Kaiser Permanente
QUEST Integration
Provider Manual
March 2024
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This Provider Manual is available to all Kaiser Permanente QUEST Integration providers in
electronic version unless the provider requests a hard copy. The Provider Manual is available
online at no additional charge here: QUEST Integration | Community Provider Portal | Kaiser
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
KP22-016 Provider Manual
Permanente. Requests for hard copies are provided at no charge to the provider within thirty
(30) days.
The electronic version of the Provider Manual will be updated within five calendar days of any
changes. Kaiser Permanente QUEST Integration providers will be notified of changes made via
email broadcast. Providers, and network providers making a request, will be notified in writing.
Providers may also be notified of updates in the provider newsletter. All notifications will be
available at no additional charge.
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Aloha & Welcome
As a Practitioner with Kaiser Permanente Hawaii, you are part of a unique organization within
the community. Our size and experience enable Kaiser Permanente to attract outstanding
physicians and professional staff who provide our members with quality and compassionate care.
Kaiser Permanente is committed to preventing disease, promoting health, and serving our
members by Caring for Hawaii’s People like Family. We take pride in the skills, experience and
caring that our physicians and staff offer our members. Working as a team, our medical staff
provides comprehensive, high-quality medical care to more than 253,000 members statewide.
Our relationship with you is very important to us. Our goal is to provide you with the best quality
support and communication as we continue our partnership. To help the relationship run
smoothly, we present this manual to provide information about Kaiser Permanente. This
manual is designed as a reference guide for you and your staff. The contents will be periodically
updated as we continue to move forward to improve best practices in alignment with the
National Committee for Quality Assurance (NCQA), and Federal and State regulatory agencies.
In addition, we welcome your suggestions to support your needs. Please share this manual with
your Admissions, Quality Assurance, Business Offices and any other appropriate staff. Feel free
to place this manual on your computer systems for access by your departments. However,
because it is copyrighted, please do not reproduce it.
Kaiser Permanente appreciates your willingness to work with Kaiser Permanente and looks
forward to a continued valuable relationship. Thank you for your participation and should you
need additional information or have any questions, please do not hesitate to contact the Provider
Contracting and Relations staff at 808-432-5429.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
KP22-016 Provider Manual
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Table of Contents
Chapter 1: About Kaiser Perman ente 5
Who Are We? 5
Our Service Ar eas 5
Our Medicaid Members 6
Our Structure 6
Our Hawa ii Service Area 7
Our Medical Group’s Values Statement 7
Chapter 2: Contact Information 8
Chapter 3: Membership Identification Card 9
Chapter 4: Member Rights and Responsibilities 9
Member Rights a nd Responsibilities 10
Hospital pat ient rights and responsibilities 13
Member Inquiry and Grievances Process 15
General Requirements for Member Inquiries and Grievances 17
Member Grievance Process 17
Filing a claim 18
Appeals 18
Expedited review 20
External rev iew 21
Medicaid ombudsman program 23
Access to Care Standards 24
Interpreter/translation services 24
Advance Directives for Health Care 24
Cultural Competency Plan 24
Implementing Stepped approach to Behavioral Health 25
Chapter 5: Availability of Providers 26
Chapter 6: Provider Rights and R esponsibilities 26
Provider Requirements 26
Reporting Overpayme nts and Refunding Kaiser Permanente 27
PCP Selection and Change 27
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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PCP Monitoring 28
Provider Access 29
Hospitalists 29
Provider Grievances & Appeals 29
Out-of-Plan/Network Referrals 32
Prior Authori zations 33
Prior Authori zations for Non-Emergency Tra nsportation Services 33
How to Submit a Prior Authorization 34
Transition of Car e 35
Chapter 7: Compliance and Fraud, Waste, and Abuse 36
Compliance with the Law 36
Kaiser Permanente Principles of Responsibility 36
Kaiser Permanente Ethics and Compliance Progr am Description (C ompliance Plan) 37
Fraud, Waste, and Abuse (FWA) 37
Chapter 8: Quality Management Program 38
Integrated Quality Program 38
Utilization Management P rogram 38
Guidelines for Patient Medical Records 39
Chapter 9: Pharmaceutical Management Pro cedures and Drug Formulary 41
Chapter 10: Credentialing 42
Credentialing 42
Confidentiality of Credentialing Information 45
Chapter 11: Claim and Invoice Submission 45
Members with Ot her Insurance 62
Claims Adjudication Overview 66
Claim Co des 66
Claim Co de Distribution 67
CRM Process 67
Chapter 12: Kaiser Permanente QUEST Integration Program Covered Benefits 68
QUEST Integra tion Covered Benefits a nd Services 70
Value-Added Services 99
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Covered by DHS Med-QUEST but not by Kaiser Permanente 100
Services from other agencies in the com munity: 101
Services that are typically NOT covered under the QUEST Integration Program 103
Emergency Services 104
QUEST Integration Health Coordination 105
Definitions 108
Chapter 1: About Kaiser Permanente
We hope the following overview of Kaiser Permanente organization will help you learn about
Kaiser Foundation Health Plan, Kaiser Permanente's history, and the philosophy of Kaiser
Permanente.
Who Are We?
Kaiser Permanente is one of the nation's largest not-for-profit health plans, serving 12.6 million
members. At Kaiser Permanente, physicians are responsible for medical decisions. The
Permanente Medical Groups, which provide care for Kaiser Permanente members,
continuously develop and refine medical practices to help ensure that care is delivered in the
most efficient and effective manner possible.
Founded in 1945, Kaiser Permanente headquartered in Oakland, California, comprises:
Kaiser Foundation Health Plan, Inc.
Kaiser Foundation Hospitals and its subsidiaries
The Permanente Medical Groups
Mission
Kaiser Permanente exists to provide high-quality, affordable health care services and to
improve the health of our members and the communities we serve.
Our Service Areas
Kaiser Permanente evolved from private industrial medical care programs during the 1930s and
1940s and opened enrollment to the public on California’s West Coast in 1945. Today, Kaiser
Permanente serves the following local markets:
Northern and Southern California
Colorado
Georgia
Hawaii
Mid-Atlantic States (Maryland,
Washington, D.C., Virginia)
Pacific Northwest (Oregon and parts of
Washington)
Washington
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Kaiser Permanente service areas are subject to change at any time. Learn more at kp.org
Our Medicaid Members
Beginning in 1971, with 500 public assistance families under a contract with the Hawaii
Department of Human Services called X5, Kaiser continued to provide services to families with
low-to-moderate income not eligible for public assistance through federal and state contracts. In
August 1994, Kaiser was one of the first health plans to participate in the Hawaii QUEST
program. Effective January 2015, Kaiser became one of five health plans participating in the
QUEST Integration program, which integrates the aged, blind, and disabled population into the
prior QUEST program. The goal of the QUEST Integration program is to improve health
outcomes by integrating programs and benefits, streamline care for members when health status
changes, and to minimize the administrative burden on providers.
At Kaiser Permanente, we aim to not only increase access to care for the undeserved, but also
to ensure these populations are afforded high-quality care. This is especially relevant for
members whose multiple or high-risk conditions account for a larger share of medical services.
We take pride in knowing that our members in these programs will have the same access and
quality standards as all other members.
