Provider Manual
Table of Contents SECTION 11: DEFINITIONS... 3 Revised 2011 2
All defined terms in this Section are capitalized throughout this Manual. Capitalized terms that are used in this Manual, but not defined, will have the meanings given to them in your Agreement. Added Choice Point-of-Service (POS): Brand name of Kaiser Permanente s point-of-service product. A point-of-service product is a health benefit plan that allows eligible Members access to different benefit levels based on different provider delivery systems. Advance Directives: Advance Directives are written instructions, such as a living will or Durable Power of Attorney for Health Care, which provides a Member the opportunity to participate in medical decision making and in determining the course of their medical care, in the event the Member becomes unable to make health care decisions on his own. Adverse Determination: Written denial from Kaiser Permanente for coverage of a prospective or retrospective Service. Agreement: Health Care Services Agreement is the contract between Ohio Permanente Medical Group, Kaiser Foundation Hospitals, Kaiser Foundation Health Plan(s), or any combination of the three (Kaiser Permanente), and health care Providers (which include, but are not limited to Physicians, hospitals, skilled nursing facilities, durable medical equipment Providers) to provide, or arrange for the provision of, medical care Services for persons enrolled in a Kaiser Permanente health plan. American Specialty Health Networks, Inc. (ASH Networks): Kaiser Permanente Members have access to discounts through ChooseHealthy. ChooseHealthy, a product of American Specialty Health Networks, Inc. (ASH Networks) and Healthyroads, Inc., provides discounted rates on chiropractic care, acupuncture, massage therapy, and other Services; dietary supplements and other products; and health and fitness equipment, books, and videos. Appeal: Written request for a review of a prospective or retrospective Adverse Determination. Authorization: Kaiser Permanente s approval for the provision of Covered Benefits to Members by persons designated to provide such approval, pursuant to Kaiser Permanente s utilization management programs, and in the manner specified as described in Section 4 of the Provider Manual. Further, Authorization also means the document or electronic documentation indicating Kaiser Permanente s approval, as the context requires. Authorized means provided pursuant to and in compliance with an Authorization. Revised 2011 3
Centers for Medicare & Medicaid Services (CMS): The federal agency responsible for administering Medicare and oversight of states management of Medicaid. Formerly known as Health Care Financing Administration (HCFA). Claim: A request for payment for Services rendered to a Member submitted in accordance with the terms of your Agreement and the Provider Manual. Clean Claim: An itemized Claim that (i) is submitted for payment of Covered Services, (ii) includes each of the data elements specified in Section 5 of the Provider Manual and (iii) complies with applicable Law. Coinsurance: The dollar amount a Member pays for Covered Services after Deductibles have been met. Complaint: Any verbal or written expression of a Member s dissatisfaction with a Plan Provider which is not amenable to prompt resolution at the point of service and requires follow-up and investigation (for example, a Grievance). Concurrent Review Concurrent Review is Utilization Review conducted during a Member s hospital or skilled nursing facility stay, or any other ongoing course of treatment. Coordination of Benefits (COB): Procedure used to prevent duplicate Claim payments when a Member is covered by more than one health plan. Copayment: The dollar amount, if any, the Member must pay at the time of Service for Covered Services that have not been fully prepaid by membership dues. Covered Benefits: The health care Services and benefits that a Member may be entitled to receive under the applicable Membership Agreement, as determined by Kaiser Foundation Health Plan of Ohio (or the applicable Payor). Covered Services: Those Services rendered by Plan Providers to Members that are Covered Benefits, Medically Necessary and Authorized or otherwise approved for payment. Revised 2011 4
