Claims

After visiting an Out-of-Network Provider:

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

If your plan has an annual deductible:

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

Filing claims for emergency care services:

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

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

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

If you file a claim:

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

Claim Submission Address:

National Claims Administration – Georgia
P.O. Box 370010
Denver, CO 80237-9998
EDI Payer ID: 21313

What if my claim is denied?

We are committed to providing you with quality care, in a timely response to your concerns. If we have denied coverage for certain services or supplies, in whole or in part, then you may request that we review this decision, also referred to as an “adverse benefit determination”. In addition, you may request that we review our determination of any cost shares (copayments, deductibles or coinsurance) or other amounts that you may owe. You have the right to appeal our decision by sending your request for review in writing to:

Kaiser Permanente Appeals Department
Nine Piedmont Center
3495 Piedmont Rd NE
Atlanta, GA 30305
Phone: (855) 364-3185
Fax: 404-949-5001

In your request, please include

• your name, medical record number, claim number;
• your medical condition or symptom;
• the specific treatment, service or supply that you received;
• the specific reason(s) for your request that we review our initial decision; and
• all supporting documents. Your request and the supporting documents constitute your appeal.

We must receive your request within 180 days of your receiving the notice of our adverse benefit determination. Please note that we will count the 180 days starting 5 business days from the date of the notice to allow for mail delivery time, unless you can prove that you received the notice after that 5-business day period.

A decision about your appeal will be made within 30 days of receipt of your request for review at each level.

As a member of a group with health coverage insured by Kaiser Permanente Insurance Company (KPIC), your internal review process includes a mandatory appeal.  If you disagree with our decision on your appeal, your adverse benefit determination notice will tell you how to respond if you so choose.

Appointment of a Representative

If you would like to have someone act on your behalf during our review, you may appoint an authorized representative.  You must make this appointment in writing. Please send the name, address and telephone contact information of Kaiser Permanente Appeals Department at the contact information set forth above.

If you want to review the information that we have collected regarding your claim for this service, you may request, and we will provide without charge, copies of all relevant documents, records, and other information. Separately, you have the right to request the diagnostic and treatment codes and their meanings that may be the subject of your claim.

You may send us additional information including comments, documents, or additional medical records which you believe supports your claim.  Please send all your additional information to the contact information set forth above.

In addition, you may give testimony in writing or by telephone.  To learn more about providing testimony or Kaiser Permanente’s procedures for sharing additional information, please contact the Kaiser Permanente Appeals Department at the address set forth earlier.

Should you have any questions regarding your appeal rights, please contact Member Services at 404-261-2590.

For information on Pharmacy claims, please see the Pharmacy section.