ISSUE 3 | 2011
Produced by Kaiser Foundation Health Plan of Ohio
Please be advised that the primary care physician
name and phone number will be eliminated from all
identification cards issued to Kaiser Permanente Members
on or after October 15, 2011. Eligibility, benefits, and
primary care physician selection are best verified either
online or by calling the Customer Relations department.
As indicated in your Kaiser Permanente Provider Manual,
the responsibility for verifying a Member’s eligibility rests
with your office; otherwise, you provide services at
your own financial risk. Each time a Member presents
at your office for services, the Member’s current eligibility
status must be verified. Do not assume that coverage
is in effect because a person has a Kaiser Permanente
Member identification (ID) card. Check a form of photo
identification to verify the identity of the Member.
To confirm a Member’s current primary care physician
(PCP) or to verify eligibility and covered benefits in
advance of a scheduled appointment, choose one of the
options on the next page.
(continued on page 2)
Telephone Encounters Pose a Risk
for HIPAA Privacy Violations! . . . . . . . . . . . . . . . . . . . . . . . 2
CPP News and Announcements. . . . . . . . . . . . . . . . . . . . . 3
Members Rights and Responsibilities . . . . . . . . . . . . . . . . 4
Kaiser Permanente Signature Plans . . . . . . . . . . . . . . . . . . 6
Lower Member Prices on Certain
Generic Drugs in 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Epocrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Drug Formulary Available Online
Through Lexi-Comp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
The Importance of Advance Care Directives . . . . . . . . . 9
Complex Case Management Program . . . . . . . . . . . . . 10
Practitioner and Provider Credentialing and
Recredentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Kaiser Permanente Ohio’s Policy on
Financial Incentives and Utilization Management . . . . . 12
Referrals Management and Clinical Review Updates . . . . . 13
Medical Records –Safe, Secure and Well-Maintained . . . . . 14
Medical Appropriateness Criteria . . . . . . . . . . . . . . . . . 16
2011 Christmas and New Year’s Holiday Schedule . . . . 17
On the Web with Kaiser Permanente . . . . . . . . . . . . . . . 17
Claims Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Updates were made to the following clinical guidelines
since July 12, 2011: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Important Changes Regarding Kaiser Permanente Member ID Cards
(continued from page 1)
authorization and the Member insists on being treated,
you must inform the Member upon registration that he/she
will have 100% financial responsibility for the service. The
Member should sign an acknowledgement to document
his/her understanding of financial responsibility. If a Kaiser
Permanente Member is not properly informed of his/her
financial responsibility, per your Kaiser Health Care Services
Agreement, the Member is to be held harmless and you
cannot bill him/her for the services provided.
Customer Relations Department:
1-800-441-9742, option 1, Monday through
Thursday, 8:15 a.m. to 5 p.m., or Friday, 9 a.m.
to 5 p.m. Provide the Member’s name and
Medical Record Number (MRN).
KP Online-Affiliate: Member eligibility, PCP
selection, and information regarding covered
services are available online via KP OnlineAffiliate at There
is no charge for this service.
Eligibility and benefits information is available on
websites such as or
If you have any questions, or you are interested in obtaining
a user ID for KP Online-Affiliate, please contact your
Network Associate or the Customer Relations department
at 1-800-441-9742, option 1.
Thank you for the care and service you provide to
Kaiser Permanente members. Your compliance with Kaiser
Permanente plan policies and procedures is appreciated.
If at the time of service you are not the Member’s PCP
of record or you are unable to confirm eligibility or verify
Communicating by telephone is a great way to keep
in touch with our members/patients and helps support
Kaiser Permanente’s vision in delivering clinically superior
care, promoting the health of the communities we serve,
recognizing the uniqueness of each member/patient,
earning loyalty through personalized care and service, and
inviting dialog and involvement, ensuring that we share in
making decisions and taking action. But remember that
telephone conversations with members/patients must
be held to the same protections of protected health
information (PHI) as is done with in-person encounters.
Meaning the clinician should be sure to minimize the
potential risk of a Health Insurance Portability and
Accountability Act (HIPAA) privacy violation by closing the
door to the office or exam room from which the clinician
is calling the member/patient. Also, remember that others
not involved in the care should not be in the office or exam
room with the clinician during these telephone encounters.
MRN, and address. Dr. Smith then begins discussing her
condition, diagnosis, status, and medications. During
the course of the conversation, Dr. Smith may address
the member by her name a couple times (i.e., “So, Mrs.
Member” and “Yes, Betty”). Meanwhile the door to the
office is open and workforce individuals and/or other
members/patients are passing by the opened door on
their way to the restroom or to another room. Also, Nancy
Nurse is in the room during the telephone conversation
using the copier for an unrelated project. As you may
have determined, this situation leaves the potential for
overheard PHI by individuals who are not involved in the
care (which may be a minimum necessary HIPAA violation).
Please be sure to Do the Right Thing and protect PHI
during your telephone encounters.
For more information on protecting PHI and telephone
encounters, contact Yvonne Wolters, CLA, CHPC, Privacy
& Security Officer, at [email protected] or 216-4795261 or Stephen Camper, JD, CIPP, Regional Compliance
Officer, at [email protected] or 216-479-5085.
For example, Dr. Smith calls Mrs. Betty Member to
discuss her health concerns and treatment. During the
conversation, Dr. Smith validates the member by her name,
ISSUE 3 | 2011
Effective November 11, 2011, the following significant
changes have been made to the Ohio Provider Manual,
Section Four, posted on the Community Providers
Section 4.2: Concurrent Review Process:
• Failure to provide clinical information for Authorized
days/Services by the next assigned review date can
result in a denial of all days/Services beyond the initial
Authorization period.
Section 4.7.1: Precertification of Emergency
• Plan Facilities are responsible for calling the
Kaiser Permanente Precertification Line for all
inpatient Emergency admissions at 1-866-433-1333.