Deductible: A fixed amount of health care dollars of which a Member must pay 100 percent before his/her health benefits begin. The dollar amount in Tiers Two and Three of the Kaiser Permanente Added Choice Point-of-Service (POS) plan that must be incurred by an individual or family, per calendar year, before benefits will be paid at the allowed amount. The individual or family is financially responsible for 100 percent of all Deductibles. Direct Access: Specific specialty Services (Ob/Gyn, Optometry and Behavioral Health), where a Member may see a Plan Provider without a Referral from the Member s Primary Care Physician. Eligibility: Status of Member s enrollment with Kaiser Foundation Health Plan of Ohio. Eligibility is based on a number of factors, including age, residence, relationship to the Subscriber, etc. Emerald Health Network, a HealthSmart Company: The preferred provider network Kaiser Permanente contracts with to provide Tier Two Services for Kaiser Permanente Added Choice Point-of-Service (POS) Members. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: Serious jeopardy to the Member s health or, in the case of a pregnant woman, the health of the woman or her unborn child, or serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, all as described in the Federal Emergency Medical Treatment and Active Labor Act (42 USC 1395dd) and its implementing regulations and any similar State Law (EMTALA). Emergency Services: Covered Services necessary to screen, evaluate and stabilize an Emergency Medical Condition in compliance with the Federal Emergency Medical Treatment and Active Labor Act (42 USC 1395dd) (EMTALA) and State Law. Emergency Services do not include post-stabilization Services. Encounter Data: Data relating to Services rendered by a Plan Provider to a Kaiser Permanente Member. Data is generally submitted to Kaiser Permanente via a CMS 1500 or UB04 form, regardless of whether the Provider was reimbursed on a capitated or fee-for-service basis. Revised 2011 5
Evidence of Coverage: The written, legally binding contract between the Subscriber/Member and Kaiser Foundation Health Plan of Ohio, which summarizes the Covered Benefits, exclusions and limitations under a specific insurance plan. Explanation of Payment (EOP): A written statement to a Plan Provider showing action taken on a Claim. Financial Responsibility Form: A form provided by a Plan Provider for execution by a Member, to acknowledge the Member s responsibility to pay for those non-covered Services specifically described on the form. This form shall not be required of a Member prior to his/her receipt of Emergency Services. Formulary: A list of approved prescription medications, both name brand and generic, that are covered under a Member s prescription drug benefit. All Formulary medications have FDA approval. Kaiser Permanente has two Formularies (Commercial and Medicare Part D) which are to be followed by all Plan Providers. The medications included in the Formularies are chosen by a group of Kaiser Permanente Practitioners, pharmacists and nurses known as the Pharmacy and Therapeutics Committee. Grievance: Any Complaint or dispute, other than one involving an Adverse Determination, expressing dissatisfaction with the manner in which Kaiser Permanente or delegated entity provides health care Services, regardless of whether any remedial action can be taken. HEDIS (Healthcare Effectiveness Data and Information Set): The Healthcare Effectiveness Data and Information Set is a tool used by health plans to measure performance on important dimensions of care and Service. HEDIS is designed to assist purchasers and consumers with the information they need to compare the performance of managed health plans. Kaiser Foundation Health Plan of Ohio (KFHP): An Ohio nonprofit corporation which operates health care benefit plans and provides or arranges for the provision of Medically Necessary health care Services to Members. Kaiser Foundation Hospitals (KFH): A California nonprofit public benefit corporation, under which KFH agrees to provide or arrange for certain Medically Necessary hospital or facility Services for Members. Kaiser Permanente: Health Plan, Kaiser Foundation Hospitals, or Ohio Permanente Medical Group (OPMG), or any combination of one or more of them, as applicable. Revised 2011 6
Kaiser Permanente Medicare Plus: The brand name of Kaiser Permanente s Medicare Cost Plan. Law: Local, state or federal Law, regulation or rule, as applicable. Medically Necessary Services or supplies that are proper and needed for the diagnosis or treatment of a Member s medical condition; are used for the diagnosis, direct care and treatment of a Member s medical condition; meet the standards of good medical practice in the local community; are not mainly for the convenience of the Member or a Plan Provider; and, their omission would adversely affect a Member s health. Medical Necessity: Medical Necessity refers to a decision by the Health Plan that a requested treatment, test, or procedure is necessary