KAISER PERMANENTE Medicaid Care Program User Guide
- May 15, 2024
- KAISER PERMANENTE
Table of Contents
KAISER PERMANENTE Medicaid Care Program User Guide
Introduction
Welcome to the Kaiser Permanente Network. As a valued Participating Provider, you provide services to members of the Kaiser Permanente Health Plan of the Mid-Atlantic States, Inc. You have access to many systems of care.
The legal name of our health maintenance organization (HMO) is Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (KPMAS). We operate under the trade name “Kaiser Permanente”. We are a subsidiary of the national organization, Kaiser Foundation Health Plan, Inc. The local HMO and its parent are both non-profit organizations.
Kaiser Permanente provides or arranges for health care services through an exclusive agreement between the Kaiser Foundation Hospitals, Inc., a non- profit corporation and the Permanente Medical Group. Each division of the national program has its own autonomous medical group. In the Mid-Atlantic States, the physician group is the Mid-Atlantic Permanente Medical Group, P.C. (MAPMG). All community-based Participating Providers who provide services to Kaiser Permanente members hold contracts with MAPMG. This Provider Manual and any revisions and updates shall serve as an extension of your contractual agreement with MAPMG and KPMAS.
This Service Area
Two local markets comprise Kaiser Permanente’s Service Area. The Metropolitan Washington local market includes the District of Columbia, counties in Suburban Maryland and counties in Northern Virginia. The Baltimore Metropolitan local market includes Baltimore City, Baltimore County and the surrounding suburbs of Anne Arundel, Harford, Howard, Carroll and Frederick counties.
Using This Manual
This Participating Provider Manual is intended to complement your on-site orientation and to be a reference manual for administrative procedures and clinical issues. It provides a quick and easy resource with contact phone numbers, detailed processes and site lists for various services.
These policies and procedures are specific to the KPMAS Participating Providers. Any change to the policies and procedures included in this manual will have an effective date at least sixty (60) days after distribution of the written notice of such change to all Participating Providers.
The Provider Experience Department is available to provide continued support to you and your office staff. This includes providing updates and revisions to this manual when issued, as well as supporting you and your staff with operational inquiries and education on new products or plans.
If, at any time, you have a question or concern about the information outlined in this manual or about the Kaiser Permanente Medical Care Programs, you can reach the Kaiser Permanente Provider Experience Department by calling ****877-806-7470.
Provider Experience Department
KPMAS is committed to supporting the role of the Network Participating
Providers – community providers who are contracted and credentialed. The
Provider Experience Department staff provides comprehensive and personalized
support for all Participating Providers and their staff.
As the liaison between the Participating Providers and KPMAS, the Provider
Experience staff is responsible for the following support functions:
- Ensuring that each Participating Provider’s issues or concerns are addressed and resolved to satisfaction
- Communicating pertinent information regarding medical management procedures, compensation models, referral processes and new products to all Participating Providers
- Assisting Participating Providers in identifying appropriate network medical facilities and services available for patient care
The Provider Experience Department can be contacted at ****877-806-7470.
Utilization Management Operations Center
The Kaiser Permanente Utilization Management Operations Center (UMOC) is a telephonic Utilization Management (UM) and Referral Management Service Center designed to assist the MAPMG and Participating Providers in coordinating health care services (preservice) for Kaiser Permanente members.
To contact UMOC call 800-810-4766. For external referral, fax 800-660-2019 or send a referral message by logging on to Online Affiliate at www.providers.kp.org/mas.
- Authorization services for planned inpatient, outpatient or office care are available Monday-Friday from 8:30 A.M. to 5 P.M.
- Urgent preservice referrals are managed seven days a week, including holidays from 8:30 A.M. to 5 P.M.
- On weekends and holidays, nurses can be reached from 8:30 A.M. to 5 P.M. by calling the UMOC Weekend and Holiday Line: 301-960-1436.
Registered Nurses at the UMOC work collaboratively with licensed, board-
certified UM Physician Managers and practitioners in managing the patient’s
medical, surgical, or behavioral health care through telephonic utilization
review of requested services and equipment, and by coordinating care across
the continuum.
The following services are coordinated through the UMOC:
- Preservice Medical, surgical admissions to acute care facilities;
- Preservice Medical, post-surgical
- Retrospective review of inpatient acute care that was not pre-authorized
- Retrospective review of outpatient care that was not pre-authorized
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- Home care
- Durable medical equipment (DME)
- Follow-up primary care practitioner
- Specialty referrals (including radiology and laboratory) outside KPMAS centers
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Pre-service review is required for selected procedures and services. This process is administered at the UMOC. UMOC registered nurses (RNs) (Referral and DME and Home Health nurses) and UM ancillary staff manage the referrals following KPMAS UM policies and procedures. Referrals requiring medical necessity review are forwarded to Board Certified UM Medical Directors. All UM Physicians are Certified Medical Directors by the State of Maryland. The UMOC can be reached at ****800-810-4766 and follow the prompts to speak with a staff member. The UMOC staff can assist with the following:
- Provide information regarding utilization management processes
- Check the status of referral or an authorization
- Provide copies of criteria/guidelines utilized for decision making
- Answer questions regarding a benefit denial decision
- Connect callers to a UM physician on any adverse medical necessity denial decision ( ****800-810-4766 and select the appropriate option when prompted)
Member Services Department
The Member Services Department has representatives to assist both Participating Providers and members who call for:
- General verification of member eligibility/ enrollment
- Clarification of member benefits and coverage
- Information about services available at KPMAS medical facilities
- Maps, driving directions, and other KPMAS literature
- Information about or assistance with filing a complaint or appeal
- Assistance with solving a problem
- Information about plan providers/assistance with selecting a Primary Care Physician (PCP)
- Requests for replacement member identification card(s)
- Requests by a member to change the member’s address or phone number
KPMAS Member Services representatives can be reached Monday – Friday between 7:30 A.M. and 9:00 P.M.. KPMAS Medicare Members Services can be reached seven days a week between 8:00 A.M. and 8:00 P.M.
Member Services: **800-777-7902
Medicare Member Services :
**888-777-5536
TTY for the hearing impaired: ****711
Patient Medical Centers & Network Resources
This section includes the location, hours, phone numbers and services offered at:
- Kaiser Permanente Medical Centers
- Participating Hospitals
- Kaiser Permanente Ambulatory Surgery Centers
- Kaiser Permanente Urgent Care – After Hours Medical Centers
For complete listing of medical centers and network resources for Flexible
Choice members, see Section 15.0 of this manual.
This resource listing is accurate and complete, as of the date of
distribution. The continued availability and location of physicians or
services at any Kaiser Permanente Medical Center is subject to change.
Addresses, telephone numbers, and hours of operation are subject to change in
our Provider Directory and/or our Provider Website. Not all services are
available at each medical center or site. Kaiser Permanente reserves the right
to relocate services. Consult our online directory at
https://healthy.kaiserpermanente.org/ for the most current listing of Kaiser
Permanente Medical Centers, participating Hospitals, and Participating
Provider locations.
If, at any time, you have any questions or concerns about Kaiser Permanente and/or Participating Provider resources available to members please, contact Provider Experience at
**877-806-7470.
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