Provider Manual - Kaiser Permanente

Transcription

Provider Manual
 Member Eligibility and Benefits
Determination
 Product Descriptions
 Drug Benefits and Formulary
8/31/2012
Welcome
To
Kaiser
Permanente
This section of the Provider Manual was created to help guide you and your
staff in working with Kaiser Permanente’s Member eligibility and benefit
determination policies and procedures. It provides a quick and easy
resource with contact phone numbers, detailed processes and site lists for
services related to Member eligibility and benefit determination. This
Section also briefly describes our products.
If at any time you have a question or concern about the information outlined
in this Section of the Provider Manual, you can reach our Member/Provider
Services Department by calling (303) 338-3800 for Denver/Boulder and (888)
681-7878 for Southern Colorado.
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8/31/2012
Table of Contents
SECTION 3: MEMBER ELIGIBILITY AND BENEFITS DETERMINATION .................
3.1 MEMBER ELIGIBILITY VERIFICATION .......................................................................................... 4
3.2 RETROACTIVE ELIGIBILITY CHANGES......................................................................................... 5
3.3 BENEFIT COVERAGE VERIFICATION ........................................................................................... 5
3.4 EXCLUSIONS AND LIMITATIONS .................................................................................................. 6
3.5 PRODUCTS AND ID CARDS .......................................................................................................... 6
3.5.1 HMO Products ...................................................................................................................................6
3.5.1.1 Member ID Cards for HMO ............................................................................................................ 11
3.5.2 Point-of-Service (“POS”) Products ................................................................................................ 13
3.5.2.1 Member ID Cards for POS .............................................................................................................. 17
3.5.3 PPO Products ..................................................................................................................................... 20
3.5.3.1 PPO Member ID Cards .................................................................................................................. 21
3.5.4 Medicare Products ............................................................................................................................ 27
3.5.4.1 Member ID Cards ........................................................................................................................... 28
3.5.5 Self-Funded (SF) Product ............................................................................................................... 29
3.5.5.1 Member ID Card ............................................................................................................................. 29
3.5.6 Medicaid Product ............................................................................................................................ 29
3.5.6.1 Member ID Card ............................................................................................................................. 29
3.6 PRECERTIFICATION REQUIREMENTS .......................................................................................... 29
3.6.1 POS Precertification Requirements ……………..……………………………………....29
3.6.2 PPO Precertification Requirements ………………………..…………………………....31
3.6.3 KPIC Precertification Requirements……………………….…………………………....32
3.7 DRUG BENEFITS AND FORMULARY ........................................................................................... 33
3.7.1 Kaiser Permanente Participating Network Pharmacies: ............................................................. 35
3.7.2 Physician Access : Southern Colorado Only ................................................................................. 40
3.8 VISITING MEMBERS..................................................................................................................... 41
Kaiser Permanente Provider Manual
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Section 3: Health Plan Member Eligibility
and Benefits Determination
Section 3: Member Eligibility and Benefits
Determination
3.1 Member Eligibility Verification
You are responsible to verify a Member’s eligibility each time the Member presents at
your office for services. Do not assume that coverage is in effect because a person
produces a Kaiser Permanente Member ID card. The process for verifying eligibility is
as follows:
1. Request Kaiser Permanente Member ID card and check identity against a
photo ID.
2. Contact Kaiser Permanente by telephone, interactive voice response (IVR)
system or by web, as described in the chart below
3. If you cannot verify eligibility because Kaiser Permanente’s eligibility
verification systems are closed, you should verify eligibility on the next
business day.
If Kaiser Permanente is unable to verify eligibility or if services are requested after
hours, you must ask the person to complete a financial responsibility form, and explain
that the person will be responsible to pay for the services if it is later determined that he
or she did not have coverage on the date of service. See Section 3.2 of the Manual
regarding retroactive eligibility changes.
To confirm a Member’s current PCP or to verify eligibility, choose one of the options
below.
Example:
Option
Description
#1
Interactive Voice Response (IVR) System: The IVR can be accessed for member eligibility,
copayment information, and the name of the PCP assigned to the member through the
Member/Provider Services Department for Denver/Boulder (303) 338-3800 and Southern
Colorado (888) 681-7878, Mon-Sun from 8am to 5pm. Please have the member’s ID number
and date of birth available when you call. Interactive Voice Response -- Non KP Letter
#2
Member/Provider Service Line: If you are unable to use the IVR system to confirm member
eligibility or PCP assignment, you may speak with a customer service representative by
calling the Member/Provider Services Department Line for Denver/Boulder (303) 338-3800
and Southern Colorado (888) 681-7878, M-F from 8am to 5pm. Please provide the member’s
name and member ID number, inclusive of suffix, which is located on the Kaiser Permanente
ID card.
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Option
Description
#3
www.providers.kp.org/cod: Eligibility verification is available to providers via AffiliateLink the
Kaiser Permanente website at www.providers.kp.org/cod, a secured site, for which a user ID
number and password are required. To obtain access, call (303) 338-3216.
3.2 Retroactive Eligibility Changes
Kaiser Permanente may determine retroactively that a person was not eligible for
coverage on the date of service. This occurs, for example, when eligibility data is
received late from employer groups, or is adjusted by employer groups. The applicable
Payor is not responsible to pay for services in that case, but if you obtained a financial
responsibility form from the person, you may bill the person directly for the services. If
you have already received payment for the services, the applicable Payor will notify you
of the adjustment.
Member eligibility may change retroactively in the following conditions:
Kaiser Permanente receives delayed information, e.g., from Member’s employer,
that an individual is no longer a Member
The individual policy/benefit contract has been terminated
The Member decides not to purchase continuation coverage
The eligibility information received by Kaiser Permanente is later determined to
be false.
