805.22.1 Third Party Liability Guidelines . 815.23 WORKERS’ COMPENSATION . 815.24 PROHIBITED BILLING PRACTICES . 815.25 EXPLANATION OF PAYMENT AND REMITTANCE ADVICE . 825.26 INVOICES. 825.26.1 Other Contracted Functions Related to Professional Services . 835.26.2 Other Contracted Functions Related to Services Delivered at KFH (NonProfessional). 845.26.3 1099 Tax Documents . 856. PROVIDER DISPUTE RESOLUTION PROCESS . 866.1TYPES OF DISPUTES . 866.2SUBMITTING PAYMENT DISPUTES . 866.2.17.Directions for Submission of Payment Disputes . 866.2.1.1Payment Disputes Related to Referred Service Claims . 866.2.1.2Payment Disputes Related to Emergency Services Claims . 876.2.1.3Payment Disputes Related to Vising Member Claims . 876.2.2Required Information for Provider Payment Dispute Notices . 886.2.3Time Period for Submission of Provider Dispute Notices . 896.2.4Timeframes for Acknowledgement of Receipt and Determination ofProvider Dispute Notices . 896.2.5Instructions for Resolving Substantially Similar Payment Disputes . 896.3DISPUTING REQUESTS FOR OVERPAYMENT REIMBURSEMENTS . 906.4OTHER DISPUTES . 90MEMBER RIGHTS AND RESPONSIBILITIES . 917.1MEMBER RIGHTS AND RESPONSIBILITIES STATEMENT . 917.2NON-COMPLIANCE WITH MEMBER RIGHTS AND RESPONSIBILITIES . 97v

7.2.1Members. 977.2.2Providers . 977.3HEALTH CARE DECISION-MAKING . 987.4ADVANCE DIRECTIVES . 997.4.17.5Physician Orders for Life Sustaining Treatment (POLST). 100MEMBER GRIEVANCE PROCESS . 1007.5.1Provider Participation in Member Grievance Resolution . 1017.5.2Member Grievance Resolution Procedure. 1017.5.3Processes for Grievance Resolution . 1027.5.47.5.3.1Quality of Care Grievances . 1027.5.3.2Expedited Review . 1027.5.3.3Instructions for Filing a Grievance . 103Department of Managed Health Care Complaint Process—Non-Medicare1077.5.4.17.5.5Independent Medical Review Program Availability—NonMedicare . 107Demand for Arbitration . 1088. PROVIDER RIGHTS AND RESPONSIBILITIES . 1098.1PROVIDERS’ RIGHTS AND RESPONSIBILITIES . 1098.2COMPLAINT AND PATIENT CARE PROBLEMS . 1108.38.2.1Administrative and Patient Related Issues . 1118.2.2Claim Issues . 111REQUIRED NOTICES. 1118.3.1Provider Changes That Must Be Reported . 1118.3.1.1Provider Illness or Disability . 1118.3.1.2Practice Relocations. 1118.3.1.3Adding/Deleting New Practice Site or Location . 1118.3.1.4Adding/Deleting Practitioners to/from the Practice . 1128.3.1.5Changes in Telephone Numbers. 1128.3.1.6Federal Tax ID Number and Name Changes . 1128.3.1.7Mergers and Other Changes in Legal Structure . 112vi

8.3.1.8Provider Directories Information per Health and Safety Code §1367.27 . 1128.3.2Contractor Initiated Termination (Voluntary) . 1148.3.3Other Required Notices . 1148.4CALL COVERAGE PROVIDERS . 1148.5HEALTH INFORMATION TECHNOLOGY . 1159. QUALITY ASSURANCE AND IMPROVEMENT (QA & I) . 1169.1NORTHERN CALIFORNIA QUALITY PROGRAM AND PATIENT SAFETY PROGRAM . 1169.2QUALITY ASSURANCE AND IMPROVEMENT (QA & I) PROGRAM OVERVIEW. 1179.3PROVIDER CREDENTIALING AND RECREDENTIALING . 1189.3.1Practitioners . 1199.3.2Practitioner Rights . 1209.3.39.3.2.1Practitioner Right to Correct Erroneous or DiscrepantInformation. . 1209.3.2.2Practitioner Rights to Review Information . 1209.3.2.3Practitioner Right To Be Informed of the Status of theCredentialing Application . 1209.3.2.4Practitioner Right to Credentialing and Privileging Policies . 120Organizational Providers (OPs) . 1209.3.3.19.49.5Corrective Action Plan or Increased Monitoring Status for OPs121MONITORING QUALITY . 1229.4.1Compliance with Legal, Regulatory and Accrediting Body Standards . 1229.4.2Member Complaints . 1229.4.3Infection Control . 1229.4.4Practitioner Quality Assurance and Improvement Programs . 122QUALITY OVERSIGHT . 1239.5.1Quality Review . 1249.5.2OPs’ Quality Assurance & Improvement Programs (QA & I) .1259.5.3Sentinel Events / Reportable Occurrences for OPs (Applicable to AcuteHospitals, Chronic Dialysis Centers, Ambulatory Surgery Centers,Psychiatric Hospitals, SNFs and Transitional Residential RecoveryServices Providers) .1259.5.3.1Definitions: Sentinel Events and Reportable Occurrences .125vii