Precertification of Emergency admissions is expected
prior to admission for Kaiser Permanente HMO,
Added Choice® Point of Service (POS) and Out-of-Area
(PPO) Members. After emergency evaluation and
stabilization of the patient, failure to call and secure
authorization prior to admission can result in denial
of payment of the admission.
The Network Development and Performance
Department is pleased to announce that the Ohio
Provider Manual, posted at the Community Provider
Portal (, will be updated on a regular
basis with notification of changes found in the News and
Announcement portion of the Provider Connection. If
any revisions constitute a change to your agreement with
Kaiser Permanente, written notification will be sent in to
your office 90 days in advance of the change.
• For Kaiser Permanente Medicare Plus Members,
notification is requested as soon as possible, but no
later than 48 hours after admission.
We encourage plan providers to check the website on a
regular basis to view any updates regarding plan policies
and procedures, current provider directories, drug
formularies, clinical guidelines, and Auto Pay and Auto
Authorization Lists. If you have any questions regarding
the information posted on the website, contact your
Network Associate.
Section 4.7.4: Ambulance Transfers:
• For Kaiser Permanente HMO, Added Choice® Point
of Service (POS) and Out-of-Area (PPO) Members,
all non-emergent ambulance transfers from facility to
facility must be precertified. In addition, all ambulance
transfers of stable patients, even if the patients have
received emergency services, are to be arranged
through the Emergency Case Management HUB at
1-866-433-1333 (toll free), option 2.
The following updates and changes have been made to
the Ohio Provider Manual:
• The Provider Line is merged with the Customer
Relations department telephone lines.
• For Kaiser Permanente Medicare Plus Members,
notification is requested.
• The telephone number for routine provider inquiries is
1-800-441-9742, option 1.
• All ambulance transfers, including air ambulance, will
be reviewed against Centers for Medicare and Medicaid
Services (CMS) ambulance criteria as described in the
Medicare Benefit Policy Manual.
• Referrals are no longer required for Kaiser Permanente
Medicare Plus Members, as announced in a mailing
sent to all plan providers on July 1, 2011.
Updated appendices were posted on September 28, 2011.
• The new fax number for the Kaiser Permanente Home
Health Care department is 216-778-6073.
We are your partner in health care. We count on your participation in treatment and
your willingness to communicate with Kaiser Permanente’s health care professionals.
Working with you, we will ensure you receive appropriate and effective health care. If
you are an adult member, you can exercise these rights yourself. If you are a minor, or
if you become incapable of making decisions about your health care, these rights will
be exercised by the person having legal responsibility for participating in decisions
concerning your medical care.
• Receive information about Kaiser Permanente, its
services, the practitioners and providers who provide
your health care, and your rights and responsibilities as
a Kaiser Permanente member.
• Be assured of privacy and confidentiality. You have
the right to be treated with respect and recognition of
your dignity and need for privacy. Kaiser Permanente
will not release your medical information without your
authorization, except as required or permitted by law.
You have the right to review and receive copies of your
medical records, unless the law restricts our ability to
make them available.
• Participate with practitioners in your health care
and receive the medical information you need to
make health care decisions. We will try to make this
information as understandable as possible. You have the
right to have ethical issues that arise in connection with
your health care reviewed. You have the right to accept or
refuse a recommended treatment. Emergencies or other
circumstances occasionally may limit your participation
in a treatment decision. In general, however, you will
not receive any medical treatment before you or your
legal representative give consent. You are entitled to an
interpreter if you need one.
• Have a candid discussion of appropriate or medically
necessary treatment options for your condition,
regardless of cost or benefit coverage.
• Use customer satisfaction resources. We welcome
your questions and comments about Kaiser Permanente,
our services, the practitioners and other health care
professionals providing your care, and your rights and
responsibilities. You have the right to voice complaints
or file appeals without concern that your care will
be affected. You have the right to know about the
complaints, grievances, and appeals procedures. In order
to assist you, the Customer Relations staff is available to
answer your questions and resolve problems.
• Make recommendations regarding Kaiser Permanente’s
members’ rights and responsibilities policies.
• Express your wishes concerning future care in an
advance directive. You have the right to choose a person
to make medical decisions for you if you are unable to do so.
Your choices regarding your future care may be expressed
in such documents as a durable power of attorney for health
care or a living will. You should inform your family and
practitioner of your wishes and give them any documents
that describe your choices regarding future health care.
• Have impartial access to medically indicated treatment
that is a covered benefit regardless of your race,
religion, gender, sexual orientation, national origin,
cultural background, disability, or financial status. You
have the right to access emergency health care services for
conditions of sufficient severity that a prudent layperson
could expect the absence of immediate medical attention
to result in serious jeopardy to your health or serious
impairment or dysfunction of bodily functions.
(continued on page 5)
ISSUE 3 | 2011
Members Rights and Responsibilities
(continued from page 4)
• Have a safe, secure, clean, and accessible health care
• Understand your health problems and participate in
developing mutually agreed-upon treatment goals, to
the degree possible.
• Participate in physician selection. You have the right to
select a physician with an open practice as your primary care
practitioner and to change your primary care practitioner at a
future date. You have the right to a second opinion by a Kaiser
Permanente practitioner. You have the right to consult with a
non–Kaiser Permanente practitioner at your own expense.
• Know the extent and limitations of your health care
benefits. An explanation of these is contained in your
Evidence of Coverage.
• Identify yourself with your member ID card. You are
responsible for your membership card, for using it only
as appropriate, and for ensuring that other people do not
use your card.
• Receive relevant information and education that helps
ensure your safety in the course of treatment.
• Receive information about the outcomes of care you
have received, including unanticipated outcomes.
• Keep scheduled appointments or cancel, in a timely
manner, any appointments you are unable to keep. You
are responsible for promptly canceling any appointment
that you don’t need or cannot keep.