If you have received payment on a claim(s) that is impacted by a retroactive eligibility
change, a claim adjustment will be made. The reason for the claim adjustment will be
reflected on the remittance advice.
3.3 Benefit Coverage Verification
You are responsible for verifying that a Member has coverage under his or her
Membership Agreement for the services you will be providing, and for obtaining any
required prior authorization. See Section 4 of the Manual for information regarding
authorization requirements. To determine a member’s benefit coverage, choose on the
options below.
1. Contact the Member/Provider Services Department for Denver/Boulder 303-3383800 and Southern Colorado 888-681-7878 to verify member benefit coverage.
2. Access member benefit coverage via AffiliateLink website at
www.providers.kp.org/cod a secured site, for which a user ID number and
password are required. To obtain access, call 303-338-3216
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3.4 Exclusions and Limitations
The benefits described in each Membership Agreement are subject to various
limitations and exclusions. It is important to inquire about coverage before rendering a
service so the Member can be informed of potential payment responsibility.
Information can be obtained by calling for Denver/Boulder 303-338-3800 and Southern
Colorado 888-681-7878.
3.5 Products and ID Cards
Kaiser Permanente of Colorado offers different products to individuals and employer
groups. The Member’s identification card will indicate which product he/she is enrolled
in. Kaiser Permanente members should present their ID cards prior to services.
Additionally, it is recommended you obtain a copy of the card (front and back) each time
services are rendered. This will assist you in referencing required insurance information.
You are contracted to treat Kaiser Permanente Members who are enrolled in the
following plans:
HMO Products:
Traditional HMO Product
Traditional HMO Medicare Product(s)
Deductible / Coinsurance HMO (DHMO)
Deductible Product with Health Savings Account (DPHSA)
HMO Plus
Deductible Coinsurance HMO Plus
Medicare Senior Advantage Plus Choice Plan (HMOPOS)
Point of Service (POS) Products
Added Choice Products
Added Choice POS: HMO + Indemnity
Added Choice Triple Option: HMO + PPO + Indemnity
Added Choice Deductible Coinsurance: DHMO + PPO + Indemnity
MultiChoice POS
PPO Products:
Traditional PPO
PPO with Health Savings Account (HSA)
Out-of-Area PPO
3.5.1 HMO Products
Traditional HMO Product
Our Traditional HMO product covers Kaiser Permanente’s largest membership. With
this product our members choose Primary Care Physicians within the Colorado
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Permanente Medical Group and receive almost all of their care within the Kaiser
Permanente traditional Group Model System. A referral from a CPMG physician is
required to obtain services outside of the traditional system. Within this product, Kaiser
Permanente offers a wide selection of benefit choices. To verify eligibility and benefit
information only, contact The Member Services for Denver/Boulder (303)-338-3800 and
Southern Colorado (888) 681-7878 or e-mail: [email protected].
Deductible / Coinsurance HMO Product (DHMO)
Deductible/Coinsurance HMO has been part of the Kaiser Permanente portfolio since
January 1, 2004. DHMO is available for large group, small group and individual lines of
business. DHMO products are based on our core HMO plan but with a deductible that
results in a lower monthly premium. Members have access to any Kaiser Permanente
physician. Preventive services (defined in DPHSA section) are covered at no extra
charge. Copayments apply to doctor’s visits and prescriptions. The member must meet
a deductible for certain procedures, hospitalization and outpatient surgery before
coinsurance begins. Copayments and the deductible do not count toward meeting the
out-of-pocket maximum.
Deductible – The amount a member must pay in a calendar (or contract) year for certain
services before coinsurance begins. Members must pay full charges when they receive
specified services until they meet their deductibles. Kaiser Permanente’s DHMO plans
have deductibles that range from $250-$2,000 per individual per year and $750-$6,000
per family per year. The following services are subject to these deductibles:
Procedures received during an office visit or scheduled procedure visit.
o Outpatient surgery services.
o Inpatient hospital services.
o Inpatient medical detoxification, including chemical dependency residential
rehabilitation.
o Dialysis services.
o Emergency services.
o Non-emergency, non-routine procedures received after hours.
o Home health services.
o Hospice services.
o Inpatient psychiatric hospitalization services.
o Inpatient treatment in a multidisciplinary rehabilitation program.
o Skilled nursing facility services.
o Diagnostic and therapeutic X-ray services.
o Special procedures such as CT, PET, MRI and nuclear medicine.
Coinsurance – A percentage of the charges members must pay when they receive a
covered service and have already met the terms of their deductible. Coinsurance will be
10, 20 or 30 %, depending on the plan option. For example, if the plan calls for the
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member to pay 20 % of the total charge of an eligible service, Kaiser Permanente would
pay 80 % – or the remaining charge. The coinsurance applies to contracted, not billed,
charges. Out-of-pocket maximum – Limits the total amount of coinsurance a member
must pay over the course of a single year. For example, a deductible/coinsurance plan
might have an out-of-pocket maximum of $2,000. Once a member has paid their
deductible and that amount in coinsurance within a single year, Kaiser Permanente
would pay 100 % of the cost of eligible services after that.
Copayment – These policies also include copayments for office visits. Primary care
office visit copayments range from $15 to $35. Specialist office visit copayments range
from $35 to $55. Copayments do not apply to the medical deductible. Copayments do
not apply to the Out-of-Pocket maximum.
Contract Financial Terms
Affiliated providers of Kaiser Permanente are responsible for collecting the member’s
liability for copayments, deductible and coinsurance arising from visits or services
rendered by you that resulted in these liabilities.
Kaiser Permanente members will be responsible for copayments at the medical office
visit. For deductible and coinsurance, we ask that you submit claims to Kaiser
Permanente. We will determine the member’s financial responsibility by calculating their
deductible, coinsurance and out-of-pocket maximum. We ask that you bill the member
directly for financial liabilities resulting from deductible and coinsurance.