Our Structure
Kaiser Permanente is a collaborative organization of three contractually linked organizations
briefly described below. Joint decision-making by the professions of medicine and business
management, including all significant Program policy, planning, and resource allocation
decisions, enables Kaiser Permanente to continue its pursuit of excellence in care and services
for its members.
The Kaiser Foundation Health Plan, Inc. (KFHP) is a nonprofit corporation with t he
responsibilities of marketing, benefit plan design, computation of rate struct ures, data collection
and enrollment. It contracts with the Hawaii Permanente Medical Group, Inc. and Kaiser
Foundation Hospitals to provide health care services to members.
Hawaii Permanente Medical Group, Inc. (HPMG) is a for-profit corporation of board-eligible
and board-certified physicians and other health care providers representing all major specialties
and most subspecialties. It contracts with Kaiser Foundation Health Plan, Inc. to provide care
to members at Kaiser Permanente’s medical offices and hospital. The contract with Kaiser
Foundation Health Plan, Inc. helps providers focus their attention on the practice of medicine
rather than devoting energy to administrative tasks and the acquisition of facilities and
equipment.
Kaiser Foundation Hospitals (KFH) is the third component of the Kaiser Permanente
organization. It is a nonprofit corporation which provides hospital care, including room and
board, nursing care and other standard services provided by a large community hospital.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Our Hawaii Service Area
The Hawaii Service Area of the Kaiser Permanente health care program began in 1958. It
introduced the concept of a group practice prepayment plan to Hawaii's residents. Beginning
with one medical center and 5,000 members, Kaiser Permanente now serves more than 260,000
members and features the Moanalua Medical Center in addition to more than 20 convenient
locations on the islands of Oahu, Maui, Hawaii and Kauai. Services provided on the island of
Kauai consist of contracts with independent primary and specialty practitioners including
specialty care at the Kauai Medical Clinic. Kaiser Permanente currently owns and operates a
275+ bed inpatient facility.
Kaiser Permanente only offers QUEST Integration managed care membership to Medicaid
beneficiaries who reside on the islands of Oahu and Maui.
Our Medical Group’s Values Statement
The Hawaii Permanente Medical Group (HPMG) seeks associate physicians and other
providers who support and promote Kaiser Permanente's mission of providing quality care and
comprehensive medical services in an accessible, cost-effective manner for m embers. In addition,
the HPMG Board of Directors has identified professional and personal values that enhance
individual and collective medical practice. The following are our core values:
The characteristics of pro fessional competency, integrity, flexibility, reliability,
compassionate caring, and a striving for excellence are core values necessary for our
associates. Furthermore, we value good-natured team players who are approachable by
colleagues and staff. We expect our associates to be hardworking professionals capable
of an innovative approach to solving problems, who make efficient use of time and
resources. And we expect a professionally appropriate attitude that embraces and
accepts cultural diversity, excluding bigotry and prejudice.
We value individuals who are responsive to constructive criticism and demonstrate
courtesy and respect to fellow workers as well as patients. We place value on quality
work with consistent standards. It is important for Kaiser Permanente to recognize
professional limitations in forming the boundaries of work, matching confidence with
competence.
We seek associates who will actively assist the organization to function efficiently and
effectively. Our strength comes from a shared sense of responsibility for the Medical
Group and from our collective talents as medical professionals. Finally, we seek to
achieve a balance between a satisfying career and a fulfilling personal life.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Chapter 2: Contact Information
We appreciate your willingness to work with Kaiser Permanente in providing quality care to
our Members. The Hawaii Kaiser Permanente Provider Contracting and Relations Department
is committed to providing support to you and your staff which includes answering your
contractual and operational questions.
Should you need additional information or have any questions, please do not hesitate to contact
the Provider Contracting and Relations team or other departments as listed below:
Contact Numbers
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
KP22-016 Provider Manual
General
information/assistance
Claims: 1-877-875-3805
Customer Service: 1-808-432-5955
(Oahu), 1-800-966-5955 (Toll Free)
Monday through Friday
8 a.m. to 4:30 p.m.
Assistance with QUEST
Integration Health
Coordination
Kaiser Permanente QUEST
Integration Provider Call Center
808-432-5330 (Oahu)/
1-800-651-2237 (toll-free) or by
TTY 1
-
877
-
447
-
5990
Monday through Friday except
Kaiser Permanente -
Observed Holidays
7:45a.m. to 4:30 p.m.
Questions regarding claims Claims Customer Service
Department (877) 875-3805
Monday through Friday except
Kaiser Permanente -
Observed Holidays
7:45 a.m. to 4:30 p.m.
Routine transfers
Oahu Outside Care Coordinator
808-432-7252
808-432-7250 – after hours
Fax: 808-432-7251
Monday through Friday except
Kaiser Permanente -
Observed Holidays
8 a.m. to 4:30 p.m.
Emergency transfers to
Kaiser Permanente
Moanalua Medical Center &
routine transfers after clinic
hours
Emergency Hotline
808-432-7038 24 hours
Questions regarding out of
plan services and
authorization
Authorization and Referrals
Management
808-432-5687
808-432-5691 (facsimile)
Monday through Friday except
Kaiser Permanente -
Observed Holidays
8 a.m. to 4:30 p.m.
Questions regarding the
QUEST Integration program
Kaiser Permanente QUEST
Integration Call Center
808-432-5330 or toll-free at
1-800-651-2237
Monday through Friday
except State holidays
7:45 a.m. to 4:30 p.m.
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Chapter 3: Membership Identification Card
When enrollment forms have been processed, the Kaiser Foundation Health Plan sends each
new member a permanent membership card (example below). The card displays the member's
medical record number which is used for identification.
[
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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]
The QUEST Integration identification card has additional information required by DHS:
Member’s Kaiser Permanente Member Identification Number
Member’s name
Effective date of member’s Kaiser Permanente QUEST Integration coverage
Primary clinic name and telephone number
Third Party Liability (TPL) information
QUEST Integration Call Center telephone number
After Hours Advice Line telephone number
How to use the identification cards:
Members should show their Kaiser Permanente identification card and photo ID when they
need medical care or services. Even if they do not have their card, we can still verify coverage in
our membership system as long as they bring a photo ID. Members should only use their cards
when they have maintained their Kaiser Permanente membership, and they should never let
anyone else use their cards.
Chapter 4: Member Rights and Responsibilities
All Kaiser Permanente QUEST Integration members are sent a handbook with
information about their rights and responsibilities.
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Member Rights and Responsibilities
Member Rights
As a person using our services, a member has specific rights regardless of age, cultural
background, gender, gender identity, sexual orientation, financial status, national origin, race,
religion, or disability.
For detailed information about member rights to privacy, please refer to Notice of Privacy
Practices. A member can find the Notice of Privacy Practices on our website at
kaiserpermanente.org, or contact our Customer Service Center at 808-432-5955 (Oahu) or 1-
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
KP22-016 Provider Manual
800-966-5955 (Neighbor Islands).
A member has the right to:
Receive information about Kaiser Permanente, our services, our health care
practitioners and providers, and his/her rights and responsibilities.
Get information about the people who provide health care including their names,
professional status, and board certification.
Be treated with consideration, compassion, and respect taking into account his/her dignity
and individuality, including privacy in treatment and care.
Be free from neglect, exploitation, and verbal, mental, physical and sexual abuse.
Make decisions about his/her medical care. This includes advance directives to have life-
prolonging medical or surgical treatment given, ended, or stopped, withholding
resuscitative services, and care at the end of life. The member has the right to assign
another person to make health care decisions for him/her, to the extent allowed by law.