for a Member s health or to treat a diagnosed medical problem. Medical Record Number (MRN): Unique identification number assigned to each enrolled Member of Kaiser Foundation Health Plan of Ohio. Medicare: The Federal Health Insurance for the Aged and Disabled Act. Medicare is an entitlement program run by the Centers for Medicare and Medicaid Services (CMS) of the federal government through which people age 65 and older or disabled receive health care insurance. Medicare Cost: Kaiser Permanente s Medicare Cost Plan is called Medicare Plus. Medicare Cost is a plan offered by Kaiser Foundation Health Plan of Ohio to Members eligible for Medicare and entitled to benefits under Medicare Part A and enrolled in Medicare Part B, or enrolled in Medicare Part B only. The difference in Kaiser Permanente s plan is that Kaiser Foundation Health Plan of Ohio is a secondary Payor to the Centers for Medicare & Medicaid Services (CMS). If a Member s health care is Authorized by Kaiser Permanente and coordinated by a Plan Provider, then Kaiser Permanente will pay for Deductibles and Coinsurance that CMS does not cover. Medicare Part D (Medicare Prescription Drug Coverage - Part D): The Medicare Modernization Act of 2003 (MMA) expanded Medicare to include outpatient prescription drug coverage to traditional Medicare, Medicare Cost plans and Medicare private fee-for-service plans that do not offer drug coverage. Part D also provides drug coverage for low income beneficiaries and protection for those with the highest annual drug costs. Revised 2011 7
MedImpact Health Care System: Pharmacy benefit management (PBM) company contracted with Kaiser Permanente to administer Eligibility and Claims payment for Plan pharmacies. Member: An individual entitled to Covered Services (at the time such Services are rendered) under a Membership Agreement issued by a Payor or an other arrangement with a Kaiser Payor. Members include the following categories: 1. Medicare Members who include: a. Medicare Advantage Members (formerly known as Medicare + Choice Members) are Medicare Members enrolled under a Medicare Advantage contract between a Kaiser Payor and the Centers for Medicare and Medicaid Services (CMS) of the US Department of Health and Human Services (DHHS). This definition will apply to Kaiser Foundation Health Plan of Ohio Members if Kaiser Foundation Health Plan of Ohio enters into a Medicare Advantage contract with CMS. b. Medicare Cost Members, who are enrolled under a Medicare Cost contract between Kaiser Foundation Health Plan of Ohio (or an other Kaiser Payor) and CMS. c. Medicare Fee-for-Service (FFS) Members, who are Members i. entitled to coverage under Part A only or Part B only or Parts A and B of Medicare but a. are not enrolled under a Medicare Advantage contract or a Medicare Cost contract between Kaiser Foundation Health Plan of Ohio (or an other Kaiser Payor) and CMS and b. for whom the Medicare program is the primary Payor for Medicare-covered Services under Medicare reimbursement rules, or ii. enrolled under a Medicare Advantage contract and are hospice patients receiving care from Plan Providers for Services unrelated to the hospice patient s terminal condition. 2. Commercial Members, who are Members who are not Medicare Members. Membership Agreement: A description of a plan of health benefits covered, issued, sponsored or underwritten by a Payor. The term Membership Agreement includes the relevant Evidence of Coverage, Statement of Coverage, Certificate of Insurance, or Summary Plan Description issued by an other Payor or other description of Covered Benefits issued to a Member, as amended from time to time. Meritain: The Third Party Administrator contracted with Kaiser Permanente to administer Claims payment for Tiers Two and Three of Kaiser Permanente s Added Choice Point-of- Service (POS) product. Revised 2011 8
National Committee for Quality Assurance (NCQA): A private not for profit organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers and the public sector. It is best known for its work in assessing and reporting on the quality of the nation s managed care plans through accreditation and performance measurement programs. To earn accreditation, a health plan must report on its performance in selected areas, including Member satisfaction, quality of care, access and Service. National Provider ID (NPI): NPIs are unique 10 digit numbers required by the Health Insurance Portability and Accountability Act (HIPAA) for all providers across the country. It is the standard system for uniquely identifying all providers of health care services, supplies and equipment. NPIs will be used to identify