The member’s liability will be based on the provider’s contracted amount with Kaiser
Permanente. A provider may call Kaiser Permanente’s Member Services at (303) 3383800, option 3 regarding any questions on the member's current accumulation towards
their deductible or out-of-pocket maximum limits.
Deductible Product with HSA Options (DPHSA)
Kaiser Permanente introduced Deductible Plans with HSA Options on January 1, 2005.
For Denver/Boulder, the product is offered to large group, small group and individual
lines of business. In Southern Colorado, the product is offered to both small group and
large group lines of business. Members are responsible for all medical costs, excluding
preventive which is covered at no cost, until reaching their deductible. Deductibles and
coinsurance apply to the out-of-pocket maximum.
Deductible – The amount a member must pay in a calendar year for services. For this
plan, the first dollar applies to the deductible. Members must pay full charges when they
receive services until they meet their deductibles, and then some members pay
coinsurance amounts until the out-of-pocket maximum is met. Current plans have
individual deductibles ranging from $1,500 to $3,000 per year and family deductibles
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ranging from $3,000 to $6,000 per year. All services are subject to the deductibles
EXCEPT Preventive services (defined below).
Beginning January 1, 2006, per federal regulations, DPHSA members must pay full
charges for pharmacy until they meet their deductible. Depending on the benefit plan,
some members will pay pharmacy copays until their out-of-pocket maximum is met.
10 or 20 %, depending on the plan option. For example, if the plan calls for the member
to pay 20 % of the total charge of the eligible service, Kaiser Permanente would pay 80
% or the remaining charge. Coinsurance applies to contracted, not billed, charges.
Out-of-pocket maximum – Limits the total amount of deductible and coinsurance dollars
a member must pay over the course of a single year. For example, a plan might have
an individual out-of-pocket maximum of $5,000. Once a member has paid their
deductible and that amount of coinsurance within a single year, Kaiser Permanente
would pay 100% of the cost of eligible services after those criteria have been met.
Preventive services – The following benefits have been defined as preventive, and will
not apply to the deductible:
o Adult Preventive Care Exam
o Adult Preventive Care Screenings (tests & interpretation)
o Prostrate specific antigen screening (PSA)
o Fecal occult blood screening (Hemocult)
o Flexible sigmoidoscopy screening
o Colonoscopy screening when ordered by an MD
o Cholesterol screening (lipid profile)
o Fasting blood glucose test for diabetes screening
o Well-Woman Care
o Screening pap and interpretation
o Screening mammogram and interpretation
o Clinical breast exam
o Chlamydia screening test and interpretation
o Immunizations (excluding travel immunizations)
o Well-Child Care (exams and immunizations in accordance with Medical Group
guidelines)
Contract Financial Terms – Affiliated providers of Kaiser Permanente are responsible
for collecting the member’s liability for deductible and coinsurance payments arising
from visits or services rendered by you that resulted in these liabilities. To check on a
member’s deductible balance, you may contact. Member Services at 303-338-3800,
Option 3. This will enable affiliated providers to collect as accurately as possible at the
point of care.
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HSA Option – Kaiser Permanente members who are enrolled in these plans have the
option to hold a health savings account (HSA) with an accredited financial institution.
This is an investment or savings account owned by the member who can be used for
healthcare expenses as defined by the I.R.S. Kaiser Permanente has named Wells
Fargo as a preferred partner, although members can have an HSA with any accredited
financial institution. Those members who have their HSA with Wells Fargo will be given
the choice to have a Visa debit card to access their funds for healthcare services. This
card works like any other Visa debit card. Below is how the debit card looks like:
HMO Plus - Launched in July 2007, HMO Plus provides members the full benefits of
Kaiser Permanente’s HMO plus the option to receive care from any licensed physician,
up to a set dollar amount each year. The set annual amount of the Plus benefit is based
on Kaiser Permanente's contribution amount. Once the member reaches his Plus
benefit limit, only the HMO portion of the coverage will remain. HMO Plus is available to
both large and small groups.
Deductible Coinsurance HMO Plus
Deductible Coinsurance HMO Plus provides members all the benefits and resources of
Kaiser Permanente’s DHMO plan, plus the convenience to receive care from any
licensed community physician at any time, up to a set dollar amount each year. The set
annual amount of the Plus benefit is based on Kaiser Permanente’s contribution
amount. Once the member reaches his Plus benefit limit, only the Deductible
Coinsurance HMO portion of the coverage will remain. Deductible Coinsurance HMO
Plus is available to both large and small groups.
Please refer to Physician Information Document for HMO Plus and Deductible
Coinsurance HMO Plus and forms for additional information.
Physician Information Document for HMO Plus
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Medicare Senior Advantage Plus Choice Plan (HMOPOS)
Effective January 1, 2010, Senior Advantage Plus Choice is a Medicare Advantage
HMOPOS plan with Kaiser Permanente HMO benefits and a limited out-of-network point
of service (POS) benefit for out-patient services. Under the limited POS benefit Plus
Choice members can self-refer to an out-patient Medicare-approved provider whether or
not the provider is contracted with Kaiser Permanente. Orders written for a Plus Choice
member may be performed at Kaiser Permanente medical offices; there are laboratory
and radiology order forms for you to complete and fax if the member prefers to return to
Kaiser Permanente for these services. Prescription drug orders must be filled at a
Kaiser Permanente Denver/Boulder pharmacy for the member to receive the
prescription under their Part D plan benefit. The limited annual amount of the POS
benefit is based on Kaiser Permanente's contribution amount. Once the member
reaches his POS benefit limit, only the HMO portion of the coverage will remain. Senior
Advantage Plus Choice is only available to individuals.