Discuss all medically necessary treatment options, regardless of cost or benefit coverage.
Voice his/her complaints freely without fear of discrimination or retaliation. If the
member is not satisfied with how his/her complaint was handled, the member may have
us reconsider his/her complaint.
Make recommendations regarding Kaiser Permanente's Member Rights and
Responsibilities statement.
Be involved and include his/her family in the planning of his/her medical care. The
member has the right to be informed of the risks, benefits, and consequences of his/her
actions.
The member may refuse to participate in research, investigation and clinical trials.
Refuse care, treatment and services.
Choose his/her primary care physician, change his/her primary care physician, or obtain a
second opinion within Kaiser Permanente. The member also has the right to consult
with a non-Plan doctor at his/her own expense.
Have direct access to a practitioner of women’s health services to ensure continuing care.
Find out about his/her care. Have the right to talk it over with his/her doctor. Talk with
the doctor about his/her medical condition. Discuss the diagnosis. Discuss what kind of
treatment is available. The member may discuss alternatives to treatment. The member
has a right to have these presented in a way that is appropriate to his/her condition and
ability to understand.
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Have an interpreter for his/her language. The member has a right to have an interpreter
when needed to understand his/her care and services.
Be involved in considering ethical issues. The member has the right to contact our
Bioethics Committee for help in resolving ethical, legal, and moral matters relating to
his/her care
Be informed of the relationship between Kaiser Permanente and other health care
programs, providers, and schools.
Be informed about how new technologies are evaluated in relation to benefit coverage.
Receive the medical information and education he/she needs to participate in his/her
health care.
Give informed consent before the start of any procedure or treatment.
Give or withhold informed consent to produce or use recordings, films, or other images
of the patient for purposes other than his / her own care.
Have access to medically necessary services and treatment, including emergency
treatment, and covered benefits, in a timely and fair way. Services should not be
arbitrarily denied or reduced in amount, duration or scope because of diagnosis, type of
illness, or condition.
Receive services in a coordinated manner. The PCP is in charge of the member’s medical
care. He or she treats the member, refers the member to specialists when needed, and
connects the member to all of his/her services. The doctor will work with the member to
help the member meet his/her health goals so that the member can live well.
Have Kaiser Permanente consider and respect the member’s needs. We respect the
member’s cultural and spiritual needs. We respect the member’s psychological and social
needs.
Have privacy and confidentiality for all discussion and records of the member’s care. We
will protect the member’s confidentiality. The member or a person the member choose
can ask for the member’s medical records. The member can see the records or get a copy.
The member can ask to amend or correct them, within the limits of the law. In addition,
the member has the right to limit, restrict or prevent disclosure of protected health
information.
Be treated in a safe, secure, and clean environment. Be free from physical and chemical
restraints. Exception: these can only be used when ordered by a doctor, or in the case of
an emergency. Even then, they can only be used when needed to protect the member or
others from injury.
Get appropriate and effective pain management. Get it as an important part of the
member’s care plan.
Get an explanation of the member’s bill and benefits. The member has this right
regardless of how the member pay. The member has the right to know about our available
services, referral procedures, and costs.
Get other information and services. These are things required by various state or federal
programs.
When appropriate, be told about the outcomes of care. That includes outcomes that were
not expected.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Discuss “do not resuscitate” wishes or advance directive instructions for health care with
the member’s surgeon and anesthesiologist prior to an operative procedure when the
member wish to have the “do not resuscitate” honored in the event of a life-threatening
emergency during an operative procedure.
Medicaid patients receiving services, including in the Ambulatory Surgery Center, who
wish to file a complaint or voice a concern may contact the Hawaii Medicaid
Ombudsman, Koan Risk Solutions, Inc., email: [email protected],
1-844-844-2430 (toll-free) or 808-488-7988 (Oahu). Medicare patients may contact the
Medicare Beneficiary Ombudsman to get help with your Medicare-related questions or
concerns, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-
2048. If your inquiry requires a response from the Medicare Beneficiary Ombudsman, a
1-800-MEDICARE representative can direct your inquiry to the Medicare Beneficiary
Ombudsman as needed.
For more information visit www.cms.gov/Center/Special-Topic/Ombudsman/Medicare-
Beneficiary-Ombudsman-Home. The patient receiving services in the Ambulatory
Surgery Center may also contact Accreditation Association for Ambulatory Health Care;
5250 Old Orchard Road, Suite 200, Skokie, IL 60077. Tel: 847-853-6060, or by email:
Be informed about 432E HRS Patient’s Bill of Rights and Responsibilities.
Be included in development of a service/treatment plan.
Only be responsible for cost sharing in accordance with 42CFR Section 447.50.
Member Responsibilities
As a partner in his/her health care, the member has the following responsibilities:
Give Kaiser Permanente correct and complete information about the member’s health.
Tell Kaiser Permanente about the medical conditions the member have now. Tell
Kaiser Permanente about the medical conditions the member had in the past.
Follow the treatment plan. The member and the member’s health care practitioner
agreed on the plan. Tell them if the member does not understand or cannot follow
through with the member’s treatment.
Understand his/her health problems. As much as possible, work with the practitioner
to come up with treatment goals the member and they can agree on.
Tell Kaiser Permanente who the member is. Use his/her Kaiser Permanente
identification card the way it’s supposed to be used.
Cooperate with our staff. Help Kaiser Permanente diagnose and treat his/her illness or
condition properly.
Keep appointments. If the member cannot keep them, cancel them in a timely manner.
Know the plan benefits. Know the member’s plan. Know the member’s plan limits.
Sign a release form. If the member chooses not to follow the recommended treatment or
procedures, we will provide the member with adequate information to make an informed
decision and will ask the member to sign a release form.
Realize the effects lifestyle has on health. Understand that decisions the member make
in his/her daily life, such as smoking, can affect his/her health.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Be considerate of others. Respect the rights and feelings of the staff. Respect the privacy
of other patients.
Don’t make a disturbance. Don’t disrupt our operations and administration. Cooperate
with staff. That way we can continue what we’re doing for other patients.
Follow all hospital, clinic, and health plan rules and regulations. Respect hospital
visiting hours.
Cooperate in the proper processing of third-party payments.
Tell Kaiser Permanente when the member or his/her covered dependents change
addresses.
Be responsible for his/her actions. If the member refuse treatment, do not follow
instructions, and if his/her actions or behavior interfere with facility and/or patient care,
his/her care may be rescheduled. Should his/her medical condition change, the treatment
plan may be modified.
For Ambulatory Surgery Center (ASC) patients: Arrange for a responsible adult to
take the member home and stay with the member for 24 hours, if required by his/her
doctor.
Hospital patient rights and responsibilities
As a person using our services, the member has specific rights. These rights are the members’,
regardless of:
age
cultural background
gender
gender identity
sexual orientation
financial status
national origin
race
religion
disability
As a patient in the Moanalua Medical Center members have the right to:
Know his/her rights and responsibilities. We’ll give the member the information when
the member become a hospital patient.
Have proper discharge from the hospital or transfer to another. This may be for
his/her welfare. It may be for another patients’ welfare. It may be for other causes as
determined by his/her doctor. The member has a right to have reasonable advance notice.
The member has a right to have discharge planning. Qualified hospital staff will make
sure the member get the right care in the right place when the member get out of the
hospital.