• Make complaints and receive a summary of information
on the appeals and grievances other members have
filed in the past.
• Provide accurate and complete information regarding
your current address, your eligibility status, the eligibility
status of your dependents, and coverage or payments for
health services available to you from other sources.
• Have prescriptions refilled within a reasonable period
of time.
• Receive information about drug coverage and costs.
• Recognize the effect of your lifestyle on your health.
Your health depends not just on care provided by Kaiser
Permanente, but also on the decisions you make in your
daily life.
• Provide accurate and complete information about
your present and past medical conditions (to the extent
possible) that the organization and its practitioners and
providers need in order to provide care. You should report
unexpected changes in your condition to your practitioner.
• Be considerate of others. You should respect other
people and their property, as well as the people and
property of Kaiser Permanente.
• Fulfill financial obligations. You should pay on time any
money you owe Kaiser Permanente.
• Follow the treatment plan to which you and your
health care practitioner agree. You should inform
your practitioner if you do not clearly understand your
treatment plan and what is expected of you. If you
believe you cannot follow through with your treatment,
you are responsible for telling your practitioner.
For more detailed information, please refer to your Evidence
of Coverage.
Kaiser Permanente of Ohio introduced two new health benefit plans: “Signature HMO” and “Signature POS.” In these plans,
Members receive their primary care services from Ohio Permanente Medical Group (OPMG) physicians at Kaiser Permanente
medical offices. These Signature plans are OPMG-based and do not include primary care physicians (PCPs) from external
physician or hospital groups, which differs from our Traditional HMO and Tier 1 Added Choice POS plans.
- Tier 2 - In this level, Kaiser Permanente has partnered
with Emerald Health Network (renamed in May 2011 as
HealthSmart Preferred Network) for care needed inside
Ohio, plus the Private Health Care Services (PHCS)
network for care needed outside of Ohio.
- Tier 3 – This level lets Members receive care from any
licensed provider in the United States who doesn’t
belong to either Tier 1 or Tier 2.
Additional Information regarding Signature plans:
• Members in a Signature plan follow all the same rules and
referral patterns for specialty care and precertification as
Members in other like plans. The Signature plan Member’s
PCP will coordinate all specialty care when necessary with
OPMG or contracted community specialists.
• The services for which Signature Members do NOT need
a referral remain the same:
- Behavioral Health
• If an existing HMO Member currently has a contracted
(non-OPMG) PCP and his/her employer chooses a
Signature HMO plan going forward, the Member will need
to switch to an OPMG PCP.
• Just as in the Traditional HMO plan, Signature HMO and
Signature Tier 1 Added Choice Members can self-refer
to non-OPMG contracted network specialists for these
services. These self-referral specialists are listed in the
Signature provider directory.
• Signature POS Members will need to select an OPMG
PCP in order to access their benefits at the Tier 1 Level.
Signature POS Members may still see non-OPMG PCPs
under their Tier 2 or Tier 3 benefits.
• The Signature Point-of-Service (POS) plan gives Members
access to three tiers (levels) of coverage, just like the
Traditional Added Choice POS plan, except that they must
utilize an OPMG PCP when accessing Tier 1 benefits.
- Tier 1 - Essentially our Signature HMO Plan featuring
OPMG physicians.
If you have any questions regarding what plan a Member
belongs to, please call 1-800-441-9742, Option 1 to
verify Member benefits or log in to KP Online-Affiliate at and click Sign On.
ISSUE 3 | 2011
Please note that Kaiser Permanente Pharmacies are again
offering lower prices on certain generic drugs in 2012.
These new reduced prices are a dollar lower than the
reduced prices of 2011. The generic medications included
treat chronic conditions such as asthma, hypertension, high
cholesterol, diabetes, and depression.
Medicare 2012 Part D Plan Structure
Tier 1: Preferred Generics Drugs
(Similar to our Discounted Generic List)
Tier 2: Generic Drugs
Tier 3: Preferred Brand Drugs
Tier 4: Non-Preferred Brand Drugs
Tier 5: Specialty Drugs
The following reduced Member rates are in effect January
1 through December 31, 2012:
• $7 for 30-day supply
• $9 for 60-day supply
• $11 for 90-day supply
Researchers from the University of California, Los Angeles,
and Kaiser Permanente’s Division of Research in Oakland,
CA, found that patients with diabetes, high blood pressure,
or high cholesterol who ordered their medications by mail
were more likely to take them as prescribed by their doctors
than did patients who obtained them from a local pharmacy.
The study, “Mail-Order Pharmacy Use and Adherence to
Diabetes-Related Medications,” is published online in the
American Journal of Managed Care (
As always, when Members refill a prescription at a Kaiser
Permanente Pharmacy, they will pay the lowest price
available, whether it is their standard copayment or the
new generic price. To see a list of medications covered
under this program or for more information, please see
the “Pharmacy” section of or contact
your Kaiser Permanente Pharmacy.
Using mail order can also save Members time and money.
Depending on the Member’s direct mail prescription drug
benefit, a two-month supply of maintenance medications
may be purchased for one copayment (some benefit
plans offer up to a three-month supply for one or two
copayments). There is no need to drive to a pharmacy or
wait in line, and shipping is free.
Kaiser Permanente is restructuring our Medicare plan
in 2012. Nearly all FDA-approved medications will be
available to Medicare Members, but at a different cost share.
Medications excluded by CMS, like benzodiazepines, will
continue being not covered.
When possible, please encourage your Kaiser Permanente
patients to use our Direct Mail Pharmacy. Please be sure
to write the prescription for a 90-day supply, preferably
with refills. For more information about the Direct Mail
Pharmacy program, please see the “Pharmacy” section of or call our provider line for the Direct
Mail Pharmacy at 216-676-6099.
