Participating Provider Network Orientation - Kaiser...

Participating Provider Network Orientation

Provider Experience

2 | © 2011 Kaiser Foundation Health Plan, Inc.June 2019

Introduction

Kaiser Permanente is an integrated healthcare delivery system. We are a healthcare provider and we offer medical services at our medical centers and through affiliated Participating Providers throughout the Mid-Atlantic region.


Kaiser Permanente Medical Centers

31 Medical Centers

Primary & Specialty

CarePharmacy,

Labs, Radiology,

etc.

Urgent Care

Ambulatory Surgery Centers

Critical Decision Unit

Behavioral Health Care

Urgent Care Centers

• District of Columbia• Capitol Hill (24hr HUB)

• Maryland• Camp Springs• Gaithersburg (24hr HUB)• Kensington• Largo (24hr HUB)• Baltimore Harbor• South Baltimore County (24hr

HUB)• White Marsh

• Virginia• Fredericksburg• Manassas• Reston• Tysons Corner (24hr HUB)• Woodbridge (24hr HUB)


Contracted Resources

Contracts• Affiliated Hospitals

• Kaiser Permanente Care Management staff at certain locations

• Physician Contracts• Primary• Specialty & Multi-Specialty• Hospital Faculty

• Behavioral Health• Urgent Care• Ambulance

Ancillary Services

• Laboratory• Kaiser Permanente Medical Centers• Quest Diagnostics

• Radiology• Kaiser Permanente Medical Centers• For a complete list of Participating

Radiology Providers, please refer to the Kaiser Permanente Provider Manual, Chapter 12


Membership

Total Membership:

750,000*

Washington, DC

Baltimore City/County (includes Anne

Arundel, Carroll, Harford and

Howard Counties)

Suburban Maryland

and Frederick

Northern Virginia (Including

Culpeper and Stafford

Counties)*as of June 2019


Product OverviewProduct Description

SignatureTM HMO

SelectTM HMO

Added ChoiceTM 2-Tier Point of Service Plan

Flexible ChoiceTM 3-Tier Point of Service Plan

Medicare Plus Medicare Cost Plan

Medicare Advantage Medicare Risk Plan

Exclusive Provider Organization Self-Funded Plan

Virginia Premier Virginia Medicaid Plan

Maryland HealthChoice Maryland Medicaid Plan


SignatureTM

Traditional HMO plan Services are accessed at Kaiser Permanente Medical Centers. Care is

provided by Mid-Atlantic Permanente Medical Group (MAPMG) physicians. Referral/authorizations are required for specialty care Approved referrals are required for hospital care and other facility services

Medical Advice/Appointments

703-359-78781-800-777-7904

Pre-certification 1-800-810-47661-800-660-2019 (fax)

Member Services 1-800-777-7902

Claims Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998


SelectTM

Traditional HMO plan Services are accessed at Kaiser Permanente Medical Centers and through

Participating Providers within our service area Members may choose a PCP from a Kaiser Permanente Medical Center or

within our Participating Provider network. The PCP coordinates care. Referral/authorizations are required for specialty care Approved referrals are required for hospital care and other facility services


703-359-78781-800-777-7904





Added ChoiceTM

2-tiered plan – HMO and OON HMO – MAPMG (SignatureTM) or MAPMG & Participating Provider Network

(SelectTM), copays apply OON – Any licensed provider, deductibles and coinsurance apply*certain OON services may require pre-certification


703-359-78781-800-777-7904

Pre-certification 1-800-810-4766




Flexible ChoiceTM

Administered by Kaiser Permanente Insurance Company (KPIC) 3-tiered plan – HMO, PPO and OON HMO – MAPMG (SignatureTM), copays apply PPO – PHCS and MultiPlan providers, deductibles and coinsurance apply OON – Any licensed provider, deductibles and coinsurance apply

HMO Tier


703-359-78781-800-777-7904


Member Services

1-888-225-7202

Claims:Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998

PPO & OON Tier

Pre-certification

1-888-567-6847

Member Services

1-800-392-8649

Claims KPICP.O. Box 261130Plano, TX 75026


Flexible ChoiceTM

Tier 1: HMO Signature Delivery System, referral/authorization rules

apply

Tier 2: PPOPHCS and MultiPlan Network Providers Care is self-

directed but some pre-certification is required. Deductible, coinsurance apply; no balance billing

Tier 3: OON Any other licensed provider. Care is self-directed through licensed providers; some require pre-certification. Higher

deductibles; coinsurance for all except emergencies.