Ask for a visit by clergy at any time. The member has a right to take part in social and
religious activities. The member may do this unless it harms the rights of other patients or
would hurt his/her medical care.
Get and use his/her own clothes and things as space permits. The member may do this
unless it harms the rights of other patients, violates our safety practices, or would hurt
his/her medical care.
Give informed consent before the start of any recording, films, or other images for
purposes of nonpatient care.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Access protective and advocacy services.
Get appropriate educational services. The member need these when a child or
adolescent patient’s treatment requires a significant absence from school.
Be protected from requests to perform services for Kaiser Foundation Hospital. T he
member does not need to do things that are not included for therapeutic purposes in
his/her plan of care.
Be free from any form of restraint or seclusion as a means of coercion, discipline,
convenience or retaliation. Federal regulations limit the use of restraints and seclusion.
Receive visitors of his/her choice including a spouse, domestic partner, family member,
or friend. All or certain visits may be excluded at his/her request or discretion of staff,
physicians, or administration to allow for his/her and other’s rights, safety or well-being.
File a complaint in the hospital, either verbally or in writing with the department
manager or supervisor. If the member is not satisfied with the response, please contact
Hospital Administration. They are located on the first floor of the hospital. Or call the
operator at 808-432-0000 and ask for them. If the concern cannot be resolved by the
hospital, the member may contact The Joint Commission by phone, mail, fax, or email.
Phone: Toll free U.S., weekdays 8:30 a.m.–5 p.m. Central time, 1-800-994-6610. Mail:
Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard,
Oakbrook Terrace, IL 60181. Fax: 630-792-5636. Email:
As a QUEST Integration member, the member has the following additional rights and
responsibilities.
Members have a right:
Not to pay for our debts if we go broke.
Not to pay for services if the state doesn’t pay us.
Not to pay for covered services if we or the state do not pay the doctor or the person who
gave the member the service.
To receive covered services outside of Kaiser Permanente (under a contract, referral or
other arrangement) if we are unable to provide the service for the member and for as long
as we are unable to provide it. The member will not have to pay more than if we provided
the services directly.
To get direct access to a specialist through a standing referral for the same condition if
the specialist treated the member before and the member have special health care needs.
Special health care needs are determined by an appropriate health care professional.
To receive information on available treatment options and alternatives in a way that the
member can easily understand and in a manner that takes into consideration his/her
special needs.
Freely exercise his/her rights, including those related to filing a grievance or appeal.
Exercising those rights do not negatively affect the way we treat the member.
To receive all written materials in an easily understood language and format.
Receive services according to appointment waiting time standards.
Receive services in a culturally competent manner.
Receive services in a coordinated manner.
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Members must tell DHS and Kaiser Permanente when there are any of these changes in his/her
family:
Death in the family (recipient, spouse, dependent)
Birth
Adoption
Marriage
Divorce
Change in health condition (such as pregnancy or permanent disability)
Change of address
Institutionalization (such as nursing home, state mental health hospital or prison)
Also, the member must notify Kaiser Permanente if:
Some other person, organization or program needs to pay for his/her care (such as no-
fault insurance for a car accident, or workers’ compensation for an injury on the job)
He/she will need continuing medical care while visiting another island
He/she is going to be away from home for more than 90 calendar days
Please report the above information to Kaiser Permanente at 808-432-5330 or toll free
at 1-800-651-2237 or 711 (TTY).
Member Inquiry and Grievances Process
Definitions
Action:
1. The denial or limited authorization of a requested service, including the type or level of
service.
2. The reduction, suspension, or termination of a previously authorized service.
3. The denial, in whole or in part, of payment for a service.
4. The failure to provide services in a timely manner as defined by the State of Hawaii.
5. The failure of the health plan to act within prescribed timeframes
6. For a rural area member or for islands with only one contractor or limited providers, the
denial of a member’s request to obtain services outside the network:
a) From any other provider (in terms of training, experience, and specialization) not
available within the network.
b) From a provider not part of the network that is the main source of a service to the
member, provided that the provider is given the same opportunity to become a
participating provider as other similar providers. If the provider does not choose to
join the network or does not meet the qualifications, the member is given a choice
of participating providers and is transitioned to a participating provider within 60
days; however, Kaiser Permanente is still responsible for reimbursement for the
services the provider rendered.
c) Because the only plan or provider available does not provide the service because of
moral or religious objections.
d) Because the member’s provider determines that the member needs related services
that would subject the member to unnecessary risk if received separately and not all
related services are available within the network.
e) The State determines that other circumstances warrant out-of-network treatment.
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Authorized Customer Feedback System (CFS) User: Staff members who are granted access
to and authorized to use the CFS system.
Clinical Urgency: A situation which could jeopardize the life or health of the member or the
member’s ability to regain maximum function.
Customer Feedback System: The electronic database system used for the recording,
documentation, and tracking of customer concerns and denials.
Grievance: An expression of dissatisfaction from a member, member’s representative, or a
provider, with written consent, on behalf of member, about any matter other than an action,
as “action” is defined above. Examples of issues that will be resolved through the grievance
process include quality of care issues, waiting times in physician offices and rude or
unresponsive physician or staff and failure to respect enrollee’s rights. Standard disposition
of a grievance and notice to the affected parties may not exceed 30 days from the date the
grievance is received.
Inquiry: A question regarding any aspect of the Health Plan’s or Provider’s operations,
activities or behavior or to request disenrollment but does not express dissatisfaction.
Local Accountable Group: The organizational entity responsible for the delivery of quality
patient care and member service and response to any customer concerns with that care and
service.
Organization determination: an initial decision by Health Plan to pay or deny a request for
payment or coverage of a service or item.
Sentinel Event: an unexpected occurrence involving death or serious physical or
psychological injury or the risk thereof. The phrase “or the risk thereof” includes any process
variation for which a recurrence would carry a significant chance of a serious adverse
outcome. Such events are called “sentinel” because they signal the need for immediate
investigation and response. The terms sentinel event and medical error are not synonymous;
not all sentinel events occur because of error and not all errors result in sentinel events. A
distinction is made between an adverse outcome that is primarily related to the natural course
of the patient’s illness or underlying condition, and a death or major permanent loss of
function that is associated with the treatment or lack of treatment of that condition, or
otherwise not primarily related to the natural course of the patient’s illness or underlying
condition. Kaiser Permanente sentinel events are inclusive of all Joint Commission S entinel
Events.
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General Requirements for Member Inquiries and Grievances
Members may designate a representative or provider to make an inquiry or file a grievance
on their behalf and may request a State administrative hearing
Members may provide verbal consent for Kaiser Permanente staff to interact with the
authorized representative or provider. The member’s designation will be documented in
the applicable Kaiser Permanente system when consent from the member is provided
verbally.
Members will be provided with any reasonable assistance in completing forms and taking
other procedural steps including, but not limited to, providing interpreter services and
toll-free numbers with TTD and interpreter capability.
The Kaiser Permanente systems used to record, and track inquiry and grievance
information contain protected member demographic and medical care information.
System users will handle this information in strictest confidentiality in accordance with
Regional Policy 6226-06-01 “Regional Confidentiality and Security of Information” and
MQD-RFP-2014-005.
Members may submit an inquiry or file a grievance by calling 808-432-5955 or toll-free
at 1-800-966-5955, or by 711 (TTY). Members may also write to Kaiser Permanente
at:
Kaiser Foundation Health Plan, Inc.
