Provider Manual Section 1: Kaiser Permanente Medical Care Program

Transcription

1 Provider Manual Section 1: Kaiser Permanente Medical Care

2 Welcome to Kaiser Permanente of Ohio It is our pleasure to welcome you as a Plan Provider with Kaiser Permanente of Ohio. As a valued Plan Provider, we want this business relationship to work well for you, your medical support staff, and our Members. This section of the Manual was created to help provide you and your staff with basic organizational information regarding the Ohio Region of Kaiser Permanente. Our Network Development and Performance Department is committed to providing support to you and your staff. This includes responding to your operational inquiries and providing education regarding new products and plans. If, at any time, you have a question or concern about the information outlined in this Manual, you can reach our Provider Relations Department by calling toll-free , option 1. Welcome to Kaiser Permanente of Ohio. Revised February

3 Table of Contents INTRODUCTION... 4 SECTION 1: KAISER PERMANENTE MEDICAL CARE PROGRAM HISTORY ORGANIZATIONAL STRUCTURE Kaiser Foundation Health Plan of Ohio ( Health Plan ) Kaiser Foundation Hospitals ( KFH ) Ohio Permanente Medical Group, Inc. ( OPMG ) KAISER PERMANENTE OF OHIO SERVICE AREA Kaiser Permanente Medical Facilities in the Kaiser Permanente Service Area... 7 Revised February

4 Introduction This Provider Manual ( Manual ) is referenced in your Agreement ( Agreement ) with a Kaiser Permanente entity. The information in this Manual is proprietary and may not be used, circulated, reproduced, copied or disclosed in any manner whatsoever, except as specified in your Agreement, or with prior written permission from Kaiser Foundation Health Plan of Ohio. This Provider Manual is posted on the Kaiser Permanente s Community Providers website at providers.kaiserpermanente.org/oh. Updates, changes and additions to the information contained herein are posted on this website and made part of this Manual as the date posted thereon, unless otherwise required by your Agreement or applicable Law. If there is a conflict between this Manual and your Agreement, the terms of your Agreement will control. All defined terms in Section 12 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. Network Development and Performance Department (Provider Relations) For your convenience, Kaiser Permanente has established a phone system that allows Plan Providers to call one phone number to address most issues or questions regarding Kaiser Permanente Plan protocols or Kaiser Permanente Members. Representatives are available to answer your questions Monday through Thursday, from 8:15 a.m. to 5 p.m. and on Fridays from 9 a.m. to 5 p.m. Once you dial (toll free), you will be prompted to select one of the following options: Option 1: Option 2: Option 3: This option will connect you with a representative in the Customer Relations Department who can assist with any of the following inquiries Member Eligibility and Covered Benefits verification. Claims payment inquiries (that is, to check on the status of Claim payment, an over or under claim payment, a denial or partial denial of Services, or Coordination of Benefits). Claims submission questions. Obtain current Plan Provider directories. EDI clearinghouse information. If a Kaiser Permanente Member needs to be admitted to a hospital, select option 2. Option 2 will connect you with a representative in the Kaiser Permanente Repatriation Department. To initiate an urgent or emergent request for Services requiring Referral or Precertification, select option 3. Option 3 will connect you with a representative in our Referrals Management and Clinical Review Department ( [toll free]). To initiate a new Referral request Revised February

5 for routine Services requiring Authorization, fax your request to the Kaiser Permanente Referrals Management and Clinical Review Department at For the following inquiries, contact your Network Associate: Add or delete a Practitioner in the practice. Confirm or change the open or closed status of a Practitioner s practice with Kaiser Permanente. Provide demographic updates. Agreement questions. See Section 2 of this Manual for a contact list of Associates, by territory. If a Member has a question about Covered Benefits, desires to change his/her Primary Care Physician, would like to file a compliment or Complaint, or appeal an Adverse Determination, refer the Member to Kaiser Permanente s Customer Relations Department, Monday through Thursday, 8:15 a.m. to 5 p.m., and Friday, 9 a.m. to 5 p.m. at (toll free). The hearing/speech impaired may call (toll free TTY). Revised February

