Claims

Before your visit to a non-Kaiser Permanente provider:

• Find out if you’ll need to submit a claim.
• 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 and take the “HMO Flex Flyer” with you to the appointment. This flyer will help them take care of you.

At your provider’s office:

• Collect the necessary documentation.
• On the day of the visit, take the “HMO Flex Flyer” with you and give it to your provider.
• Your doctor may require you to pay the full cost of the visit. If so, you will need to submit claim forms and itemized bills for reimbursement.
• If they will be submitting the claim for your visit, please ask them to follow the instructions on the flyer. The claims address is also on the back of your ID card.
• If they confirm that you should submit the claim, 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 your visit to a non-Kaiser Permanente provider:

• Make copies of your itemized bills and receipts for your records.
• Write “process under the HMO Flex Rider benefit” at the top of the bill. This will ensure that the claim gets processed as quickly as possible.
• Submit your Medical Claim Form with the itemized bills and receipts to the address below.

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

• Within 30 days of receiving your claim, you will receive an Explanation of Benefits (EOB) that will detail what you need to pay and what the health plan has paid. 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 member reimbursement claim:

• You have up to 365 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. We’ll keep track of your visits and provide a summary, which will be mailed to you after claims for out-of-network services have been processed.

Send your claim form with itemized bill and receipts to the following address:

Kaiser Foundation Health Plan, Inc.

National Claims Administration

Hawaii Claims (HMO Flex rider)

P.O. Box 378021

Denver, CO 80237-9998

What if my claim is 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. You have the right to appeal our decision by sending your request for review to the following address in writing:

Kaiser Foundation Health Plan, Inc.
ATTN: Regional Appeals Office
711 Kapiolani Blvd.
Honolulu, HI 9681
Phone: 1-800-238-5742
Fax: 866-240-9384
Electronic mail at:
KPHawaii.Appeals@kp.org

In your request, please include:
(1) your name and your medical record number;
(2) the specific reason(s) for your request that we review our initial payment decision, and
(3) any relevant information regarding the claim for payment.

We must receive your request within 180 calendar days of your receipt of this EOB. Please note that we will count 180 calendar 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.

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 contact the Customer Service Call Center at (808) 432-5955 or toll free at (800) 966-5955 for information about how to appoint a representative.

If you want to review the information that we have collected regarding your claim for this service, you may request in writing, 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. To make a request, you should contact the Customer Service Call Center at (808) 432-5955 or toll free at (800) 966-5955.

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 Appeals Program at the address listed 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 Customer Service Call Center at (808) 432-5955 or toll free at (800) 966-5955.

We must make our decision about your appeal within 30 calendar days of receipt of your request for review.

Should you have any questions regarding your appeal rights, please contact the Customer Service Call Center at (808) 432-5955 or toll free at (800) 966-5955. For the deaf and hearing­impaired: contact TTY 1-877-447-5990.