Customer Service Center
711 Kapiolani Blvd.,
Honolulu, HI 96813
Member Inquiry Process
All member oral or written inquiries will be addressed and provided a response in a timely manner.
All member inquiries will be entered into the MACESS tracking system.
If at any time during the inqu iry process (written or telephone request), the member expresses a
complaint of any kind, the inquiry then becomes a grievance or appeal and the member will be
given his/her grievance and/or appeal rights, as applicable.
Member Grievance Process
If members are unhappy with Kaiser Permanente, they may file a grievance or have a
representative or a provider file the grievance for them. They can ask anyone at Kaiser
Permanente to send it to Member Services or mail it to: Member Services, Kaiser Permanente,
711 Kapiolani Boulevard, Honolulu, HI 96813. If they would like someone to help write the
grievance, or they want to file their grievance by telephone, call the QUEST Integration Call
Center at 808-432-5330, toll free at 1-800-651-2237, or 711 (TTY).
A letter will be sent to the member within five business days to let them know that we have
received the member’s grievance. We will send it to the supervisor of the area they wrote or
called about. That person will answer the grievance within 30 calendar days from when it was
received.
If the member received Kaiser Permanente’s answer, but they are still not satisfied, the member
may ask for a state grievance review from the State of Hawaii’s Department of Human Services
Med-QUEST Division. The member must call or write to Med-QUEST within 30 days of getting
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
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the member’s answer from Kaiser Permanente. If the member does not do this, the member’s
complaint will be considered resolved.
To ask for a State grievance review, call the Med-QUEST Division at 808-692-8094. Or mail a
request to:
Med-QUEST Division
Health Care Services Branch
PO Box 700190
Kapolei, HI 96709-0190
Med-QUEST will review the member’s complaint. They will decide on it within 90 calendar
days from getting the member’s request. Their decision will be final.
Filing a claim
How to file a claim for payment
If the member receives medical care outside of Kaiser Permanente, the member may submit a
claim with us. We review each claim to decide if we will pay. We look to see if the member’s
care was referred by us. We will see whether it was medically needed emergency care or urgent
care. If we approve the member’s claim, we will pay according to the member’s plan benefits.
If the member has questions relating to filing a claim, please contact the QUEST Integration Call
Center at 808-432-5330 or toll free at 1-800-651-2237. If the member has questions about a
claim already submitted, please call Claims Administration toll free at 1-877-875-3805.
The member may have someone file the claim on their behalf. If the member chooses to do this,
the member must name this person in writing and state who is authorized to file the claim for the
member. Both the member and the member’s representative must sign this statement unless the
person is the member’s attorney. When necessary, the member’s representative will have access
to medical information about the member that relates to the request. If the member prefers, the
member may call our QUEST Integration Call Center at 808-432-5330 or toll free at 1-800-651-
2237 or 711 (TTY) to request a form.
Appeals
Did Kaiser Permanente health plan or the member’s doctor refuse an item or service the
member asked for? If the member does not agree with a decision that was made about the
services the member is getting, or want to get, the member may ask for a review of an adverse
benefit determination taken by Kaiser Permanente for the member’s medical care. Some of the
other reasons the member may want to file an appeal are if we stopped care that we already
approved; if the member don’t get care when the member need it; if we don’t give the member
an answer to a grievance or an appeal that the member already filed by the time we’re supposed
to; or if we can’t provide the member with a medically necessary covered service within Kaiser
Permanente and we don’t authorize coverage for that service outside Kaiser Permanente. If the
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member provides written consent, providers may file an appeal on the member’s behalf if we
deny coverage of a service.
After the member gets a denial notice or Notice of Adverse Benefit Determination, the member
has 60 calendar days to make the member’s appeal. The member may make an appeal orally or
in writing. The member may ask Kaiser Permanente or someone else to help the member write
the member’s appeal. If the member would like help to write the member’s appeal, call the
QUEST Integration Call Center at 808-432-5330, toll free at 1-800-651-2237, or 711 (TTY). The
member may also request an interpreter to help the member through this process.
Only the member or someone with the member’s permission may make an appeal. If the member
gives someone else permission to make an appeal on their behalf, the member can let Kaiser
Permanente know by sending Kaiser Permanente a letter or by calling 808-432-5330, toll-free
at 1-800-651-2237 or 711 (TTY). If the member lets Kaiser Permanente know by phone, the
member must also send a letter confirming that the member is giving another person permission
to make an appeal for them. The member’s letter must have the name of the person authorization
for that person to file an appeal for the member. The member and authorized person must both
sign and date the letter. When necessary, the member’s representative may have access to
medical information about the member that relates to the request.
Send the member’s appeal to:
Kaiser Foundation Health Plan Inc.
Attn: Regional Appeals Office
711 Kapiolani Blvd.
Honolulu, HI 96813
You may fax the member’s appeal to 808-432-5260 or send it by email at
[email protected]. The member may also contact the QUEST Integration Call Center
at 808-432-5330, toll free at 1-800-651-2237 or 711 (TTY).
We will write to the member within five business days to say we got the member’s appeal. The
member will have a chance to present evidence and to argue facts or law if the member wants to.
The member may do this in person or in writing. The member or the member’s representative
may examine the case file. The case file may have medical records and any other papers and
records that we will look at during the appeals process. The member may give Kaiser
Permanente written comments, papers, medical records, or other information to consider. We
will review the case and give the member a written decision within 30 calendar days. We may
take up to 14 more calendar days if the member asks Kaiser Permanente to or if we need more
information and it would be in the member’s best interest if we had more time before deciding. If
the member didn’t ask for the delay, we will make reasonable efforts to give the member prompt
oral notice of the delay. We will also send the member a letter to explain why we need extra time
within 2 calendar days. Then we will inform the member of the member’s right to file a
grievance if the member disagrees with our decision.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
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Expedited review
Sometimes we must review the member’s appeal more quickly. When we receive the member’s
appeal, we will decide if taking the regular amount of time to review it could mean a danger to
the member’s life, physical or mental health, or ability to attain, maintain, or regain maximum
function. If we or the person who treats the member finds that it could, we will use a faster
process. We call it an expedited review of the member’s appeal. It’s the same as the regular one
except:
If the member asks for it orally the member don’t have to follow it up in writing
We must ensure that the person who treats the member won’t be punished for helping the
member ask for the faster appeal
We must make a decision on the appeal as fast as needed for the Member’s health
condition. We can’t take more than 72 hours from when we receive the appeal. We may
take up to 14 more calendar days if you or the Member requests an extension. If we need
the extension, we will provide the reason to DHS and explain why the extension would is
in the Member’s best interest. If the Member didn’t ask for the delay, we will make
reasonable efforts to give prompt oral notice of the delay. If the request to extend the
timeframe was made by you or us, we will also send the Member a letter explaining why
the delay is needed within two calendar days and let the Member know that they have the
right to file a grievance if they don’t agree with the decision. We will issue and carry out
the determination as quickly as needed based on the Member’s health condition and no
later than the date the extension expires. We will provide written notice and make
reasonable efforts to provide oral notice to the Member, of the resolution of an expedited
appeal.
