Claims

After visiting a Non-Participating Provider:

• When you receive care from a Non-Participating 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 Form with an itemized bill for reimbursement. See claim form for further instructions.

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.

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

• After your claim is processed, you will receive an Explanation of Benefits (EOB) that will detail what you need to pay and what the insurance plan will pay. An EOB statement is not a bill from your health 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 365 calendar days from the date you received care to submit your claim.
• Kaiser Permanente Insurance Company will review the claim and decide what payment or reimbursement may be owed to you.
• Care must be medically necessary. Refer to your Certificate of Insurance (COI) for more information.
• You’ll need specific information from your service provider. Your PPO Member Handbook has the steps to take to file a claim.

Claim Submission Address:

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

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

What if my claim was 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.

As a member of a group with health coverage insured by Kaiser Permanente Insurance Company (KPIC), your internal review process includes a mandatory appeal. You, or a representative whom you formally appoint in writing, have the right to appeal our decision by asking that we review it. To appeal the decision, please send your request for review to:

Kaiser Permanente Insurance Company
Member Relations Appeals
P.O. BOX 1809
Pleasanton CA 94566
Phone: 1-800-788-0710

In your request, please include:
(1) your name and, your medical record number
(2) your medical condition or symptom
(3) the specific treatment, service or supply that you are requesting
(4) the specific reason(s) for your request that we review our initial decision, and
(5) 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.

If you disagree with our decision on your appeal, your adverse decision 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 to:

Kaiser Permanente Insurance Company
Member Relations Appeals
P.O. BOX 1809
Pleasanton CA 94566
Phone: 1-800-788-0710

We will share any additional information that we collect in the course of our review by sending it to you in advance of our final decision. If we believe on review that your request should not be granted, before we issue our final decision we will also share with you in writing any new or additional reasons for that decision. We will send you a letter explaining the new or additional information and/or reasons. Our letters will tell you how you can respond to the information provided if you choose to do so. If you do not respond before we must make our final decision, that decision will be based on the information in your claim file. You are entitled to receive, upon request and free of charge, reasonable access to and copies of all documents and records relevant to your claim for benefits. In addition, you may give testimony in writing or by telephone. Please send your written testimony to Kaiser Permanente Insurance Company at the address set forth above. To arrange to give testimony by telephone, you should contact 1-800-788-0710. We will add all of the new information to your claim file and we will review it without regard to whether this information was submitted and/or considered in our initial adverse benefit determination.

For questions about your claim status, benefits, or eligibility call Customer Service at 1-800-788-0710 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Pacific time

Should you have any questions regarding your appeal rights, please call Kaiser Permanente Insurance Company 1-800-788-0710.

Independent Medical Review (IMR):

An Independent Medical Review (IMR) is a process where expert independent medical professionals are selected to review specific medical decisions made by the insurance company.

• The California Department of Insurance (DOI) administers an Independent Medical Review program that enables you to request an impartial appraisal of medical decisions within certain guidelines specified by the law.  For more information about how to obtain this review, please visit the CA DOI Website directly for assistance.