6 1.1 History Kaiser Permanente s origins date back to the late 1930s and the prepaid health program developed by industrialist, Henry J. Kaiser and a young physician, Dr. Sidney R. Garfield. Initially, the health care program was only available to construction, shipyard and steel mill workers employed by the Kaiser Permanente industrial companies during the late 1930s and 1940s. The program was opened for enrollment to the general public in Today, Kaiser Permanente is one of the largest nonprofit integrated health systems in the country. It is a nonprofit group practice program headquartered in Oakland, California. Kaiser Permanente serves more than 8.7 million Members in nine states and the District of Columbia. Kaiser Permanente encompasses the nonprofit Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals and their subsidiaries, and the for-profit Permanente Medical Groups. Nationwide, Kaiser Permanente includes approximately 164,000 technical, administrative and clerical employees and caregivers, and more than 15,000 Practitioners representing all specialties. Traditionally, Kaiser Permanente Members receive Covered Services directly from Practitioners in the Ohio Permanente Medical Group (OPMG). In order to expand our product offerings and enhance our marketability, Kaiser Permanente of Ohio has broadened its choices of Plan Providers to include local community-based Practitioners and Providers who share the commitment to providing appropriate, high quality care to Members. 1.2 Organizational Structure Kaiser Permanente of Ohio is comprised of three separate legal entities: Kaiser Foundation Health Plan of Ohio ( Health Plan ) Health Plan is a tax-exempt organization that operates health care benefit plans and provides or arranges (primarily through Kaiser Foundation Hospitals [KFH] and the Ohio Permanente Medical Group [OPMG]) for the provision of Medically Necessary health care Services for its Members Kaiser Foundation Hospitals ( KFH ) KFH is a tax-exempt organization that owns, operates, and contracts for hospital, skilled nursing, dialysis, home health and other Facility Services. KFH also sponsors charitable, educational, and research activities. Health Plan contracts with KFH to provide or arrange for Medically Necessary hospital and Facility Services for Members. In turn, KFH contracts with community Providers to provide Covered Services to Members and improve geographic coverage and access to care. Revised February

7 1.2.3 Ohio Permanente Medical Group, Inc. ( OPMG ) OPMG is a professional corporation of Practitioners. Kaiser Foundation Health Plan of Ohio contracts with OPMG to provide or arrange for Medically Necessary professional and outpatient Services for Members. In turn, OPMG contracts with community Practitioners to provide professional Services to Members, and improve geographic coverage and access to care. A Key Contact list with location and telephone numbers for specific Kaiser Permanente of Ohio personnel and departments available to assist Plan Providers can be found in Section 2 of this Manual. 1.3 Kaiser Permanente of Ohio Service Area The chart below indicates those counties that are within the Service Area of each product offered by Kaiser Permanente of Ohio. Health Maintenance Organization (HMO) Kaiser Permanente Added Choice Pointof-Service (POS) Kaiser Permanente Self-Funded Exclusive Provider Organization (EPO) Kaiser Permanente Medicare Plus (Medicare Cost) Cuyahoga Geauga Lake Lorain Medina Portage Stark Summit Wayne Kaiser Permanente Medical Facilities in the Kaiser Permanente Service Area The following map of the Ohio Service Area indicates the locations of all Kaiser Permanente medical Facilities within the state of Ohio. An ancillary directory with a listing of Kaiser Permanente laboratory, imaging, and pharmacy locations is posted on the Kaiser Permanente s Community Providers website at providers.kaiserpermanente.org/oh. If you prefer a paper directory, contact your Network Associate or the Kaiser Permanente Customer Relations Department at tollfree , option 1. To schedule an appointment at a Kaiser Permanente Medical Facility or to speak with an Ohio Permanente Medical Group Practitioner, call the Member Service Center at (toll free). The hearing/speech impaired may call (toll free TTY). Revised February

8 Revised February