Medicare PlusTM

Acts as a supplemental plan for Medicare when services are coordinated and authorized by Kaiser Permanente Part A – Kaiser Permanente is secondary Part B – Kaiser Permanente is secondary when services are

accessed outside Kaiser Permanente Medical Centers Medicare must be billed primary

If a member is not eligible for Part A, Kaiser Permanente should be billed as primary

If a member chooses to access care outside of Kaiser Permanente, they must use their traditional Medicare benefits Traditional Medicare deductibles and co-insurance apply

and are the member’s responsibility Kaiser Permanente will not be responsible for unauthorized

services For authorized services provided by contracted or non-

contracted providers Providers send the full bill to Medicare directly Once Medicare has paid its portion, the claim is forwarded

to Kaiser Permanente to pay the remaining allowable amount (minus any member responsibility)


Medicare Advantage

Members must already have Parts A & B Part D (prescription drug coverage) is included in all Kaiser Permanente Medicare Advantage plans Services are accessed at Kaiser Permanente Medical Centers and the Kaiser Permanente Medicare

Advantage Network Approved referral/authorizations are required for specialty care, hospital care and other facility services Medicare Advantage plans available in DC and MD (Harford, Baltimore, Baltimore City, Howard,

Montgomery, Anne Arundel, and Prince George’s counties) Kaiser Permanente must be billed as primary


703-359-78781-800-777-7904





Exclusive Provider Organization (EPO)

Self-Funded plan administered by KPIC Mirrors the HMO SignatureTM product Health Reimbursement Account – employer owned savings account for use by

members with high deductible plans. Members pay for patient liability using an employer provided Visa debit card.


703-359-78781-800-777-7904



Claims KPIC Self-Funded Claims AdministratorP.O. Box 30547Salt Lake City, UT 84130-0547


Virginia Premier / Kaiser Permanente Medicaid Program

VA Premier and Kaiser Permanente partnership HMO – MAPMG (SignatureTM) and Virginia Medicaid Participating Provider

Network Use the Kaiser Permanente Medical Record

Number when billing Kaiser Permanente


703-359-78781-800-777-7904





Maryland HealthChoice

Maryland Medicaid MCO HMO – MAPMG (SignatureTM) and Maryland HealthChoice Participating

Provider Network Use the Kaiser Permanente Medical Record Number when billing Kaiser

Permanente


703-359-78781-800-777-7904





Exchanges

Mirrors the SignatureTM plan Identification cards are similar to the

SignatureTM plan cards with the exception of Capitol Hill employees


703-359-78781-800-777-7904





Referrals and AuthorizationsUtilization Management Operations Center (UMOC)

Referral Management Unit: 8:00am – 4:30pm, weekdays

Concurrent Review Unit: 8:30am – 5:00pm, weekdays

Home Care/DME Unit: 8:30am – 5:00pm, weekdays

Emergency Care Management (ECM): 24/7, 365 days/yr.

Referrals, Authorizations, Hospital Observation & Inpatient AdmissionsOnline Affiliate www.providers.kp.org/mas

General Number (listen for prompts) 800-810-4766

Fax Numbers:• Specialty Care Referrals• DME & all PT/OT/ST (new referrals)• DME (reauth)• SNF PT/OT/ST & OP rehab PT/OT/ST (reauth)• Home Health PT/OT/ST (reauth)• Early Intervention• Concurrent Review

800-660-2019800-660-2019855-414-1695855-414-1698855-414-1695855-414-1695855-414-1708

http://www.providers.kp.org/mas


Referrals and AuthorizationsUtilization Management Operations Center (UMOC)Pre-service review is required for selected procedures and services

List of self-referred services and services requiring pre-service review can be found in the Kaiser Permanente Provider ManualCall the UMOC for notification of observation and inpatient admissions