Provider information document for Senior Advantage Plus Choice Plan (HMOPOS)
3.5.1.1 Member ID Cards for HMO
Denver/Boulder Traditional HMO Plan
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Denver/Boulder Deductible/Coinsurance HMO Plan
Denver/Boulder Deductible Plan w/ HS Option
Southern Colorado Traditional HMO Plan
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Southern Colorado Deductible Coinsurance HMO Plan
Southern Colorado Deductible Plan w/ HS Option
3.5.2 Point-of-Service (“POS”) Products
Point of Service Products (MultiChoiceSM POS, Added Choice® Point of Service,
Added Choice® Triple Option POS, and Added Choice® Deductible Coinsurance)
Kaiser Permanente Insurance Company a subsidiary of Kaiser Permanente,
underwrites all Out-of-Plan portions of the POS, Out-of-Area, and PPO plans. Members
seeking services from providers outside of the Kaiser Permanente system can self-refer
to providers of their choice at the time of medical need, or at the "point of service". They
will have a Kaiser Permanente POS membership ID card.
"In-Plan" If the POS member stays in-plan (using the HMO tier of his plan), obtain
referral information and bill Kaiser Permanente in your usual manner.
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"Out-of-Plan" If the Added Choice member receives treatment without an HMO referral
authorization, they have elected to go out-of-plan. Payment is made under the PPO or
indemnity contract and all contracted discounts apply. Bill Kaiser Permanente indicating
the POS member’s ID number. Kaiser Permanente will send remittance advice to both
you and the member itemizing the member's balance due.
MultiChoice POS
Effective January 1, 2008, Kaiser Permanente introduced MultiChoice, our new 3-tier
Point-of-Service product. MultiChoice members have three tiers of benefits – a
deductible coinsurance HMO coverage for those who seek care with Kaiser
Permanente or affiliated healthcare providers and medical offices, Preferred Provider
coverage within the Private Healthcare Systems (PHCS) network, and Out-of-Network.
Copays for office visits, deductibles, coinsurance, and out-of-pocket maximums now
match between the plan’s HMO and PPO coverage tiers, to reduce or eliminate benefit
disparity between these networks.
Added Choice Triple Option
Kaiser Permanente added a PPO network option to the Added Choice product in 2001.
These members have three tiers of benefits – HMO, Preferred Provider Network and
Out of Network. Members with three-tier POS plans like the Added Choice Triple Option
plans may choose to see non-Kaiser Permanente providers who are part of the Private
Healthcare Systems PPO Network (PHCS), or any other licensed outside provider.
Check the members’ ID card for applicable co-pays and coinsurance. If the out-of-plan
provider is also a contracted Kaiser Permanente provider, and the member has no
Kaiser Permanente referral, the claim will be handled as either a PPO or indemnity
claim. The claim system will monitor appropriate PPO discounts.
Note: Added Choice Triple Option and Added Choice Deductible Coinsurance products
are no longer being offered to new groups with Kaiser Permanente.
Contract Financial Terms - All current financial agreements apply to Kaiser Permanente
members enrolled in the POS plans. However, if you have a capitation agreement these
members are not included in your per member/per month calculation.
They will be reimbursed at the discounted fee for service terms in your contract. You
may not collect from Kaiser Permanente or the member a combination of payments
greater than your contractual rate for covered services rendered to POS members. For
"out-of-plan" cases, the member's deductible/coinsurance payment obligations are
calculated based on your contractual rate.
Deductibles - The amount a member must pay in a calendar or contract year for
services. Members with POS plans must meet individual/family deductibles before
coinsurance applies. For members of the Added Choice Triple Option, there are no
deductibles in the traditional HMO tier for these members. Payments to satisfy
Deductibles do not apply to the Out-of-Pocket Maximums.
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Note: Deductibles for all Added Choice products are separate in each tier, and they do
not accumulate across tiers. In MultiChoice, members’ payments to satisfy their PPO
tier deductible also apply to their HMO tier deductibles. However, payments towards the
HMO tier or Out-of-Network tiers apply only toward those respective tiers.
10% to 50%, depending on the plan option. For example, if the plan calls for the
member to pay 20% of the total charge of the eligible service, Kaiser Permanente would
pay 80% of the remaining charge, up to the UCR. Coinsurance applies to contracted,
not billed, charges. Coinsurance %ages vary by tier, with highest cost sharing in the
Out-of-Network tier. For Point of Service products (including Triple Option), only
coinsurance payments apply to the applicable Out-of-Pocket Maximum accumulations.
Copayment – These policies also include copayments for office visits and prescriptions
in the HMO and PPO tiers. Copayments do not apply to the medical deductibles.
Copayments do not apply to the Deductibles or the Out-of-pocket maximums in any tier
of POS plans.
Out-of-Pocket Maximum – Limits the total amount of coinsurance a member must pay
over the course of a single year. For example, a deductible/coinsurance plan might
have an out-of-pocket maximum of $2,000. Once a member has paid their deductible
and that amount in coinsurance within a single year, Kaiser Permanente would pay 100
% of the cost of eligible services after that (except for applicable copayments, which are
always required). The Out-of-Pocket Maximums in the Point-of-Service plans are
separate in each tier, and do not cross-accumulate. Only coinsurance applies to the
Out-of-Pocket Maximum accumulators.
Some Point-of-Service benefits are covered only under Tier 1 (Kaiser Permanente). For
all POS plans, these include:
Inpatient mental health care
Inpatient / outpatient alcohol and substance abuse
Inpatient physical, occupational, and speech therapy
Durable Medical Equipment (except prosthetic arms and legs)
Organ transplants
Oxygen
Skilled nursing facility
Emergency room care
Ambulance
Hearing exam
Pre-certification Requirements for PPO and Out-of-Network services
Pre-certification is the evaluation of treatments and services to assure that members’
care is appropriate and medically necessary for health care needs.
