Kaiser Permanente Provider Newsletter Affiliated HMO and QUEST Provider User Guide

Kaiser Permanente Provider Newsletter Affiliated HMO and QUEST Provider

Product Information

Kaiser Permanente Pediatric Occupational Therapy Services

Kaiser Permanente offers Pediatric Occupational Therapy Services based on medical necessity with a focus on functional outcomes.
These services aim to enhance a child’s successful participation and independence in self-care, productive, and leisure activities.

Authorization Requirements

• Only claims with specific CPT codes will be authorized
• Failure to obtain proper authorization or perform services not included in the specified list will result in claims denial

Specifications

• CPT Codes: 97165, 97166, 97167, 97168, 97110,
  97112, 97129, 97530, 97535

• Effective Date: March 15, 2024

Product Usage Instructions

Authorization Procedure

Providers must strictly adhere to the authorization procedures for the specified CPT codes for efficient claims processing.

Provider Disputes

1. Access KP OLAOnline Affiliate, a secured 24/7 tool.
2. Use the Claim Dispute/Reconsideration Form on the Community Provider Portal.
3. Contact the Claims Customer Service Department at 1-877-875-3805 and request a Reference/CRM # after your call.

FAQ

What should I do if my claim is denied?

If your claim is denied, ensure you have followed the proper authorization procedures and performed services included in the specified CPT codes list.
If you believe the denial is incorrect, you can dispute it using the provided options in the Provider Disputes section.

Aloha, Affiliated Contracted Providers! We have provided a few important reminders and updates.

MD CALL CENTER808-643-6363

• This ED-to-ED emergency transfer hotline is staffed 24/7 by emergency department RNs, who work directly with our emergency department physicians at Kaiser Permanente Moanalua Medical Center.
• When you encounter a Kaiser Permanente member at your emergency department who may need to be admitted or requires follow-up care, we request that you call the MD Call Center (808-643-6363), which will be able to assist you in providing care to our members, including transfers and follow-up care. When necessary, the support staff will also arrange for Medical Flights for inter-island transfers.

Clinical Review Guidelines Reimbursement Policy

Providers may receive letters that provide information on rules that govern National Payment Integrity (NPI) Clinical Review processes related to determining payment for claims under review.
NPI Clinical Review is responsible for reviewing facility and professional claims to ensure that providers comply with billing and coding standards that services rendered are appropriate and medically necessary, and that payment is made under applicable contract, provider manual, and policy requirements, including guidelines. Please see the attached Clinical Review Policy.

Clinical Review Payment Determination

Pediatric Occupational Therapy Services Authorization Requirements

• Kaiser Permanente (KP) Pediatric Occupational Therapy Services are based on medical necessity with an emphasis on functional outcomes.
• The focus of KP Pediatric Occupational Therapy Services is to increase a child’s successful participation and independence with their self-care, productive, and leisure activities.
• In alignment with this focus, effective March 15, 2024, Kaiser Permanente will only authorize claims for Pediatric Occupational Therapy Services with the following CPT codes:

Evaluation

Code| Description
97165| OT Evaluation, Low Complexity
97166| OT Evaluation, Moderate Complexity
97167| OT Evaluation, High Complexity
97168| OT Re-evaluation
Therapeutic Procedures

Code| Description
97110| Therapeutic Procedure
97112| Neuromuscular Reeducation
97129| Therapeutic Interventions that focus on

Cognitive Function + 97130 (for each additional 15 minutes of 97129)

97530| Therapeutic Activities
97535| Self-care/Home Management Training

Failure to obtain proper authorization or perform services not included on the above list will result in claims being denied. We kindly urge you to strictly adhere to the authorization procedures for the specified codes for efficient claims processing.

Electronic Visit Verification (EVV) Manual Editing and Entry of Visits

• Med-QUEST Memo QI-2305B (Update to QI-2305A)
• All Home Health and Home Care Agencies need to limit their EVV manual edits and entries to no more than 15% per month. Oversight and corrective actions by QI Health Plans will begin on April 1, 2024.

Provider Disputes

Important information about your rights to dispute our determination on this claim

1. The preferred and quickest option is to access KP OLA-Online Affiliate, a secured 24/7 tool.
2. Use the Claim Dispute/Reconsideration Form located in the Community Provider Portal.
3. Contact our Claims Customer Service Department at 1- 877-875-3805 for all your inquiries and make sure to request a Reference/CRM # after your call.

Quest Updates

QUEST Provider Manual Important Reminders

(Hawaii Medicaid Provider Bulletin) – Provider Billing—Clients—Billing Limitations—4.6.1
Providers must accept the Medicaid Program’s established rates as payment in full.

• Providers may not bill or collect from Medicaid clients the difference between a provider’s charge and the total payments received from all sources including Medicaid.
• A provider may bill and accept payment from a Medicaid client only for TPL payments and the patient’s cost share.

QUEST HOKU Registration Requirement

• QI-2315, Requirement for Providers To Register With Hoku For Active Status.
• Health plans are required to ensure that existing and new providers who are providing services to Hawaii Medicaid members are registered in the HOKU system.
• Effective January 1, 2024, provider payments will be denied for providers not registered in HOKU. Payments will be reprocessed once HOKU registration is confirmed.

