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 claim 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.

What if my claim is denied?

• It is your right to file an appeal if you disagree with a decision not to pay for a claim. Read your Evidence of Coverage for more information.

Claim Submission Address:

Kaiser Permanente Claims Department
P.O. Box 370010
Denver, CO 80237-9998
EDI Payer ID: 21313