individual Kaiser Permanente Plan Providers in standard medical Claims and remittance advice transactions. Nonformulary: A prescription medication that is not on Kaiser Permanente's drug Formulary (list of Covered drugs). Ohio Permanente Medical Group, Inc. (OPMG): Kaiser Foundation Health Plan of Ohio has entered into an agreement with OPMG, an Ohio professional medical corporation under which OPMG agrees to provide or arrange for the provision of certain Medically Necessary professional and outpatient Services for Members. Out-of-Area Plan Preferred Provider Organization (PPO) Product: Kaiser Permanente s health plan designed for group employees who are living outside the HMO Service Area. Payment Dispute: If a Plan Provider is dissatisfied with a verbal response to a question or concern regarding the way a particular Claim was processed, the level of Claim payment, or the reason why the Claim was denied (other than Authorization denials), the Plan Provider may file a formal Payment Dispute in writing. Payor: Any entity that falls within either category below: 1. Kaiser Payor, a Kaiser Permanente affiliate having responsibility for the provision or arrangement of health care Services to Members. Without limitation, a Kaiser Payor includes a. a corporation or other organization owned or controlled, either directly or through subsidiary corporations, by Kaiser Foundation Health Plan, Inc. (such as Kaiser Permanente Insurance Company) or under common control with Kaiser Foundation Health Plan, Inc. (such as Kaiser Foundation Hospitals) and Revised 2011 9
b. any regional Permanente Medical Group; and 2. Other Payors, any public or private entity other than a Kaiser Payor that a. sponsors, administers, and/or funds a plan of health benefits coverage or is otherwise responsible for the arrangement for health care Services rendered to Members under a Membership Agreement and b. enters into an administrative and/or management service agreement with a Kaiser administrative services organization, an affiliate that is contracted to perform certain administrative and/or management services on behalf of an Other Payor, and includes a Kaiser Permanente regional health plan, where permitted by Law, and Kaiser Permanente Insurance Company (KPIC). PCP Roster: Monthly report of all Members enrolled with a Kaiser Permanente participating Primary Care Physician. Plan Facility(ies) Facilities owned and operated by Kaiser Permanente or hospitals, skilled nursing facilities, dialysis centers, ambulatory surgery centers, institutions, locations or any other sites (such as medical offices), used by Plan Providers (or any Subcontractor) to provide Covered Services to Members. Plan Physician: A Primary Care Physician or Specialist who works for the Ohio Permanente Medical Group or who is contracted with Kaiser Permanente to provide Covered Services to Members. Plan Provider: A Plan Facility, a Plan pharmacy, and/or Plan Physician. Point-of-Service Product (POS): A health benefit plan that allows enrolled Members the ability to receive care from a Plan Provider, or a preferred provider network physician, or any other licensed physician. Different benefit levels apply based upon which practitioners/providers are seen. The brand name of Kaiser Permanente s point-of-service product is Added Choice Point-of-Service (POS). Post-Service Appeal Requests for payment for Services already received by a Member, including Claims for out-of-plan Emergency Services. Only a Member or appointed representative may file a Post-Service Appeal. Practitioner(s): Health care Practitioners (including Physicians, nurses, physician assistants, nurse practitioners, and physical therapists) who, by way or ownership of, employment by, or Revised 2011 10
contracts with Plan Provider (or any Subcontractor) to provide Covered Services to Members. Precertification: A determination by Kaiser Permanente that an admission, extension of stay or other health care Service has been reviewed and, based on the information provided meets the clinical requirements for Medical Necessity, appropriateness, level of care, or effectiveness under the auspices of the Member s applicable health benefit plan. Precertified means provided pursuant to and in compliance with a Precertification. Pre-Service Appeal Requests that Kaiser Foundation Health Plan of Ohio provide or pay for a Service that a Member has not yet received. If Members receive any of the requested Services before a final determination is issued, the Appeal will become a Post-Service Appeal. Only a Member or appointed representative may file a Post-Service Appeal. Primary Care Physician (PCP): A Doctor of Internal