Medicare 2011 Part D Plan Structure
Tier 1: Formulary Generic Drugs
Tier 2: Formulary Brand Drugs
Tier 3: Specialty Drugs
Due to extremely low utilization, the Kaiser Permanente of Ohio drug formularies will no longer be available on Epocrates
beginning October 1, 2011. Formularies are available to view and print online at
Online access to the Kaiser Permanente Online Drug Formulary is available through Lexi-Comp Online™.
The Online Drug Formulary can be accessed at At the login screen, type the login and password:
Instructions for how to use the Online Drug Formulary search engine for easy formulary information retrieval is below.
Please note the Online Drug Formulary is not intended for use by Members. Members may access the Member Formulary
online at
The Online Drug Formulary is updated frequently to reflect monthly formulary changes made by the Kaiser Permanente Regional
Pharmacy and Therapeutics Committee. Formulary changes are also published in the Drug Therapy Advisory monthly newsletter.
For instructions to access the Online Drug Formulary using a PDA or for questions regarding the Online Drug Formulary,
contact the Formulary Management Services by e-mail at [email protected] or phone 216-265-4410.
Thank You,
Kaiser Permanente Ohio
Clinical Pharmacy Services
Step 1:
In the top left search frame, type a brand or generic drug name in the “Search for:” box, using the
default “Within:” subcategory “Name” from the dropdown menu. Click on the SEARCH button or hit
Enter on your keyboard.
Step 2:
The “Search Results” frame will display results of the search. A drug monograph only appears in the
Kaiser Permanente Ohio Region database if at least one dosage form of the drug is formulary.
The database monographs contain specific Kaiser Permanente Ohio information such as formulary
dosage forms, formulary restrictions, guidelines, and related information links. To review the formulary
status of the drug, click directly on the drug name listed under “Kaiser Permanente Ohio Region”
database and review the information in the respective “Dosage Forms Covered” fields within the
drug monograph that opens in the right side frame. For many nonformulary drugs, preferred formulary
agents may be listed instead with “Substituted with” in green text after the drug name searched.
The INDEXES button in the top left search frame may also be used to search the Kaiser Permanente Ohio
Region database. This will allow you to:
- View a list of drugs starting with a selected letter by Generic Name or U.S. Brand Name
- View a list of Charts/Special Topics or “Freetext Sections” available
- View all changes made in the past 7 and 30 days or new documents created in the last 90 days
- View a list of drugs in a specific Pharmacology/Therapeutic Category
ISSUE 3 | 2011
An advance health care directive is instructions given by
individuals that specify what actions should be taken in
the event that they are no longer able to make health
care decisions due to illness or incapacity, and appoints a
person to make such decisions on their behalf.
Kaiser Permanente sets forth an expectation that our
organization will ensure compliance with the requirements
of federal and state laws (whether statutory or recognized
by the Ohio courts) and regulatory agencies regarding
advance directives. This includes a patient’s right to accept
or refuse medical or surgical treatment and the right to
formulate advance directives.
Advance directives can include a living will or health care
power of attorney, as well as a do-not-resuscitate order and
an organ donation request.
What is Kaiser Permanente Expectation from
HealthCare Providers Related to Advance Directives?
HealthCare Providers should:
• Ask Kaiser Permanente members if they have advance
• If they do not have an advance directive, ask them if they
would like more information about them
• If they have advance directives, let them know that Kaiser
Permanente can place their information in their electronic
medical record
It is important for anyone over age 18 to think about
filling out one or more of these documents. Serious illness
or injury can strike at any stage of life. A living will or
health care power of attorney will help to ensure that an
individual’s wishes regarding life-sustaining treatment are
followed regardless of a person’s age, and that, when they
are no longer able to voice their own wishes, their prior
decisions are followed or made for them by the person
they choose.
Where Can Kaiser Permanente Members Obtain
Advance Directive Information?
• To learn more about Advance Directive documents
and how to use them, visit, to
download an advance directives packet;
What is a Living Will?
A living will becomes effective when an individual is
terminally ill and unable to express his/her wishes regarding
health care or when he/she is permanently unconscious. In
both cases, two physicians must agree that the individual is
beyond medical help and will not recover. If an individual has
indicated he/she does not want his/her life to be artificially
prolonged and two physicians say there is no reasonable
hope of recovery, his/her wishes will be so honored.
• Request an advance directive kit by calling 216-479-5077;
What is a Health Care Power of Attorney?
A health care power of attorney (or durable power of
attorney for health care) becomes effective whenever an
individual loses the ability to make his/her own health care
decisions, even if only temporary. At these times, health
care decisions will be made by the person designated by
the individual.
• Call Customer Relations, Monday through Thursday,
8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. at
216-621-7100 or 1-800-686-7100, or 216-635-4444 or
1-877-676-6677 TTY/TDD. Medicare members can call
seven days a week, 8 a.m. to 8 p.m. at 1-800-493-6004 or
1-866-513-9966 TTY/TDD.
Why Should You Encourage Our Kaiser Permanente
Members to Create Advance Care Directives?
In 1991, the State of Ohio recognized an individual’s right
to have a voice in their health care decisions by allowing
individuals to create a living will. In addition to Ohio law,
Medicare regulations and NCQA standards all require
health care organizations to provide their members with
information about advance directives.
How Can a Kaiser Permanente Member confirm if an
Advance Directive is in his/her Kaiser Permanente
Medical Record?
• Contact the Medical Correspondence department at: 216-749-8448 or 1-866-749-8448.
The Kaiser Permanente Complex Case Management (CCM) program will commence on or before
November 1, 2011, and will consist of focused, high intensity case management and care coordination
services to positively affect the health outcomes of vulnerable, at risk, and high utilization Member
populations through the use of clinical systems, streamlined, evidence-based care pathways, and
processes. The CCM program is designed to ensure that Members at high risk for hospital re-admissions
due to catastrophic events or select chronic conditions receive evidence-based comprehensive
assessments, detailed care plans, and post-hospitalization follow-up. The goal is to quickly reconnect
Members with primary, specialty, and/or population management teams. This collaborative program
integrates catastrophic case management, resource stewardship (utilization management), and chronic
care coordination for service areas within Kaiser Permanente.