QUEST Provider Directory and Data Quality Requirements

• Provider monitoring and quality checks will be developed with the Med-QUEST Division.
• Providers are required to send updates to health plans if there are changes to the following data.
• Individual and Company name changes
• Service address
• Phone numbers
• Provider is accepting new Medicaid patients
• Accommodation for individuals with physical disabilities
• If Telehealth services are offered
• Cultural and linguistic capabilities including interpreter services.

Medicaid Eligibility Redetermination Information for Members

Stay Well Stay Covered

• After a 3-month pause, the Department of Human Services Med-QUEST Division (MQD) restarted the Medicaid eligibility renewal process in December 2023.

Med-QUEST is asking members to do the following:

• Update your contact information by logging into your QUEST account at: https://medical.mybenefits. hawaii.gov or call your Health Plan. Kaiser Permanente Customer Service: 808-432-5330 or 1-800-651-2237 or email kpquest@kp.org.
• If you no longer need QUEST (Medicaid) coverage, call Med-QUEST at 1-800-316-8005 or TTY/TDD 711 to let them know.
• Check your mail and watch for a pink envelope from Med-QUEST with instructions on eligibility renewals. A response may be required to maintain health coverage. Follow all instructions and respond, if applicable.
• If you no longer qualify for QUEST (Medicaid), check with your employer to see if you are eligible for health insurance coverage.
• If you are not eligible for health insurance through your employer, please visit the Health Insurance Marketplace at HealthCare.Gov or call 1-800-318-2596
• Med-QUEST will also be reaching out to members via text messages and phone calls to help them Stay Well and Stay Covered. Text messages will be sent from 45421 and automated phone calls will originate from 808-556-5748. These numbers are only used for outbound communications and no calls will be accepted. If you have questions, please contact the Med-QUEST service center at 1-800-316-8005. Please be aware of scams from other numbers. Med-QUEST will never ask for confidential member financial information over the phone.
• Members who no longer qualify for QUEST (Medicaid) can explore other Kaiser Permanente health plan options at https://continuecoverage.kaiserpermanente.org/

Provider Trainings

• In-Person: Fridays from 9:00 a.m. to 11:00 a.m.
• Behavioral Health: Every 3rd Tuesday from 10:00 a.m. to 11:00 a.m.
• Onboarding (New Provider) and Annual Refresher (Current Provider) Training: Every 2nd Thursday of each month from 10:00 a.m. to 11:00 a.m.
• QUEST Integration — HCBS/LTSS/Foster Home: Every 2nd and 4th Wednesday from 12:00 p.m. to 1:00 p.m.

Contact Information

• Customer Service — 800-966-5955, 808-432-5300 (fax)
• Medicaid/QUEST Integration (QI) — 808-432-5955, 800-651-2237 (fax), 808-432-5260 (fax)
• Medicaid/QI with Nurse Line off hours — 808-432-5330
• Added Choice Helpline — 800-238-5742, 800-392-8649 — Added Choice
• MD Call Center — 808-643-6363
• Authorizations / Referrals Management — 800-432-5687, 808-432-5691 (fax) — Authorizations
• DME Authorizations — 808-432-5692, 808-432-5689 (fax)
• BH Information / Appointments — 808-432-7600
• BH Authorizations — 808-243-6031
• Provider Credentialing — 808-432-7990, ext. 27927 — HI-Credentials-Department@kp.org
• Claims Department — 877-875-3805 — Mailing Address: P.O. Box 378021, Denver, CO 80237
• Continuing Care Department — 808-432-7100
• Pharmacy Administration — 808-432-5854
• Transportation, Meals, Lodging, Hearing Aides, Medical Supplies/QI — 808-432-5330 or 1-800-651-2237
• Home Health Care — (Oahu) 808-432-4661 (Maui) 808-243-6681
• Provider Demographic or Contact Changes — providerdemographicshawaii@kp.org
• Provider Relations —NDANDAPROVIDERRELATIONS@kp.org
• Provider Manuals — HMO Provider Manual and QI Provider Manual
• QI Provider Education / Training Documents — QI Provider Education and Training Documents
• Online Affiliate Tool / Provider Manual Cultural Competency Plan — Online Affiliate Support EDI/ERA/EFT — EDI
• Office Ally Payer ID — 94123 360-975-7000 — https://cms.officeally.com/
• Office Ally DDE — FREE*. This Online Claim Entry tool allows you to create CMS1500, UB04, and ADA claims on its website and submit them to KP — 360-975-7000 — Office Ally
• OLA – Online Affiliate Tool — Online Affiliate
• Check Claim Status (ANSI 276/277) Verify Member Benefits / Eligibility (ANSI 270/271) — Claims
• Hawaii Entity Agreement — Hawaii Entity Agreement
• Guest Access User Guide — Video Tour View Claim Status
• 1099 Forms — 1099Misc@kp.org

Documents / Resources

| Kaiser Permanente Provider Newsletter Affiliated HMO and QUEST Provider [pdf] User Guide
Provider Newsletter Affiliated HMO and QUEST Provider, Newsletter Affiliated HMO and QUEST Provider, Affiliated HMO and QUEST Provider, QUEST Provider
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References

• Hawaii.gov | The Official Website of the Aloha State
• Still need health insurance? | HealthCare.gov
• Healthcare Software for Your Medical Practice | Office Ally
• Continuation of Health Care Coverage | Kaiser Permanente

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