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The patient (or his/her doctor) must call SHPS (pronounced like “ships”) for precertification at least 3 days prior to any scheduled hospital admission, unless admitted
in an emergency. Pre-certification for emergency admissions must be obtained within 3
days following the admission.
To obtain pre-certification, call 1-800-448-9776 (SHPS). Both the member and provider
will receive written authorization confirming medical necessity.
Prescriptions – Members with Point-of-Service plans have two options to fill
prescriptions:
They
may purchase prescriptions at any Kaiser Permanente pharmacy, provided the
medications are on the KP formulary and medical guidelines are satisfied. Prescriptions
may be written by providers outside Kaiser Permanente. Members usually pay a
copayment. Mail order is also available through Kaiser Permanente’s mail order service.
Members may purchase any covered prescriptions through MedImpact, a network of
nearly 60,000 pharmacies nationwide. The MedImpact network includes most major
retail pharmacy chains in Colorado, including King Soopers, Albertsons, Safeway,
Long’s Drug, Wal*Mart, and Walgreens. Members pay a copayment.
Members of MultiChoice POS plans may not purchase prescriptions through
pharmacies other than Kaiser Permanente or MedImpact. Members of Added Choice
plans may purchase prescriptions from pharmacies outside the MedImpact network.
Members pay 50% coinsurance. Two-tier Added Choice pharmacy benefits may also
require members to satisfy a deductible before the pharmacy coinsurance applies.
The formulary is open for prescriptions purchased through MedImpact or Out-ofNetwork pharmacies. However, a Preferred Drug List determines members’ pharmacy
copayments on MultiChoice Plans. Members’ copayments are either Preferred Generic,
Preferred Brand, or Non-preferred Generic/Brand.
For members of MultiChoice POS plans, certain self-administered injectible drugs are
also covered when members purchase them through MedImpact pharmacies. Members
pay 20% coinsurance for these prescriptions (up to $250 per fill).
Neither Pharmacy coinsurance payments nor copayments apply to Medical deductibles
or Out-of-Pocket Maximum accumulators.
Please refer to the Physician Informational Document for POS Plans and forms for more
information.
Physician Information Document for POS Plans
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3.5.2.1 Member ID Cards for POS
Denver/Boulder MultiChoiceSM POS Plan
Denver/Boulder Added Choice Deductible/Coinsurance
Denver/Boulder Added Choice 2-Tier POS Plan
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Denver/Boulder Added Choice Triple Option Plan
Southern Colorado MultiChoiceSM POS Plan
Southern Colorado Added Choice Deductible/Coinsurance
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Southern Colorado Added Choice 2-Tier POS Plan
Southern Colorado Added Choice Triple Option Plan
3.5.3 PPO Products
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Traditional PPO
Our traditional PPO product allows the member to take advantage of Kaiser
Permanente’s preferred provider network, Private Healthcare Systems (PHCS), with
nearly 450,000 physicians and more than 4,000 facilities nationwide. Or if the member
prefers, he can go to any other licensed practitioner or hospital he chooses. If the
member gets care from within the preferred provider network, he will reduce costs
through copayments for office visits (including diagnostic x-rays and lab work performed
in the doctor’s office), as well as lower deductibles and reduced coinsurance rates for
other services. If the provider is outside the network, the member will pay higher
deductibles & coinsurance, may be required to make his own financial arrangements,
and may need to submit receipts or claims for reimbursement. Also, members are
responsible for paying the difference between the amount billed & the amount that KP
can reimburse. Prescriptions are covered and can be filled at any MedImpact network
pharmacy, which includes pharmacies at Albertsons, King Soopers/City Market, Kmart,
Longs Drugs, Medicine Shoppes, Safeway, Sam’s Club, Target, Walgreens, and
Walmart. The traditional PPO is available to large group members only.
Out-of-Area PPO
This plan is similar to our traditional PPO plan but is available to small group members
only. This plan is available to members outside of Kaiser Permanente’s service area
who are not eligible for the HMO plan.
PPO Plan with Health Savings Account (HSA) Option
With this plan, the member can take advantage of Kaiser Permanente’s Preferred
Provider Network, Private Healthcare Systems (PHCS), or if the member prefers, he
can go to any other licensed practitioner or hospital he chooses. In addition, the
member can set up a Health Savings Account (HSA) which he can use to pay for
qualified medical expenses, tax free. Kaiser Permanente has named Wells Fargo as a
preferred partner, although members can have an HSA with any accredited financial
institution. The PPO Plan with Health Savings Account (HSA) is available to large group
members only.
3.5.3.1 PPO Member ID Cards
Denver/Boulder PPO Plan
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Denver/Boulder PPO Plan w/HS Option
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Southern Colorado PPO Plan
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Southern Colorado PPO Plan w/ HS Option
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PPO Plan
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Out of Area Plan
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3.5.4 Medicare Product
Traditional HMO Medicare Product(s)
Medicare Advantage - Kaiser Permanente has contracted with the Centers for Medicare
& Medicaid Services (CMS) to offer Medicare Advantage (MA) plans to Medicare
beneficiaries. These plans are known as Senior Advantage. Kaiser Permanente offers
five individual MA plans; Senior Advantage Core, Silver, Gold, Plus Choice, and our
Special Needs Plan. The Special Needs Plan is for individuals with both Medicare and
Medicaid. These plans provide comprehensive, high-quality healthcare, including
Medicare Part D prescription-drug benefits. Based on the contract between Kaiser
Permanente and CMS, Senior Advantage covers all Medicare benefits and more.
Senior Advantage is available to Medicare beneficiaries who are eligible for Medicare
Part A and are enrolled in Medicare Part B.