The CCM program is staffed by Registered Nurses and Licensed Independent Social Workers that
provide both admission and post-hospital discharge case management/coordination. Case managers
(from the catastrophic case management team) continuously evaluate the quality of care provided
as well as outcomes of treatments and services during and immediately following acute admission
as Members and their families require focused management and support. Case managers (from
the chronic care coordination team) provide post-hospital discharge care to Members with newly
diagnosed or complex Heart Failure or HIV diagnosis to facilitate transitions and ensure Members
are able to self-manage conditions. Both teams work together to ensure Members are successfully
supported as they move across the care continuum. As additional resources to support the CCM
program become available, the overall goal of the program will be to expand criteria to include other
conditions that utilize the top 1% of all resources.
• Assist Members in regaining an optimal health status;
• Decrease inpatient re-admission rates;
• Improved functional status of chronic conditions;
• Decrease emergency department and clinical decision
unit admissions; and
• Proactively identify and attain Members for the CCM
• Promote Member satisfaction across Kaiser Permanente.
• Develop effective case management care plans that
match the Members’ health needs with timely, evidencebased care and services;
Identifying Members for Complex Case Management
• Promote improved quality of life in a cost-effective
• Members with complex chronic illnesses;
• Provide timely access to services; and
• Members who experience catastrophic health episodes;
• Provide case managers tools to positively impact the
target population.
• Members who require intense interaction with the health
care system; and
Target populations that require complex case management
fall into one of the following groups:
• Members with multiple co-morbidities;
(continued on page 11)
ISSUE 3 | 2011
Kaiser Permanente Ohio Complex Case Management Programs
(continued from page 10)
• Members predicted to have high costs associated with
their care.
people who have a complex medical condition or a newly
diagnosed medical problem such as Heart Failure or HIV
or a health condition that has required multiple hospital or
emergency department admissions.
Specific Member populations that will benefit from CCM
include Members stratified as high risk in one or more of
the following populations:
Kaiser Permanente case managers are highly experienced
registered nurses and licensed social workers who will help
you access care and coordinate the services you need to
achieve wellness. They will work closely with you to make
certain you know how to best care for yourself. In addition,
they will monitor your care and make recommendations
and/or referrals, as needed.
• HF with qualifiers
• HIV with qualifiers
• Post solid organ transplant
• End Stage Renal Disease/Dialysis
• Late stage COPD
• Late stage cancers
To see if you meet the criteria for case management
services, call the Kaiser Permanente self-referral phone line
at 888-953-5794.
• Asthma
• Multiple trauma due to motor vehicle accident or
significant burn injury
• When you call, you will be prompted to leave a message
with your name, phone number, Kaiser Permanente
medical record number, and the main reason why you
would like to have your own case manager.
• Traumatic spine injuries
• Traumatic brain injuries
• High risk pregnancy
• Within three business days, you will be contacted by a
member of the Case Management team who will speak
with you, or your caregiver, about your past medical
history, your current medical condition, where you live,
and your family/social support system.
• Complex wounds requiring specialized care
• NICU babies with anticipated prolonged length of stay
• Members in
• If you meet the criteria for case management, you will
be assigned a case manager. You can choose not to
participate in, or opt to discontinue case management
services at any time.
• Cerebrovascular accident with extensive functional deficit
• Long term ventilator management
• Advanced illness planning: pilot program Advanced
Illness Coordinated Care Program
• If you do not qualify for case management or choose not
to participate, Kaiser Permanente’s case managers can
discuss other ways to manage your care.
• Geriatric Consultation Clinic referrals
Kaiser Permanente Ohio Members can request a case
manager to help you or your caregiver coordinate your
health care. Case management services are designed for
Case management services are one more way that we at
Kaiser Permanente are helping our Members to Thrive.
To ensure the quality of physicians and allied health practitioners
who treat Kaiser Permanente members, Ohio Permanente
Medical Group (OPMG) and Kaiser Foundation Health Plan of
Ohio (KFHPO) directly credentials or provides oversight of the
credentialing function via a credentialing delegation agreement
for all their contracted practitioners and organizational providers.
OPMG and KFHPO are authorized to and responsible for
establishing and maintaining a consistent and systematic
process for the credentialing and recredentialing of all
practitioners who provide care to members. The credentialing
policies and procedures are established, monitored, and
maintained by the Regional Credentialing department and
the Credentials Committee, which regularly convenes to
review and make decisions regarding the credentialing and
recredentialing of OPMG practitioners, contracted network
practitioners, and organizational providers. All practitioners
and providers must be fully credentialed and “approved to
participate” before treating Kaiser Permanente members
in an outpatient setting and billing for services. This
includes all physicians and allied health practitioners, such
as PA-Cs, NPs, LISWs, CNMs, PhDs, ODs, DCs, etc.
KFHPO is a member of the Council for Affordable Quality
Healthcare (CAQH), and utilizes the CAQH Universal
Credentialing Datasource application form and supporting
documentation to credential and recredential all practitioners.
Initial credentialing requires a completed CAQH application
and primary source verification of licensure, hospital privileges,
DEA, NPI, education and training, board certification, proof of
professional malpractice coverage, and review of professional
liability claims history. Applicants must provide information
concerning their physical and mental health, and applications
are reviewed for complete work history. Additional verifications
include a query of the National Practitioner Data Bank/
Healthcare Integrity and Protection Data Bank and a query for
Medicare/Medicaid sanctions.
Initial appointments are granted for a two-year period.
Practitioners are subsequently considered for recredentialing
every two years. The recredentialing process requires a
completed CAQH application, and primary source verifications
are performed in the same manner as described above for
initial credentialing.