We will notify DHS within 24 hours if an expedited appeal has been granted or if an expedited
appeal time frame has been requested by the Member or by you. If we need an extension of 14
calendar days, we will provide the reason to DHS. We will notify DHS within 24 hours, or as
soon as possible from the time the expedited appeal is upheld. We will also let DHS know how
we notified you of the expedited appeal decision.
The written notice of the resolution will include:
The results of the appeal process and the date it was completed
For appeals not resolved wholly in favor of the Member:
o The right to request a State administrative hearing as described in §9.5.J., and
clear instructions about how to access this process
o The right to request an expedited State administrative hearing
o The right to request to receive benefits while the hearing is pending, and how to
make the request
o A statement that the Member may be held liable for the cost of those benefits if
the hearing decision upholds the Health Plan’s action.
If we say no to the member’s request for an expedited review, here is what we must do:
Transfer the member’s appeal to the regular appeal process of no longer than 30 days
from the day we received the appeal, with a possible 14 days extension.
Make reasonable efforts to tell the member orally what we have done
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Tell the member in writing within two calendar days from when we received the
member’s appeal the reason the decision to extend the timeframe or deny a request for
expedited resolution of an appeal
Resolve the appeal as expeditiously as the member’s health condition requires and no
later than the date the extension expires.
If we said no to the member’s request for an expedited appeal, and the member is
unhappy about it, the member may file a grievance with us.
External review
DHS administrative hearing
If the member has gone through Kaiser Permanente’s appeal process and are not happy with
the decision, we made about the member’s appeal the member can ask DHS for an administrative
hearing. Write to the Administrative Appeals Office (AAO) of DHS. The AAO must receive the
member’s letter within 120 calendar days from when the member got Kaiser Permanente’s
notice of denial disposition about the member’s appeal. Include information: any statements of
fact or laws to support the member’s request. Send the member’s appeal to:
State of Hawaii Department of Human Services
Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809-0339
There is no cost to receive copies of the appeal file. The member has the right to name someone
to file the appeal for the member. The member must name that person in writing when the
member sends the member’s appeal. The member may represent himself/herself at the hearing or
the member may have a lawyer, a relative, a friend, or someone else there to speak on their
behalf. The member will receive a decision within 90 calendar days from the date they received
the member’s request. We must follow the decision of the DHS administrative hearing. The
member must go through Kaiser Permanente’s appeal process first before asking for a DHS
administrative hearing.
The member or the member’s approved representative is considered to have used up Kaiser
Permanente’s grievance and appeal process if Kaiser Permanente does not follow the notice
and timing requirements set by Med-QUEST Division of DHS. When this happens, the member
has the right to file for a State administrative hearing. Members must exhaust Kaiser
Permanente’s internal grievance and appeals system before accessing the State’s administrative
hearing system.
Expedited DHS administrative hearing
If the member had an expedited review of the member’s appeal with us, and it didn’t go the way
the member wanted it to, then the member may ask DHS for an expedited administrative hearing.
The member must submit the member’s letter to the AAO within 120 calendar days of getting
the member’s answer from Kaiser Permanente about the member’s appeal. An expedited
administrative hearing needs to be reviewed and decided upon within three business days from
when the member’s request was filed. We will work with the State to ensure that the best results
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are provided for you and to ensure that the procedures comply with State and Federal regulations.
When an expedited State administrative hearing is requested, we will submit information that
was used to make the determination, for example, medical records, written documents to and
from you, provider notes, etc. to DHS within 24 hours of the decision denying the expedited
appeal.
Please send your request for an expedited State administrative hearing process to:
State of Hawaii Department of Human Services
Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809-0339
Receiving benefits during the appeals process or DHS administrative hearing
If we told the member that we are going to reduce, delay or stop anything that we already
approved, the member has the right to still get those services during the appeals process or state
administrative hearing process. For that to happen the member or authorized representative
should request Kaiser Permanente to continue the member’s benefits in a timely manner. This
means within 10 calendar days of getting the denial notice or Notice of Adverse Benefit
Determination, or before the date that the service is going to be reduced, delayed, or stopped.
The services the member is asking to be continued must have been approved by an authorized
provider within the time period covered by the original authorization.
If the member’s benefits are continued during the appeal or administrative hearing process, it
will be provided until one of the following happens:
You withdraw the member’s appeal
You don’t request a DHS administrative hearing within 10 calendar days of getting the
denial notice or Notice of Adverse Benefit Determination from us
The DHS administrative hearing does not decide in the member’s favor
If Kaiser Permanente or DHS do not decide in the member’s favor, the member will have to
pay for the services that the member requested to be continued during the appeal process.
If you or your authorized representative requested to continue your benefits during an Appeal or
a State Administrative Hearing process, we will continue your benefits if the following
conditions are met:
An appeal was requested within 60 calendar days following the date on the adverse
benefit determination notice
The appeal or request for State administrative hearing involves the termination,
suspension, or reduction of a previously authorized services
The services were ordered by an authorized provider
The original authorization period has not expired
You timely filed to request to continue your benefits on or before the later of the
following:
o Within 10 days of the Health Plan receiving the notice of adverse benefit
determination; or
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o The intended effective date of the Health Plan’s proposed adverse benefit
determination.
If the Health Plan continues or reinstates the Member's benefits while the appeal or State
administrative hearing is pending, the Health Plan shall not disconti nue the benefits until
one of the following occurs:
o The Member withdraws the appeal or request for a State administrative hearing;
o The Member does not request a State administrative hearing within ten (10) days
from when the Health Plan mails a notice of an adverse benefit determination; or
o A State administrative hearing decision unfavorable to the Member is made.
If the final resolution of the appeal or State administrative hearing is adverse to the
Member, that is, upholds the Health Plan’s adverse benefit determination, the Health Plan
may, consistent with the State’s usual policy on recoveries and as specified in the Health
Plan’s contract, recover the cost of services furnished to the Member while the appeal
and State administrative hearing were pending, to the extent that they were furnished
solely because of the requirements of this section.
If the Health Plan or the State reverses a decision to deny, limit, or delay services that
were not furnished while the appeal was pending, the Health Plan shall authorize or
provide these disputed services promptly, and as expeditiously as the Member’s health
condition requires, but no later than seventy-two (72) hours from the date it receives
notice reversing the determination.
If the Health Plan or the State reverses a decision to deny authorization of services, and
the Member received the disputed services while the appeal was pending, the Health Plan
shall pay for those services.
Medicaid ombudsman program
The State of Hawaii Department of Human Services (DHS) overse es the Medicaid ombudsman
program. Koan Risk Solutions is contracted with DHS to independently review concerns and
complaints against Medicaid Health Plans as another resource for members. Visit the
ombudsman website: www.himedicaidombudsman.com. To contact the Medicaid ombudsman
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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office:
Hours of Operation: 7:45am-4:30pm Monday-Friday (Excluding Hawaii State Holidays)
Office Address:
Koan Risk Solutions, Inc.
1580 Makaloa Street #550
Honolulu, HI 96814
Phone: 1-808-746-3324; Toll Free: 1-844-844-2430
Fax: 1-808-356-1645
Email: [email protected]
Deaf or Hard of Hearing may access text-telephone (TTY) captioned telephone or Braille
TTY by dialing 711.