In addition to our four individual plans, Kaiser Permanente offers Senior Advantage to
the employer group market.
Kaiser Permanente currently has over 60,000 Medicare Advantage members. The
same referral guidelines that apply to our Kaiser Permanente commercial/non-Medicare
members should also apply to our Medicare Advantage members.
Contract Financial Terms - Your contractual agreement describes the financial terms for
all Kaiser Permanente members. The terms may define separate negotiated rates for
the Medicare population. If a member has enrolled in our MA program DO NOT BILL
MEDICARE, bill Kaiser Permanente. Providers are often reimbursed through the same
mechanisms Medicare would use. For example, RBRVS, DMERC and DRG’s. Your
contract defines how you will be reimbursed for providing services.
12/14/2012
27
3.5.4.1 Member ID Cards
Denver/Boulder Medicare Advantage Plan (Non Part D)
Colorado Region Denver/Boulder/Longmont (Part D)
12/14/2012
28
3.5.5 Self-Funded (SF) Product
Refer to www.providers.kp.org/cod to obtain information regarding the
Self-Funded products.
3.5.5.1 Member ID Card
Refer to www.providers.kp.org/cod for sample ID cards for Self-Funded
Members.
3.5.6 Medicaid Product
Kaiser Permanente no longer pays you for services you provide to these Medicaid
clients (PCPP) as a result of a referral from a Kaiser Permanente provider. You will
need to bill the State Medicaid program directly in order to receive reimbursement, and
collect the appropriate copayment from the client.
Kaiser Permanente continues to offer medical services to these Medicaid clients as a
fee for service provider under the State’s Primary Care Provider Program (PCPP). Our
Medicaid provider number is 30478251. This number must be included as the referring
physician on your claim.
3.5.6.1 Member ID Card
Denver/Boulder Primary Care Physician Program (Medicaid)
3.6 Precertification Requirements
3.6.1 POS Precertification Requirements For all POS plans, pre-certification is
required for the following services or treatments:
o Comprehensive Rehabilitation Facility admissions related to services
provided under an inpatient multidisciplinary rehabilitation program;
o Inpatient Mental Health admissions and services
o. Inpatient Chemical Dependency admissions and services
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29
o Inpatient admissions and services
o Non-Hospital Residential Services, Partial Hospitalization and Day
Treatment for Mental Health
o. Non-Hospital Residential Services, Partial Hospitalization and Day
Treatment for Chemical Dependency
o Skilled Nursing Facility admissions
o Outpatient Surgical Services
o. Dental Anesthesia
oArtificial Intervetebral Disc Surgery
o.Interdiscal Electrothermal Annuoplasty (IDET)
o.Percutaneous Lumbar Discectomy
o.Vertebral Axial Decompression
o.Vertebroplasty
o.Orthognathic Surgery/TMJ
o.Reconstruction Surgery
- Craniofacial Reconstruction
- Breast Augmentation/Reduction/Implants
-. Reconstruction (including all procedures by plastic surgeon)
o.Cosmetic Procedures
- Blepharoplasty, Pitosis Repair
- Septorhinoplasty
- Sinus surgeries
o.Endoscopy (pill/capsule only)
o.UPPP and laser assisted UPPP
o Varicose Vein Treatment/Sclerotherapy
o.Upper Airway Procedures
- Pillar Palatal Implant
- Somnoplasty (RF ablation)
Outpatient Services
o Pain Management
-. Epidural Steroid Injection
- Radiofrequency Ablation
- Implantable Infusion Pump
- Spinal Cord Stimulator
o Sleep Studies (including home)
o Experimental/Investigational Procedures and Drugs
o Hyperbaric Oxyen Treatment
o. Non-Emergent Air or Ground Ambulance Transport
o Enhanced External Counterpulsation (EECP)
o Plasma Pheresis for Multiple Sclerosis
o Anodyne Therapy
o Vagal Nerve Stimulation for Epilepsy
o.Imaging Service: MRI, MRA, CTA, PET, EBCT
o Home Health, Home Infusion and Home Therapy
o Outpatient Physical, Speech, Occupational , Respiratory - 20 visits per
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30
therapy per calendar year
o.Durable Medical Equipment
o.Autism Spectrum Disorder services
3.6.2 PPO Precertification Requirements For all PPO plans or tiers, precertification is required for the following services or treatments:
o Comprehensive Rehabilitation Facility admissions related to services provided under
an
inpatient multidisciplinary rehabilitation program;
o Inpatient Chemical Dependency admissions and services
o Inpatient admissions and services, including admissions for transplants;
o Non-Hospital Residential Services, Partial Hospitalization and Day Treatment for
Mental
Health
Chemical
Dependency
o Skilled Nursing Facility admissions
o Dental Anesthesia
o Artificial Intervetebral Disc Surgery
o Interdiscal Electrothermal Annuoplasty (IDET)
o. Percutaneous Lumbar Discectomy
o Vertebral Axial Decompression
o Vertebroplasty
o Orthognathic Surgery/TMJ
o Reconstruction Surgery
-. Craniofacial Reconstruction
-. Breast Augmentation/Reduction/Implants
- Reconstruction (including all procedures by plastic surgeon)
o. Cosmetic Procedures
- Septorhinoplasty
- Sinus surgeries
o Endoscopy (pill/capsule only)
o UPPP and laser assisted UPPP
o. Upper Airway Procedures
Outpatient Services
o Pain Management
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31
- Epidural Steroid Injections
o Non-Emergent Air or Ground Ambulance Transport
o Anodyne Therapy
o Imaging Service: MRI, MRA, CTA, PET, EBCT
o Outpatient Physical, Speech, Occupational , Respiratory - 20 visits per therapy per
calendar
year
o Durable Medical Equipment
o Oxygen
o Autism Spectrum Disorder Services
3.6.3 KPICFor all KPIC plans or tiers, pre-certification is required for the
following services or treatments:
o Inpatient Rehabilitation Therapy admissions, services and programs
o Inpatient Chemical Dependency admissions and services
o Inpatient admissions and services
Mental Health
Chemical
Dependency
o Dental Anesthesia
o Artificial Intervetebral Disc Surgery
o Interdiscal Electrothermal Annuoplasty (IDET)
o Percutaneous Lumbar Discectomy
o Vertebral Axial Decompression
o Vertebroplasty
o Orthognathic Surgery/TMJ
o Reconstruction Surgery
- Craniofacial Reconstruction
- Breast Augmentation/Reduction/Implants
- Reconstruction (including all procedures by plastic surgeon)
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32
o Cosmetic Procedures
- Septorhinoplasty
- Sinus surgeries
o Endoscopy (pill/capsule only)
o UPPP and laser assisted UPPP
o Upper Airway Procedures
Outpatient Services
o Pain Management
- ESI
o Non-Emergent Air or Ground Ambulance Transport
o Anodyne Therapy
o Imaging Service: MRI, MRA, CTA, PET, EBCT
o Outpatient Physical, Speech, Occupational , Respiratory - 20 visits per therapy per
calendar year
3.7
Drug Benefits and Formulary
Kaiser Permanente members who have a prescription drug may have their prescription
filled at a Plan pharmacy at the applicable prescription drug copayment or coinsurance.
