Claims

Before visiting an out-of-network provider:

• When making your appointment, be sure to ask your provider if they intend to submit a claim to Kaiser Permanente on your behalf.
• Please print the “KP Plus Information for Out-of-Network Providers” [Coming Soon] flyer to bring with you to the appointment. This flyer can help them check you in correctly and help keep your costs more affordable.

At your provider’s office:

• On the day of the visit, take the “KP Plus Information for Physicians” [Coming Soon] flyer with you and give it to your provider.
• If they will be submitting the claim for your service, please ask them to follow the instructions on the flyer. The claims address they’ll need is also on the back of your ID card.
• You may need to pay for services from an out-of-network provider in full, and then submit a claim for reimbursement.
• If they confirm that you should submit the claim yourself, be sure to collect and keep copies of:
  • Itemized bill(s) showing the amount charged, the amount you paid, and diagnosis or treatment codes.
  • Receipts for any charges you paid that show a zero balance.

After visiting an out-of-network provider:

• When you receive care from an out-of-network provider, you may need to submit a claim for reimbursement. You may be required to pay the full amount you are billed when you receive care. If needed, submit a claim form with an itemized bill for reimbursement. For the fastest processing, file your claim online at kp.org/coverageandcosts.

You are also responsible for paying amounts that are greater than what your plan covers.

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

• Within 30 days of completing the claims processing, you will be sent an Explanation of Benefits (EOB) that will detail what you need to pay and what the health insurance plan will pay. An EOB statement is not a bill, it is an informational statement to keep you informed.
• If you file a claim: Kaiser Permanente will review the claim and decide what payment or reimbursement may be owed to you.
• Refer to your Evidence of Coverage (EOC) for more information.
• Access the Member Reimbursement Form or visit kp.org/coverageandcosts to file a claim online.

Claim Submission Addresses:

Northern California Region
KFHP Claims Department
P.O. Box 8002, Pleasanton, CA 94588

Southern California Region
KFHP Claims Department
PO Box 7004, Downey, CA 90242

What if my claim is denied?

We are committed to providing you with quality care, with 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 (co-pays, deductibles or coinsurance) or other amounts that you may owe.

You, or a representative whom you formally appoint in writing, have the right to submit a grievance to appeal our payment decision by asking that we review it. You can choose any of the following ways to submit a grievance/appeal:

(1) You can speak to a representative at our Member Service Call Center by calling 1-800-788-0710 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m. Pacific time.

(2) If it is more convenient, you can visit Member Services at your local medical facility. To find a Kaiser Permanente medical facility in California, search the Kaiser Permanente Provider Directory:

Kaiser Permanente Providers and Locations – Northern California

Kaiser Permanente Providers and Locations – Southern California

(3) You can use our website at kp.org.

(4) You can submit your appeal in writing by either sending it to:

Kaiser Foundation Health Plan, Inc.
Attention: Health Plan Clinical Review Special Services
P.O. Box 7136
Pasadena, CA 91109-7136
Or you can fax it to: (626) 405-3039.

In your written 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.

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 that person the name, address and telephone contact information for the Kaiser Permanente Appeals Department (see 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 above.

If you have any questions regarding your appeal rights, please contact KP Plus Customer Service at 1-800-788-0710 (TTY 711) Monday through Friday 7 a.m. to 7 p.m. Pacific Time.

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