24
Access to Care Standards
Kaiser Permanente consistently maintains a sufficient number of providers to service our
members. Our providers must adhere to the following QUEST Integration program wait time
standards and geo access standards to ensure timely access to care and services:
Immediate care without prior approval for emergencies
Within 24 hours for urgent care
Within 24 hours for PCP pediatric sick visits
Within 72 hours for PCP adult sick visits
Within 21 days for PCP routine visits
Within 21 days for routine behavioral health visits
Within 4 weeks for visits with a specialist
Within 4 weeks for non-emergency hospital stays
Interpreter/translation services
Kaiser Permanente offers interpreter services at no charge. If a member needs an interpreter
during a doctor visit, let Kaiser Permanente know by calling our Customer Service Center at
808-432-5955 (Oahu) or (toll-free) 1-800-966-5955 (Neighbor Islands). A Customer Service
representative may provide an interpreter over the phone or arrange for one in person. Members
who are deaf, hard of hearing, or speech impaired may call toll free 711 (TTY).
If members need information in a different language or format (including large print or Braille),
call the QUEST Integration Call Center at 808-432-5330 or toll-free at 1-800-651-2237 for
assistance.
Advance Directives for Health Care
Practitioners are encouraged to inform each adult member of his/her right to make advance
medical decisions according to the Federal Patient Self-Determination Act of 1990, and Hawaii
Revised Statutes, Section 327D. The purpose of the Act is to protect each adult patient's right to
participate in health care decision-making to the maximum extent of his/her ability and to
prevent discrimination based on whether the member has executed an advance directive for
health care.
When a member provides an advance directive, an entry should be made in the medical record.
Cultural Competency Plan
Kaiser Permanente Hawaii Market’s mission is to provide high quality affordable health care
services and to improve the health of our members and the communities we serve. Delivering
on this mission includes providing care in a culturally competent manner to all members
including those with limited English proficiency and diverse cultural and ethnic backgrounds,
disabilities, and regardless of gender, sexual orientation or gender identity.
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Kaiser members have the right to receive information in a language and manner that can be
easily understood. Communicating effectively with limited English-speaking patients or non-
English speaking patients plays a large role in ensuring the quality of and compliance with care
provided to members.
The Kaiser Permanente Hawaii Market ’s Cultural Competency Plan is available to providers
upon request at no charge. Link here: Cultural Competency Plan.
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Implementing Stepped approach to Behavioral Heal th
Kaiser Foundation Health Plan is collaborating with DHS and the other Health Plans to
develop standardized protocols for Stepped Approach to delivering effective behavioral health
services which include criteria describing how the Members should move up and down the
continuum of care. Kaiser Foundation Health Plan will implement DHS-approved protocols.
Kaiser Foundation Health Plan also supports other integrated care including Medication-
Assisted Treatment (MAT), and screening, brief intervention, and referral to treatment (SBIRT).
Please see our QUEST Integration Medication-Assisted Treatment (MAT) policy found here KP
QUEST Hawaii Policy Medication-Assisted Treatment (MAT). This policy describes coverage
of MAT for opioid use disorders (OUD) to meet the requirements for MAT within the QI RFP-
MQD-2021-008 contract and federal rules. This policy does not address MAT for other SUDs.
Getting care for Medication-Assisted Treatment (MAT)
If members need Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD),
providers can direct members to receive care in several ways.
Members may self-refer to a primary care provider (PCP). PCPs are then able to refer
members to the Integrated Behavioral Health department for Chemical Dependency
Services.
After referral, providers will assess members to identify the appropriate level of care
needed and members will receive services from internal providers or through Kaiser
Permanente’s external contracted providers. Please see more information regarding Out-
of-Plan/Network Referrals on page [32].
Members may also receive additional therapy services based on their assessed medical
needs to help with the treatment of OUD.
Referrals to external providers can also be made to Federal Opioid Treatment Programs that are
certified by SAMHSA to provide Methadone treatment. A prior authorization is needed for out
of network care.
To become a certified provider, please refer to Substance Abuse and Mental Health Services
Administration (SAMHSA) website https://www.samhsa.gov/ for more information.
Accreditation of Opioid Treatment Programs – Substance abuse and Mental Health Services
Administration (SAMHSA) is the authority – please visit SAMHSA website here:
26
https://www.samhsa.gov/medication-assisted-treatment/become-accredited-opioid-treatment-
program
Chapter 5: Availability of Providers
Kaiser Foundation Health Plan will monitor the number of Members cared for by its providers
and will adjust PCP assignments as necessary to ensure timely access to medical care and to
maintain quality of care. Kaiser Foundation Health Plan will have a sufficient network to
ensure Members can obtain needed health services within the acceptable wait times as required
in the QI RFP-MQD-2021-008 contract.
The acceptable wait times are:
o Emergency medical situations - Immediate care (twenty- four (24) hours a day, seven (7)
days a week) and without prior authorization;
o Urgent care and PCP pediatric sick visits - Appointments within twenty-four (24) hours;
o PCP adult sick visits - Appointments within seventy-two (72) hours;
o Behavioral Health (routine visits for adults and children) - Appointments within twenty-one
(21) days;
o PCP visits, routine visits for adults and children - Appointments within twenty-one (21) days;
and
o Visits with a specialist or Non-emergency hospital stays - Appointments within four (4)
weeks or of sufficient timeliness to meet Medical Necessity.
Chapter 6: Provider Rights and Responsibilities
Provider Requirements
Role and responsibility
To be employed by Kaiser Permanente, these practitioners are required to have active
licensure in the State of Hawaii. Licensure status is reviewed by the Credentials and
Privileges committee. PCPs have the responsibility for supervising, coordinating, and
providing initial and primary care to the member, initiating and coordinating both internal
and outside referrals for specialty care and maintaining the continuity of the member’s
health care and medical record.
Kaiser defines a PCP as a MD or DO who is a board certified/eligible internist, family
practitioner, or pediatrician. The definition does not include the other providers (general
practitioner, OB/Gyn, APRN, PA) in the QUEST Integration RFP, in part because there
are no access issues preventing each QUEST Integration member from linking with an
internist, family practitioner, geriatrician, or pediatrician. In addition, women (pregnant
or non-pregnant) also have open access to an obstetrician/gynecologist and to see their
OB/Gyn regularly. However, each member also has access to primary care services.
Certain members may also have regular specialty care, linked to a specialist for a
particular chronic condition. However, in addition, the member would also have a
primary care physician who would work closely with the specialist. Kaiser’s physician
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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assistants and nurse practitioners generally work in specialty areas, so do not provide
primary care.
Reporting Overpayments and Refunding Kaiser Permanente
A QUEST Integration (Medicaid) overpayment is a payment that exceeds the allowed payment
for services specified in the QUEST Integration contract.
Overpayments may occur when a service is submitted under an incorrect patient’s name or
member number, another insurance payor is identified, incorrect services are reported, or any
payments received in error.
If you discover that you have received an overpayment, you must notify us in writing of the
reason for the overpayment and return the overpaid amount to us within 60 calendar days after
identifying the overpayment as follows:
Include a copy of the Explanation of Payment (EOP) for each overpayment and highlight
the overpaid amount.
Enclose a check payable to Kaiser Foundation Health Plan in the amount of the
overpayment.
