Overview
Kaiser Permanente is a closed-network system where most claims are handled internally. Out-of-network providers submit claims to the regional Kaiser entity where the member is enrolled. Filing deadlines vary by region: typically 90-180 days from date of service.
Key Requirements
- Identify the correct Kaiser region: Northern California, Southern California, Colorado, Georgia, Hawaii, Mid-Atlantic, Northwest, Washington.
- Submit electronic claims via Availity or the regional Kaiser portal.
- Filing deadline: 90-180 days from date of service (varies by region and plan type).
- Required fields: member medical record number (MRN), provider NPI, ICD-10 diagnosis, CPT procedure codes, date of service.
- Emergency services: no prior auth required. Submit claim within 90 days of service.
Timeline
Day 1: Identify correct Kaiser regional entity. Days 1-5: Submit electronic claim with required fields. Days 6-30: Kaiser adjudicates clean claims. Days 31-45: Payment processed for approved claims. If claim pends: Kaiser may request additional documentation.
Common Denials
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-29 | Timely filing exceeded | Claim filed after regional deadline | Check your Kaiser region's specific deadline |
| CO-15 | Workers comp exclusion | Service is work-related | Verify injury is not work-related before billing Kaiser |
| CO-50 | Non-covered service | Service outside Kaiser benefits | Verify coverage and obtain auth before service |
Appeals
Appeal denied claims within 180 days of the denial date. Submit to the Kaiser regional appeals department. Include the denial notice, clinical documentation, and a letter explaining why the claim should be paid. Response time: 30 calendar days.
FAQ
How do I submit claims to Kaiser as an out-of-network provider?
Submit electronic claims through Availity or mail paper claims to the Kaiser regional claims address listed on the member's ID card. Include the member's MRN and the referral or authorization number if applicable.
What is Kaiser's timely filing deadline?
It varies by region. Northern California: 180 days. Southern California: 90 days for non-emergency. Check with the specific Kaiser regional entity for exact deadlines.
Does Kaiser accept claims from emergency providers?
Yes. Emergency services do not require prior authorization under federal law. Submit claims within 90 days of the emergency service date with supporting clinical documentation.
Prevent These Denials
Altair identifies the correct Kaiser region and filing deadline for every member automatically.