In order to receive medications under the Prescription Drug Benefit, the prescription:
1. Must be prescribed by a Plan Physician, a physician to whom a member has
been referred by a Plan Physician or a dentist (when prescribed for acute
conditions).
12/14/2012
33
2. Must be purchased at Plan Pharmacies.
Medications and accessories covered by the Prescription Drug benefit are:
1. Drugs for which a prescription is required by law. Plan pharmacies may
substitute a generic equivalent for a brand-name drug unless prohibited by the
Plan Physician. If a member requests a brand-name drug when a generic
equivalent is the preferred product, the member may pay a cost differential
dependent upon the members prescription drug benefit. If the brand-name drug
is prescribed due to medical necessity, when the generic equivalent is on the
formulary, the member pays only the brand-name copayment.
2. Insulin
3. Compounded medications are covered as long as they are on the compounding
formulary for Denver Boulder members and plan Physicians may request
compound medications through the medical exceptions process for Southern
Colorado members.
4. Home glucose monitoring supplies, disposable syringes for the administration of
insulin, glucose test strips, acetone test tablets and nitrite screening test strips for
pediatric patient home use.
Drug, Supplies and Supplements Exclusions:
1. Drugs for which a prescription is not required by law.
2. Disposable supplies for home use such as bandages, gauze, tape, antiseptics,
dressing and ace-type bandages.
3. Drugs or injections for the treatment of sexual dysfunction, unless the member’s
group has purchased additional coverage.
4. Any package other than the dispensing pharmacy’s standard packaging.
5. Replacement of prescript drugs for any reason, including but not limited to
spilled, lost, damaged or stolen prescriptions.
6. Drugs for the treatment of infertility, unless the member’s group has purchased
additional coverage.
7. Drug used to shorten the duration of the common cold.
8. Drugs used to enhance athletic performance.
9. Drugs used in the treatment of weight control.
10. Drugs which are available over the counter and by prescription for the same
strength.
11. Drugs and supplies for cosmetic purposes.
12. Vitamins and nutritional supplements that can be purchased without a
prescription.
13. Non-prescription drugs, unless they are included in the drug formulary.
14. Drugs related to non-covered services.
15. Drugs for the promotion, prevention, or other treatment of hair loss or growth.
Generic/Brand Prescription Benefit:
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34
To ensure cost effective therapy, generic equivalents are utilized when available and
appropriate. Only approved generic equivalents approved by the FDA are used.
Pharmacies may substitute a preferred generic drug for a prescribed name brand
drug unless prohibited by the physician. If a member requests a brand name drug
when a generic drug is the preferred agent, the member may pay a cost differential
dependent upon the members prescription drug benefit. If the brand-name drug is
prescribed due to medical necessity, when the generic equivalent is on the
formulary, the member pays only the brand-name copayment.
Dispensing Limitations: Kaiser Permanente may, in its sole discretion,
establish quantity limits for specific prescription drugs. For example, when there
is a shortage of a drug in the marketplace and the amount of available supplies is
limited, we may reduce the quantity of drug dispensed
Certain drugs that have a significant potential for waste will be provided for up to
a 30-day supply only (e.g.: Avonex, Procrit).
Therapeutic Interchange: Kaiser Permanente utilizes Therapeutic Interchange
programs to promote rational, safe, and effective drug therapy. Prescribing provider
approval is required before an exchange occurs.
3.7.1 Kaiser Permanente Participating Network Pharmacies:
Kaiser Permanente Medical Care Program
Colorado Region
Pharmacy Hours of Operation / Pharmacy Contacts (updated 8/31/2012)
Pharmacy
Arapahoe
Address - Phone - Fax
5555 East Arapahoe Road
Centennial, CO 80122
Hours of Operation
8:00 am - 6:00 pm Monday - Friday
8:00 am - 6:00 pm Saturday
9:00 am - 5:00 pm Sunday
(303) 850-1570
FAX 850-2056
Aurora Centrepoint
14701 E. Exposition Avenue
Aurora, CO 80012
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35
(303) 614-7305
FAX 614-7303
Baseline
CLOSED Weekends & Holidays
580 Mohawk Drive
Boulder, CO 80302
(303) 554-5015
FAX 554-5010
Brighton
Castle Rock
8:30 am – 5:30 pm Monday - Friday
th
859 4 Avenue
Brighton, CO 80601
(303) 835-5860
FAX (303) 835-5870
4318 Trail Boss Drive
Castle Rock, CO 80104
Englewood
(303) 814-4160
FAX (303) 814-4170
2955 South Broadway
Englewood, CO 80110
Evergreen
Franklin
Hidden Lake
(303) 788-1043
FAX 788-1011
2942 Evergreen Parkway
Evergreen, CO 80439
8:30am-5:500 pm Monday-Friday
(303) 318-3333
FAX 318-3336
2045 Franklin Street
Denver, CO 80205
8:00 am - 12:00 noon Saturday
(303) 861-3239
FAX 861-3604
CLOSED Sundays & Holidays
7701 Sheridan Boulevard
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36
Westminster, CO 80003
(303) 657-6707
FAX 657-6709
Highlands Ranch
9285 Hepburn Street
Highlands Ranch, CO 80129
(720) 348-4603
FAX 348-4605
Home I.V.