Medicine, Family Practice, or Pediatrics contracted with Ohio Permanente Medical Group, Inc. to provide Medically Necessary health care Services to Kaiser Permanente Members and coordinate Referrals to other Plan Providers as needed. Private Health Care Services Network: The preferred provider network Kaiser Permanente contracts with to provide Tier Two Services outside of Ohio for Kaiser Permanente Added Choice Point-of-Service (POS) Members. Provider Manual: Kaiser Permanente s Manual of policies, procedures and guidelines applicable to Kaiser Permanente s Ohio Region, including billing procedures, Authorization and Referral policies and procedures, utilization management, quality assurance and improvement, Complaints, and other guidelines and criteria for providing health care Services to Members, as updated and supplemented by Kaiser Permanente from time to time. Reconsideration: Preliminary step of the Appeal process; request for review of a prospective or retrospective Adverse Determination. Referral: A prospective, written recommendation by a Plan Provider for medical care, equipment and/or supplies. A Referral is not approved until it is Authorized by Kaiser Permanente. Repatriation: The centralized Kaiser Permanente Repatriation team (Ohio Permanente Medical Group Physicians [OPMG], HUB Coordinator and staff) review Emergency Department and inpatient cases at hospitals for quality and resource stewardship. Kaiser Permanente may transfer stable patients, when appropriate, to Revised 2011 11
Plan Facilities where Kaiser Permanente Inpatient Care Managers and Ohio Permanente Medical Group physicians are on staff and medical records are electronically accessible. Physicians and staff at any facilities are able to talk directly with an OPMG Physician on the centralized Repatriation team 24 hours a day, seven days a week at 1-877-676-6270 or 216-524-5333 to facilitate a safe transfer. If there are any issues around approvals or denials, the facility and Member will be notified. Service Area: A geographic area approved by various regulatory agencies for Kaiser Permanente enrollment. The Ohio non-medicare Service Area includes the following counties: Cuyahoga, Geauga, Lake, Lorain, Medina, Portage, Stark, Summit and Wayne. The Medicare Cost Service Area includes the following counties: Cuyahoga, Geauga, Lake, Lorain, Medina, Portage and Summit. Services: Those Services, supplies and Facilities that Plan Providers or their Subcontractors customarily provide for the delivery of health care Services, including all consults, studies, tests and procedures that are ordinary and necessary for the diagnosis and treatment of their patients. Services also include all administrative Services provided by Plan Providers (or their Subcontractors) pursuant to their Agreement or this Provider Manual. Specialist: A Plan Physician contracted with Ohio Permanente Medical Group, Inc. to provide Medically Necessary health care Services to Kaiser Permanente Members, who by virtue of his/her training, residency and/or board certification concentrates on a particular category of diseases or the diseases of one particular part of the body. Subcontractor: Any person or entity, including a facility, individual practitioner (other than an employee of Plan Provider), practitioner group, or any other individual (including a substitute practitioner), that provides or arranges for Covered Services to Members pursuant to a direct or indirect agreement or other arrangement with a Plan Provider. Subrogation: The legal right to claim or receive compensation damages or other payment for Covered Services received when the action resulting in medical expense was the fault of another person. Subscriber: The person who applied for health care coverage with Kaiser Permanente and agrees to be responsible for payment. Traditional Health Maintenance Organization (HMO): Basic HMO, non-medicare health care plan offered to individuals or employees of contracted employer groups for a fixed prepaid premium. Revised 2011 12
Utilization Review: Utilization Review is a process used to monitor the use of, or evaluate the Medical Necessity, appropriateness, efficacy, or efficiency of health care Services, procedures or settings. Utilization Review exists to assist Members in receiving appropriate Covered Services. Visiting Member: A Member from another Kaiser Permanente Region who is temporarily away from their home Service Area and in the Ohio Service Area for less than 90 days. VSP Vision Care: Kaiser Permanente selected the VSP Advantage Provider network to provide routine optometry Services to Kaiser Permanente of Ohio Members. Revised 2011 13