Transparency in Coverage

Certain services require authorization before you get them. In these cases, your participating provider can help you get authorization for care he or she considers medically necessary. We determine when covered services are medically necessary based upon certain standards that take into account your medical condition as well as generally accepted standards of care.

When you receive covered services for which you do not have prior authorization or that you receive from non-participating providers or from non-Plan Facilities that have not been approved by us in advance, we will not pay for them except in an emergency.

Some services need special approval through a utilization review. If you need services that require a review and your participating provider believes they’re medically necessary, he or she may submit a request for a utilization review for you, or you may submit a request. Routine request decisions are made within 14 calendar days from the date the request was made. Urgent request decisions are made within 72 hours.

If the request is denied, Kaiser Permanente will send you a letter. It will explain the reason for our decision and give instructions for filing an appeal if you don’t agree with the determination.

When you get care from participating providers, you won’t be responsible for paying any amounts except for any cost sharing (deductibles, copayments or coinsurance) amounts that you owe. However, you will need to pay for any noncovered services you receive, whether you get them from a participating or a non-participating provider.

If you get covered services without prior authorization — or if you get them from a non-participating provider we haven’t approved in advance — we won’t pay for them, except in an emergency. Charges for these services will be your financial responsibility, and you may be billed directly by the provider for any balance you owe.

You generally won’t have to file a claim if a Kaiser Permanente provider provides the services. The participating provider will send the bill directly to Kaiser Permanente, and we’ll handle the claim.

However, if you visit a non-participating provider without getting a referral, you may need to send us a claim with an itemized bill for any services you believe Kaiser Permanente should cover.

You can be reimbursed for covered care received from a non-Kaiser Permanente practitioner or provider, based on:

• Written referral by a Kaiser Permanente physician that is authorized by Kaiser Permanente.
• Emergency care.
• Out-of-state urgent care when traveling.

You or the provider should submit a claim, including itemized statements describing the services received. We review and authorize claims after the services have been provided, not during an emergency or urgent episode. If you, your family members, or practitioners call us during an emergency or urgent episode, we'll confirm your membership status. However, we will not authorize coverage or payment at that time. To get a claim form, contact Member Services or download it at here (PDF).

When we receive the claim(s) and medical information, we'll determine whether the services are covered by your Kaiser Permanente plan. Filing a claim does not guarantee payment of that claim. If approved, reimbursement is made to providers according to your health plan benefits. If you paid for services, you may file a claim by sending your name, the patient's name and medical record number, paid receipts, medical documentation, and a written statement describing the sequence of events to the following address within 90 days (or as soon as reasonably possible) after the patient received the out-of-plan emergency or out-of-area urgent care:

Kaiser Permanente
P.O. Box 378021
Denver, CO 80237-9998

You may also submit a claim online at the My Coverage & Costs portal. Click here to submit a claim in the online portal.

If you have chosen for Kaiser Permanente to receive advance payments of your premium tax credit, your monthly premium payment will be reduced by that amount. You need to pay any part of the premium that isn’t covered by the advance payment. If we don’t get your portion of the monthly premium by the due date, you’ll have a 3-month grace period in which to pay the late premium as well as the premiums owed for the additional 2 months of the grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. Any claims submitted for you during that grace period will be pended. When a claim is pended, that means no payment will be made to the provider until your delinquent premium is paid in full.

If you qualify for a grace period, we’ll send you a notice with details. During the first month of the grace period, we’ll pay all appropriate claims for covered services. For the second and third months, we may choose not to pay for services if we don’t get your payment for any outstanding premiums by the end of the grace period. However, you generally won’t have to file a claim if a Kaiser Permanente provider provides the services. A participating provider will send the bill/claim directly to Kaiser Permanente, and we’ll process the claim unless you don’t pay your premium and we have indicated to your participating provider that we may not pay their claim (pended the participating provider’s claim).

In certain cases, a claim may be denied retroactively — for example, if you fail to pay your premium or you get services after your membership ends. In the event of a retroactive denial, you’ll be financially responsible for the covered services you received. To ensure a claim is not retroactively denied, premiums must be paid on time. If you have questions about a claim that’s been denied, please contact Member services.

If we terminate your membership, we’ll refund any premium payments you made after your membership ended. We’ll also pay you any amounts we owe for claims while you were a member. When making these payments, we may deduct any amounts you owe Kaiser Permanente or any participating providers. Refunds for overpayment of premium are provided based on the method of payment used by the member. If you believe you have overpaid your premium and are due a refund, please contact Member Services.

Sometimes you may need a prescription drug that is not covered on Kaiser Permanente’s formulary (list of covered drugs). If you request a prescription for a non-formulary drug, and your Kaiser Permanente provider does not give you the prescription, then you may request review through the non-formulary exception review process. You or your Kaiser Permanente provider may submit the request to us with information as to why the non-formulary drug is medically necessary so that we may review your request.

To submit a non-formulary exception request to Kaiser Permanente, please contact Member Services. You must submit medical information supporting your request in order for us to complete our review. For most requests (standard requests), we will respond within 72 hours, but when exigent circumstances exist (i.e., your life, health or ability to regain maximum function would be seriously jeopardized without the non-formulary drug, or when you are already taking the non-formulary drug), then we will expedite your review request and respond to your request within 24 hours after our receipt of the request. If we grant your request, we will cover the non-formulary drug for the duration of the prescription, including refills. If exigent circumstances exist, we will cover the non-formulary drug for the duration of the exigent circumstance.

If after our review of your non-formulary drug exception request, you feel that we have denied your request for the non-formulary drug incorrectly, you may ask us to submit the case for external review. An independent review organization will review your external review request within 72 hours, or 24 hours for exigent circumstances. If the external review results in your non-formulary drug being approved, we will cover it for the either duration of the exigent circumstances or the duration of the prescription, as applicable.

You, your appointed representative, or treating provider may file the request for review. Requests for external review must be submitted to the commissioner within 130 days of receipt of Kaiser Permanente's final adverse decision. Requests for external review may be filed at the address below or by facsimile to 808-587-5379. You can reach the Health Insurance Branch of the Hawaii Insurance Division by calling 808-586-2804.
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State of Hawaii DCCA
Insurance Division - External Appeals
335 Merchant St., 2nd Fl.
Honolulu, HI 96813

An Explanation of Benefits (EOB) is a summary of services you’ve received during a specific period. It shows the charges, the date of your visit, and the name of the provider you visited. An EOB is not a bill. It’s available to help you understand the payments made for your covered services and to help you keep track of your expenses. EOBs are sent at least once a month after the Member receives services and the claim is received by Kaiser Permanente to be processed.

If you have health coverage under more than one plan, the Coordination of Benefits process helps you make the most of your coverages to make sure you get the care you need. It determines the order in which different plans pay for services, which can make it easier to get and pay for care.

The plan that pays first is the primary plan. It’s responsible for paying first regardless of whether another plan covers some expenses so long as the care is covered. The secondary plan pays next. Based on how much the primary plan pays, it may reduce what it pays so the amounts from both plans don’t total more than the allowable expense for specific services.

If you have any questions or want more information about any of the topics covered here, please contact Member Services.   One of our representatives will be happy to help.