Specialty Care ReferralsInitial consultation• Referral must be authorized by PCP or Specialist• Referral valid for 90 days (3 months), or as otherwise specified on the referralAdditional visits (specialist may initiate extension of referral) by:• Faxing request (Uniform Referral Form) to the UMOC at 1-800-660-2019, or• Calling UMOC at 1-800-810-4766 and following voice prompts to request additional visitsRemember you do not have to call the PCP to request additional visits, call the UMOC number above


Claims and Billing ProceduresBilling address for fully-funded plans:

Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998

Billing address for Flexible ChoiceTM plan tiers 2 & 3:Kaiser Permanente Insurance CompanyP.O. Box 261130Plano, TX 75026

Billing address for Self-Funded plan:KPIC Self-Funded Claims AdministratorP.O. Box 30547Salt Lake City, UT 84130-0547

Payor IDs for electronic claim clearinghouses:Change Healthcare: 52095OptumInsight/Ingenix: NG008Office Ally: 52095Availity (formerly REALMED): 54294Self-Funded plans: 94320

Timely Filing: 180 days (6 months) from date of serviceTimely Appeals: 180 days (6 months) from date of denial“Clean Claims”: standard format/completed fields, attachments, current industry standard data codingAll patient services must be billed on CMS1500 or UB04Explained in detail – Chapter 8 of ProviderManual


Member Enrollment

Open enrollment period occurs annually Member may change their PCP at any time by selecting a PCP

from the directory and calling Member Services. Changes made before the 20th of any given month are effective the first of the following month. Changes made after the 20th are effective the first of the second following month.

Please see our Provider Manual for additional assistance available to Members


Compliance and Regulatory Policy

Kaiser Permanente is committed to meeting compliance and regulatory policies enforced by federal, state/local government and health plans

For questions regarding compliance policy or to obtain a copy of the Kaiser Permanente compliance guide, “Principles of Responsibility”, please call Provider Experience at 1-877-806-7470 or visit www.providers.kp.org/mas

http://www.providers.kaiserpermanente.org/mas


Quality and Health Management

KPMAS Quality of Care and Service Program addresses all medical, behavioral health and provider service to internal/external customers. Call Member Services at 1-800-777-7902 for more information.

Providers are credentialed upon initial application and re-credentialed every three (3) years

Site visits are conducted at initial and re-credentialing processes or as needed when a deficiency is identified

Please see the Provider Manual for more quality measurement standards


Online Resources

Community Provider Portal (CPP)

KP HealthConnect Online Affiliate

www.providers.kp.org/mas

Provider Manual

Provider directories

Clinical guidelines

Network newsletters

Download forms

Trainings

News and announcements

Secured web-based application. Secured user ID needed.

View member demographics

Verify member eligibility

View benefits

View Kaiser Permanente medical records

Check claim status



Resources and ServicesProvider ExperienceCPP: Provider Manual, Provider Directory, forms for provider data changes, enrollment in KP HealthConnect Online Affiliate


Contract questions, orientation and training 1-877-806-7470Provider appeals (written form only) Mid-Atlantic Claims Administration

Kaiser PermanenteP.O. Box 371860Denver, CO 80237-9998

Claims/Member ServicesProvider claims inquiries 1-866-876-5934

Benefits and eligibility 1-800-777-7902

Automated eligibility & copay line 1-800-810-4766

Member appeals and grievances 1-800-777-7902

Behavioral Access Unit (self-referred) 1-866-530-8778



Resources and ServicesUMOCReferrals, authorizations, hospital observation & inpatient admissions• General number• Fax numbers

• Specialty Care Referrals• Concurrent Review• Homecare/DME


1-800-810-4766

1-800-660-2019855-414-1708855-414-1695

Self-Funded MembersEligibility and Benefits www.providers.kp.org/masMember-related issues 1-877-740-4117Provider claims inquiries and disputes 1-877-740-4117Referrals and authorizations 1-800-810-4766 follow voice prompts



Thank you for participating with Kaiser Permanente

Questions?

If you have any questions regarding this presentation please contact Provider Experience at 1-877-806-7470 or email us at [email protected].

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