Participating Provider Network Orientation...Total Membership: 780,000* Washington, DC Baltimore...
Transcript of Participating Provider Network Orientation...Total Membership: 780,000* Washington, DC Baltimore...
2 | © 2011 Kaiser Foundation Health Plan, Inc.October 2018
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.
3 | © 2011 Kaiser Foundation Health Plan, Inc.October 2018
Kaiser Permanente Medical Centers
30 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)
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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
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Membership
Total Membership:
780,000*
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 January 2018
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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
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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
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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
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
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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
Medical Advice/Appointments
703-359-78781-800-777-7904
Pre-certification 1-800-810-4766
Member Services 1-800-777-7902
Claims Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998
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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
Medical Advice/Appointments
703-359-78781-800-777-7904
Pre-certification 1-800-810-4766
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
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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.
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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)
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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
Medical Advice/Appointments
703-359-78781-800-777-7904
Pre-certification 1-800-810-47661-800-660-2019 (fax)
Member Services 1-888-225-7202
Claims Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998
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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.
Medical Advice/Appointments
703-359-78781-800-777-7904
Pre-certification 1-800-810-4766
Member Services 1-877-740-4117
Claims KPIC Self-Funded Claims AdministratorP.O. Box 30547Salt Lake City, UT 84130-0547
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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
Medical Advice/Appointments
703-359-78781-800-777-7904
Pre-certification 1-800-810-4766
Member Services 1-855-249-5025
Claims Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998
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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
Medical Advice/Appointments
703-359-78781-800-777-7904
Pre-certification 1-800-810-4766
Member Services 1-855-249-5019
Claims Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998
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Exchanges
Mirrors the SignatureTM plan Identification cards are similar to the
SignatureTM plan cards with the exception of Capitol Hill employees
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
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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) 1-800-810-4766
Fax Numbers:• Specialty Care Referrals• Concurrent Review• Homecare/DME (Please send clinical
information)
1-800-660-2019855-414-1708 855-414-1695
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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
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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
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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
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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
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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
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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
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Resources and ServicesProvider ExperienceCPP: Provider Manual, Provider Directory, forms for provider data changes, enrollment in KP HealthConnect Online Affiliate
www.providers.kp.org/mas
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
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Resources and ServicesUMOCReferrals, authorizations, hospital observation & inpatient admissions• General number• Fax numbers
• Specialty Care Referrals• Concurrent Review• Homecare/DME
www.providers.kp.org/mas
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
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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].