If you have any questions regarding credentialing of
practitioners, please contact the Kaiser Permanente
Credentialing Department at 216-479-5541 or via e-mail at
[email protected]
Kaiser Permanente Ohio supports quality health care
performance. However, we do not offer financial incentives
to our providers based upon utilization of services or care
management decisions.
do not encourage decisions that result in underutilization.
Kaiser Permanente Ohio’s Medical Management
Department has a formal policy in place assuring that no
incentive or additional compensation is offered directly
to physicians or other individuals conducting utilization
management activities in return for denial of care. This
ensures that our medical management processes are not
used as a barrier to health care and medical services. This
policy applies to all Medical Management Department
nurses and physicians involved in the Utilization
Management decision-making process.
Kaiser Permanente Ohio adheres to the following standards in
accordance with the National Committee for Quality Assurance:• Utilization Management decision-making is based only on
appropriateness of care and service and existence of coverage.
• The organization does not specifically reward practitioners or
other individuals for issuing denials of coverage or service care.
• Financial incentives for Utilization Management decision makers
ISSUE 3 | 2011
The Kaiser Permanente Ohio Referrals Management and
Clinical Review department coordinates and processes
all practitioner referrals and provider requests for
precertification and authorization of medical services. One
of the department’s goals is to keep you, the provider,
informed of the latest updates and enhance communication
between your practice and Kaiser Permanente.
information to expedite the process. Incomplete information
will require additional communication with your office to
clarify the request in accordance with the Sarbanes-Oxley
mandate and will delay the referral process. Please obtain
authorization prior to rendering the services to ensure
prompt consideration of claims.
*To determine if a service requires pre-certification, please reference the
Kaiser Permanente Pre-certification and Mandatory Authorization Quick
Reference Guide. The guide can be found on our Community Provider
Website at, under the Authorizations tab.
Kaiser Permanente Ohio’s Medical Management Program
ensures that:
• Utilization management decision making is based on
medical appropriateness of care and service. The Kaiser
Permanente organization does not offer compensation
to physicians or other individuals conducting utilization
review for denials of coverage or service.
• Kaiser Permanente uses nationally accepted evidencebased clinical criteria for appropriate resource stewardship
in its medical decision making. Please see the Medical
Appropriateness Criteria table on page 16 for the most
recent list of sources.
When ordering DME for our members, send requests to the
Kaiser Permanente DME department for initial processing.
Please do not send requests to the vendor first, unless it is
an urgent need or an oxygen/nebulizer request. This will
assist in our verification of benefits and coverage criteria
prior to the item being issued. Please fax DME requests to
To pre-certify an admission/surgery: 1-866-433-1333
To contact a referral specialist: 216-529-5500 or
When submitting a request for any services requiring
pre-certification, please include pertinent and complete
Keeping patient identifiable information confidential, private, and secure is essential to preserving patient trust, providing quality
health care, and complying with federal and state regulations. Be sure to access medical records only when it is essential to your
job and to keep all electronic devices — including laptops and personal digital assistants (PDAs) — password protected and secure.
The trust patients place in us to take care of them depends in large part on how we protect the confidentiality, privacy,
and security of their health information. Much of the information we collect from patients — including medical condition,
history, medications, and family illnesses — is very sensitive and protected under federal and State privacy and security
laws. It is everyone’s obligation to follow the requirements of the Health Insurance Portability and Accountability Act
(HIPAA) and other laws, as well as to follow established policies regarding patient information.
It is imperative that we abide by all administrative, technical,
and physical safeguards designed to protect patients and
their health information. These safeguards include:
that protects the safety and security of the records and the
confidentiality of information. Only authorized personnel
will have access to medical records.
• Accessing medical records or discussing patient
information only when it is specifically required for your
job to provide patient care or comply with the law.
• Following building protocols, such as keeping doors
locked and using ID badges for sensitive areas.
Medical records will be retained at least for the time period
required by state and federal law.
In addition, medical records should be maintained and
stored in a manner that protects the safety and security of
the records and the confidentiality of information. Only
authorized personnel should have access to medical records.
The medical record will not be altered except to
appropriately add or amend data. Original information
must be legible. Superseded or historical versions of
electronic data will be maintained.
The medical record standards below apply to patient medical
records - both paper and electronic - maintained by Kaiser
Foundation Health Plan of Ohio, the Ohio Permanente Medical
Group (OPMG), and contracted Plan Providers. The intent of
these standards is to promote timely, detailed and organized
medical record-keeping. These standards are designed to
permit effective confidential patient care, quality review,
and coding and billing in compliance with regulatory and
accreditation requirements. Updates or changes to medical
records standards will be posted on the Kaiser Permanente
Community Providers website at
Entries into the medical record must:
Every Kaiser Permanente member is assigned a unique medical
record number (MRN) that is generated at the time of enrollment
or when the member first requests or receives services.
Medical records should contain the following information:
• Demographic/Personal Information:
- Medical record number
- Patient name
- Current address
- Home telephone number
- Work telephone number, when applicable
- Date of birth or age
Non-member patients will be assigned a unique medical
record number when they first request or receive services
at a Kaiser Permanente facility.
Medical records will be maintained and stored in a manner
The medical record will be available for all medical office visits,
whether scheduled in advance or on the same day of service.
• Be in permanent ink when made on paper.
• Be dated with the time indicated when appropriate.
• Contain the legible identification of the provider,
including name and credential/certification.
• Be authenticated by the author, which may be a
handwritten or electronic signature.
• Have the patient’s name, medical record number, or
other identification on each page.
• Be legible to someone other than the author.
• Be complete, accurate, and timely.
(continued on page 15)
ISSUE 3 | 2011
Medical Records – Safe, Secure and Well-Maintained
(continued from page 14)
- Name and telephone number of person to notify in
case of an emergency
- Primary Care Physician name
- Information regarding the patient’s advance directives
• General Clinical Information:
- Allergies and adverse reactions, or noted as “none” or
“no known allergies.”