16601 East CentreTech Pkwy
Aurora, CO 80011
(303) 344-7010
FAX 344-7048
Ken Caryl
7600 Shaffer Parkway
Littleton, CO 80127
8383 West Alameda Avenue
Lakewood, CO 80226
(303) 239-7465
FAX 239-7405
Longmont
Oncology
CLOSED Holidays
2345 Bent Way
Longmont, CO 80501
(303) 678-3310
FAX 678-3302
Long Term Care
(720) 922-5054
FAX 922-5055
Lakewood
16601 East CentreTech Pkwy
Aurora, CO 80011
(303) 739-3513
FAX 344-7077
Franklin
8:30am - 5:15pm Monday - Friday
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37
Denver, CO 80205
Parker
(303) 861-3300
FAX 861-3333
10168 S. Parkglenn Way
Parker, CO 80138
CLOSED Weekends & Holiday
(720) 842-5810
FAX (720) 842-5815
Rock Creek
280 Exempla Circle
Lafayette, CO 80026
(720) 536-7857
FAX 536-7855
Travel Clinic
Franklin
Denver, CO 80205
(303) 861-3183
FAX 831-3756
Skyline
1375 East 20th Avenue
Denver, CO 80205
(303) 764-4670
FAX 764-4662
Smoky Hill
16290 East Quincy Avenue
Aurora, CO 80015
(303) 699-3826
FAX 699-3840
Southwest
38
5257 S. Wadsworth Blvd.
Littleton, CO 80123
12/14/2012
(303) 972-5018
FAX 972-5013
Westminster
11245 Huron Street
Westminster, CO 80234
(303) 457-6082
FAX 457-6416
Wheatridge
OPEN Holidays
4803 Ward Road
Wheatridge, CO 80033
(303) 467-5149
FAX 421-5066
PARC (Pharmacy
Automated
Refill Center)
Mail Order
16601 East Centretech Parkway
Aurora, CO 80011
(303) 326-6770
FAX 326-6775
7:00 am - 5:30 pm Monday, Tuesday
7:00 am - 4:30 pm Wednesday - Friday
Holiday Schedule Varies - CLOSED Sa
Southern Colorado Service Area:
Kaiser Permanente uses a pharmacy benefit manager, MedImpact, to administer our
prescription drug benefits in the Southern Colorado service area. In addition to the two Kaiser
Permanente pharmacies listed below, members have various retail pharmacies available to
them. For a detailed listing of participating pharmacies visit www.kp.org or call KP Member
Services.
Kaiser Permanente Medical Care Program
Southern Colorado
Pharmacy Hours of Operation / Pharmacy Contacts
Pharmacy
Address - Phone - Fax
12/14/2012
39
Hours of Operation
Briargate Senior
Health Center
Pueblo North
4105 Briargate Parkway
Colorado Springs, Co 809207842
8:00 am – 4:45 pm Monday –
Friday
(719) 282-2466
FAX (719) 282-2470
CLOSED Weekends &
Holidays
3670 Parker Blvd
8:30 am – 5:30 pm Monday –
Friday
Pueblo, CO 81008-2207
(719) 595-5367
FAX (719) 595-5370
CLOSED Weekends &
Holidays
Mail Order Service: Kaiser Permanente Offers our members a mail order pharmacy
services. The Kaiser Permanente Mail Order Pharmacy is available to all Kaiser
Commercial members, Self Funded members and Medicare Part D members regardless of
service area.
Kaiser Permanente Mail Order Pharmacy
16601 E. Centretech Parkway
Aurora, CO. 80011
Phone: (303) 326-6770
866-523-6059
3.72 Physician Access: Southern Colorado Only
Kaiser Permanente offers a secure website for practitioners to access their patient’s
prescription drug histories. Our Physician Access website provides utilization reports
and compliance reports for each patient, complete with drug refill histories over the
past 12 months.
The Web site address is: https://mp.medimpact.com/physicianportal
To obtain your user access code, please contact Provider Relations at (719) 8672131.
12/14/2012
40
3.8 Visiting Members
Kaiser Permanente offers a Visiting Member Program to ensure that Members can
receive a variety of health care services when temporarily visiting another Kaiser
Permanente Region. Visiting Member benefits may not be the same as those they
receive in their home service area and are subject to certain exclusions.
Members are eligible to receive visiting Member benefits for up to 90 days. If they
permanently move into another Region, they will be offered membership in the new
Region. Visiting Members are directed to seek health care services at the nearest
Kaiser Permanente Medical Office and contracted facilities/hospitals. If a PMG
physician needs to refer a Visiting Member to a Participating Provider, you will receive
an authorization letter explaining the start and end dates of the referral and a
description of the authorized services. Claims should be submitted to the
Denver/Boulder and Southern Colorado Kaiser Permanente claims department.
12/14/2012
41

Provider Manual - Kaiser Permanente

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