- Past medical history (for patients seen 3 times or more),
including serious accidents, operations and illnesses.
For children and adolescents (age 18 and younger), past
medical history includes significant events in prenatal
care, birth, operations, and childhood illnesses.
- Personal habits, such as sexual behavior, smoking, and
history of alcohol use and substance abuse for patients
age 14 and older who have been seen 3 times or more.
- Preventive screening and services offered to the patient
in accordance with Kaiser Permanente Preventive Care
and Clinical Practice Guidelines.
- An up-to-date immunization record for children (age 18
and younger), or an appropriate history for adults.
- Problem list indicating significant illnesses and medical
- Current medications.
• Progress Notes:
- Patient’s chief complaint or reason for visit.
-Appropriate subjective and objective information
pertinent to the patient’s presenting complaints or
purpose for visit.
- Laboratory and other studies ordered as appropriate.
- Working diagnoses consistent with findings.
- Treatment plan consistent with diagnoses.
- Follow-up instructions and timeframe for follow-up or
the next visit. The specific time of return is noted in
weeks, months, or as needed.
- Unresolved problems from previous visits are addressed
in subsequent visit notes.
- Evidence of medically appropriate care.
-When a patient does not present for a scheduled
appointment, it should be clearly indicated in the medical
record, with efforts to contact the patient documented.
• Messages:
- An entry shall be made in the medical record of communication
relating to patient care, including, but not limited to:
 Any medical advice that is given;
 Any new illness or change in health status; and
Test results or requests to return for additional
testing procedures.
• Continuity of Care:
- Documentation of all services provided directly by the
primary care physician.
- Evidence of appropriate use of consultants, as applicable.
-Evidence of continuity and coordination of care
between primary care and specialty practitioners. If
a consultation is requested, there is a note from the
consultant in the medical record.
- Results of ancillary services and diagnostic tests ordered
by a practitioner.
- All diagnostic and therapeutic services for which the
patient was referred by a practitioner, such as home
health reports, specialty physician reports, hospital
discharge reports, physical therapy reports, etc.
-Consultant summaries and laboratory and imaging
study results filed in the medical record reflect Primary
Care/Ordering Physician review.
-Consultation and abnormal laboratory and imaging
study results have an explicit notation in the record of
any follow-up plans.
Medical record site reviews may be completed on all
prospective Primary Care Physician, Ob/Gyn, and Behavioral
Health offices prior to consideration by the Kaiser Permanente
Credentials Committee. If an existing practitioner relocates,
adds an additional practice location, or adds on to an existing
office, a medical record site review may be completed by
Kaiser Permanente within 30 days of the relocation/opening
of the new office. In addition, a random medical record site
review of any plan provider’s office may be conducted at the
request of the Kaiser Permanente Associate Medical Director,
Quality, Clinical Performance Improvement and Research,
the Kaiser Permanente Credentials Committee, or the
Performance Improvement and Patient Safety Department.
Each element scored on a site visit and evaluation tool is worth
one point. The site visit and evaluation tool can be found in
Section of your Kaiser Permanente Provider Manual. Quality
clearance is given to all offices which score 90 percent or higher.
Conditional quality clearance is given to offices with a score of 80
– 89 percent and they will be required to comply with a corrective
action plan within 30 days of receiving the written request.
Any office which scores less than 80 percent will be pending
quality clearance until the office complies with the corrective
action plan within 30 days of the request and a follow-up site
visit is conducted. Follow-up visits for any purpose will occur
within 6 months of the original site visit and will continue at
least every 6 months until deficiencies are corrected.
All services authorized by the Medical Management department at Kaiser Permanente Ohio will be evaluated to determine
medical appropriateness based on the following evidence-based criteria and guidelines:
• InterQual Intensity of Service/Severity of Illness
(ISD) Acute Criteria (Adults and Pediatrics)
Hospitals/Acute Care Coordination
(Med, Surg & BHS)
• Pre-admissions Screening
• Continued Stay Reviews
• Discharge Planning
• Denial for Continuation of Care
• Milliman USA Optimal Recovery and Ambulatory
Care Guidelines
Outpatient Care Coordination
• Surgical Procedures/Treatments
Inpatient Care Coordination
• Length of Stay Efficiency (Benchmark) – Med/Surg & BHS
• Clinical Pathways: (e.g., CHF, COPD, and Community
Acquired Pneumonia)
• Kaiser Permanente Clinicians’ Clinical and
Preventive Guidelines:
- Bariatrics
- Mammoplasty
Outpatient Care Coordination
• Referrals to Specialty Care
• Referrals to Outpatient Treatment/Procedures (select
• Referrals to Outpatient Diagnostics
• Medicare Regulations (DMERC, Palmetto GBA,
Medicare Explained), as required by the Center
for Medicare and Medicaid Services (CMS)
Inpatient Care Coordination
• SNF, Inpatient Rehabilitation
Outpatient Care Coordination
• DME, SNF, Home Care, IV Drugs, Other Drugs/Treatment
Select either Part B coverage for Ohio or Durable
Medical Equipment Regional Carriers
• Kaiser Permanente Ohio: CDU Manual / P&P:
Introduction to Protocols
Kaiser Permanente’s observation level of care (Clinical Decision
Unit – CDU)
• American Society of Addiction Medicine (ASAM)
Patient Placement Criteria (required by the Ohio
Department of Alcohol and Drug Addiction
Level II Adult Admission Criteria
• Kaiser Permanente: National Transplant Network
Patient selection and site selection transplant criteria
These criteria are also available for your review by contacting Kaiser Permanente Ohio’s Referrals Management and Clinical
Review Department at 1-866-433-1333 option 4.
ISSUE 3 | 2011
Medical Offices, North Point, Regional Service Center
All Kaiser Permanente Medical Offices
for the weekend of both Christmas and New Year’s
Holiday for 2011
Emergency Departments, Care Line,
Member Service Center
Monday, December 26
Christmas Day (Observed)
Monday, January 2, 2012
New Year’s Day (Observed)
Emergency Departments and Member Service Center*
Kaiser Permanente Medical Offices, Emergency
Departments and Member Service Center
Saturday, December 24
Christmas Eve
Saturday, December 31
New Year’s Eve
Fridays, December 23 and December 30
North Point and Regional Service Center
Fridays, December 23 and December 30
completed, simply fax the forms to our Online-Affiliate
coordinator for processing at 216-479-5550. A welcome
packet will be sent to you with your personal User ID,
account activation materials, and instructions on how to
use the program.
KP Online–Affiliate is an interactive program that can be
used to access your Kaiser Permanente patients’ clinical
history, benefits information, create or review referrals, and
much more.
To sign up for KP Online-Affiliate, you will need to
complete both the User Enrollment Form and the License
and User Agreement Form. You can download the forms
on the Kaiser Permanente Community Provider website at
If you have any questions on how to enroll, please call
On January 16, 2009, the U.S. Department of Health and
Human Services announced the final rules for the 5010
Transactions sets for electronically submitted claims. Kaiser
Permanente has completed testing with our national
clearinghouses and is in full compliance for the December
31, 2011, deadline.
The remittance advice request form can be found on the
Kaiser Permanente Community Provider Website at: http:// Select the “Forms” section  Claims
and Payment forms  EDI Electronic Claims Remittance
Set-up Form. You may also contact our Customer Relations
department to obtain a form.
Kaiser Permanente has started a project to update our
claims system across the entire Kaiser Permanente program.
The new claims system, Xcelys, will standardize processes
and facilitate our preparation for ICD-10 compliance.
Complete the request form and e-mail it to [email protected], or mail it to our EDI Coordinator at
the address below. The 835 setup can usually be completed
without any further requests for information within five to
seven business days.
The requirement to begin processing claims using ICD10 diagnosis and procedure codes is going into effect
on October 1, 2013. Kaiser Permanente is preparing our
claims and other internal systems to support ICD-10 and is
on-track for full compliance by this go-live date.
EDI Coordinator, Kaiser Permanente
14600 Detroit Avenue, 7th Floor
Lakewood, OH 44107
(continued on page 19)
Kaiser Permanente has developed a wide array of Preventive Care and Clinical
Practice Guidelines to support your clinical practice in providing quality care for our
members. You can access these guidelines on our website. Clinical Guidelines are
located under the “Provider Information” section. Each guideline can be downloaded
and printed as needed.
Clinical Practice Guidelines are updated as changes and additions occur. We will note
any guideline updates in Provider Connection and in the News and Announcements
section of the website. If you are not able to access the Preventive Care and Clinical
Practice Guidelines online, you may request that hard copies be mailed to your office.
• Immunization Schedule – ages 0-6
• Immunization Schedule – ages 7-18
• Immunization Schedule – Adult
• Osteoporosis/Fracture Prevention
• HIV-STI Screening & Prevention
• Abdominal Aortic Aneurysm
• Testosterone Replacement
• Insomnia
• Prostate Cancer Screening
• Colorectal Cancer Screening
ISSUE 3 | 2011
Claims Corner
(continued from page 18)
When a Kaiser Permanente member is covered under two
Kaiser Permanente benefit plans, please submit the claim
once. Our Claims Operations team will pay under both
plans. Therefore, you will receive remittance advice and
payment under both the primary and secondary Kaiser
Permanente coverage.
Contact your EDI clearinghouse to submit claims to
Kaiser Permanente of Ohio through one of our contracted
clearinghouses using the appropriate Payer ID. There is
no need for you to contact Kaiser Permanente to begin
submitting your claims via EDI. We are ready to accept
electronic claims whenever you submit them.
(preferred provider)
Professional claims (837P),
Institutional claims (837I),
Remittance advices (835)
Eligibility and benefits inquiry (270)
Professional claims (837P),
Remittance advices (835),
Professional claims (837P),
Professional claims (837P),
Institutional claims (837I),
Remittance advices (835)
Eligibility and benefits inquiry (270)
Claims status inquiry (276)
(AHIP pilot project for Multi-Payer
Through the Availity web portal you can submit claims, receive remittance advice, and inquire as to member eligibility
and claims status.
For more information, please contact the Kaiser Customer Relations department at 1-800-441-9742, Option 1
Contact clearinghouse directly
Professional claims (837P)
Institutional claims (837I)
Remittance advices (835)
Professional claims (837P)
Institutional claims (837I)
Remittance advices (835)
If you have any questions, please contact Customer Relations at 1-800-441-9742, Option 1, or refer to the “Claims” section
on the Kaiser Permanente Community Provider website at .
If you have questions about setting up remittance advices or EFT with Kaiser Permanente of Ohio, please e-mail the EDI
Coordinator at [email protected]
Kaiser Permanente
Network Development Department
1001 Lakeside Ave., Suite 1200
Cleveland, Ohio 44114
Provider Connection
Patricia D. Kennedy-Scott
Regional President, Kaiser Foundation Health Plan of Ohio
Ronald Copeland, MD
President and Medical Director, OPMG
Carolyn Hightower
Vice President, Health Plan Administration and Strategy
Vanessa Rogal
Director, Network Development & Performance
Karen Suhy
Network Manager
Kim McKenzie
Published by the Network Development and Performance
department at Kaiser Permanente. Please contact our
Network Development and Performance department at
1-800-441-9742 or fax us at 216-479-5550 with comments,
questions, or suggestions for future issues.
In this issue:
Referrals Management and Clinical Review Updates
2011 Christmas and New Year’s Holiday Schedule
On the Web with Kaiser Permanente
and more...