Provide the following information itemized for each member:
o Reason for the overpayment refund
o Date overpayment was identified
o Patient name
o QUEST Integration member number and Medical Record Number (MRN)
o Claim number
o Date of service
o Date of payment
o Overpayment amount
Mail the EOP, check and itemized information to:
Kaiser Foundation Health Plan
Attention: Hawaii Regional Claims Recovery
P.O. Box 745820
Los Angeles, CA 90074-5820
PCP Selection and Change
In the event that a member does not choose a PCP within 10 calendar days, or chooses to
give up an existing assigned PCP, or chooses not to have a person as a PCP, they are
linked to a clinic, which may then serve as a PCP for the patient. This is made possible
by the group practice nature of Kaiser Permanente. Since staffing models at Kaiser
Permanente are applied at a clinic and area level, adequate coverage for clinic assigned
patients is assured. Primary care physicians in the particular clinic will serve the needs of
the member and ensure individual treatment plans are developed and carried out.
The member can select a PCP and change PCP at any time and for any reason. They may
notify any staff member at any clinic in person for assistance. They may contact the
QUEST Integration office, notify Kaiser Permanente in person, by regular mail, by
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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email, or may also change their PCP online. A message is sent to the business office to
initiate the change of PCP process. This may be done by email or directly through Health
Connect. PCP changes become effective the following business day.
Biography cards with information about PCPs accepting new patients help members
make more informed PCP choices. These cards are available at all clinic check-in
locations. These biographies are also available online.
In the event that a PCP is unable to fulfill their responsibilities to t he member, the
physician, patient or QUEST Integration staff member/manager will inform the QUEST
Integration Medical Director, who will assess the situation, and if necessary, develop an
action plan to transition the member to another PCP. If the original PCP is unable to
provide continued care to the member during the transition period, medical staff at the
clinic of record will provide care for the member until the transition to the new PCP is
complete. At any time, if the member’s health or safety is in jeopardy, the member will
be immediately transferred to another PCP, health plan, or provider.
On Maui and Oahu, all PCPs are members of Hawaii Permanente Medical Group. When
a PCP terminates from Kaiser, a letter is sent to the member and the member is assigned
to another physician taking over the PCP’s panel or to a new PCP of the member’s
choosing. However, during the interim, the member is automatically cared for by the
other physicians in the health care team and/or the clinic to ensure of care.
PCP Monitoring
PCP performance is monitored and supported at many levels: (1) QUEST Integration
reporting criteria, (2) teams of practitioners monitoring high risk or high volume concerns
like abnormal mammograms, positive fecal occult blood, diabetic foot screening, etc., (3)
periodic monitoring of patient and peer surveys, and (4) direct observation by the clinic
and professional chiefs.
Health Connect, our electronic medical record also supports PCPs and assists in
monitoring their performance by: (1) the Panel Support Tool and “How Are We Doing” –
data bases addressing issues of prevention , monitoring, and efficacy of care – that are
directly accessible from the patients file, (2) the record itself is formatted to
automatically document the necessary and appropriate medical information, assuring a
complete, clear and compliant document that meets appropriate medical record standards,
(3) internal and external referrals may be placed real time to minimize barriers to referral,
and (4) allowing all providers access to the complete medical record, simplifying
continuity of care.
Aside from the routine monitoring of PCP performance through the professional chiefs
and clinic chiefs, the QUEST Integration program also monitors performance through
regular reports on utilization, quality, and grievances/complaints, among others.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Provider Access
As with any Kaiser member, QUEST Integration female members have direct access to
Kaiser Permanente gynecology services without the need for a referral.
The QUEST Integration Manager monitors the number of QUEST Integration members
assigned to each PCP through a regularly produced report to maintain an overall ratio of
less than or equal to 1 PCP to 300 QUEST Integration members. This information is also
directly provided to DHS as described in QUEST Integration RFP Section 51.520.3. If
the average PCP to member ratio exceeds 1:300, the QUEST Integration Manager will
inform the QUEST Integration Medical Director who will assess and, if necessary,
develop corrective action which shall include discontinuation of auto assignment of new
QUEST Integration members who have exceeded the 1:300 ratio. Members, however,
may continue to select PCPs who have exceeded the 1 to 300 ratio as long as their
absolute panel size recommendations are not exceeded. No restrictions of auto-
assignment are applied to clinics serving as PCPs.
Hospitalists
Most Kaiser Permanente PCPs do not hospitalize their own patients. When admitted to
the hospital, the member is automatically transferred to the care of an appropriate
hospitalist or specialist that is with Kaiser Permanente at either Moanalua Medical
Center on Oahu or Maui Memorial Hospital. The staff is hired specifically to provide
these services. The PCP is notified of both the admission and the discharge and has
immediate access to the information about the hospital stay through the Health Connect
medical record. Members are scheduled for an outpatient follow-up with the PCP post
hospital discharge within a week. Members at contracted hospitals are also managed by
the facility’s hospitalist.
In the event that a PCP is unable to fulfill their responsibilities to the member, the physician,
patient or QUEST Integration staff member/manger will inform the QUEST Integration Medical
Director, who will assess the situation, and if necessary, develop an action plan to transition the
member to another PCP. If the original PCP is unable to provide continued care to the member
during the transition period, medical staff at the clinic of record will provide care for the member
until the transition to the new PCP is complete.
Provider Grievances & Appeals
Grievances and appeals filed by all providers will be proactively managed and resolved within
60 days of the day following the date of submission to the health plan. Providers are allowed 30
days from the decision of a grievance to file an appeal.
Providers may file a grievance to resolve issues and problems with the health plan (this includes
problems regarding a member). This policy is not for filing a grievance or appeal on behalf of a
member. Grievances and appeals filed on behalf of a member will be managed through the
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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established regional member policies and procedures. Providers may ask for review of their
grievance by the Provider Grievance/Appeals medical director.
Some examples of items that may be filed as a grievance are:
Issues related to availability of health services from the health plan to a member, for
example delays in obtaining or inability to obtain emergent/urgent services; medications;
specialty care; ancillary services such as transportation; medical supplies, etc.;
Issues related to the delivery of health services, for example, the PCP did not make a
referral to a specialist; medication was not provided by a pharmacy; the member did not
receive services the provider believed were needed; provider is unable to treat member
appropriately because the member is verbally abusive or threatens physical behavior;
Issues related to the quality of service, for example, the provider reports that another
provider did not appropriately evaluate, diagnose, prescribe or treat the member; the
provider reports that another provider has issues with cleanliness of office, instruments,
or other aseptic technique was used; the provider reports that another provider did not
render services or items which the member needed; or the provider reports that the plan’s
specialty network cannot provide adequate care for a member.
Benefits and limitations, for example, limits on behavioral health services or formulary;
Enrollment and eligibility, for example long wait times or inability to confirm enrollment
or identify the PCP;
Member issues, including members who fail to meet appointments or do not call for
cancellations, instances in which the interaction with the member is not satisfactory;
instances in which the member is rude or unfriendly; or other member-related concerns;
and
Health Plan issues, including difficulty contacting the health plan or its subcontractors
due to long wait times, busy lines, etc.; problems with the health plan’s staff behavior;
delays in claims payments; denial of claims; claims not paid correctly; or other health
plan issues.
An appeal is a request for review of an action. An action is defined as any one of the
following:
the denial or restriction of a requested service, including the type or level or service;
the reduction, suspension, or termination of a previously authorized service;
the denial, in whole or part, of payment for a service;
the failure to provide services in a timely manner as found in the access to care standards
on pg. 25;
the failure of the health plan to act within prescribed timeframes;
for a rural area member or for islands with only one health plan or limited providers, the
denial of a member’s request to obtain services outside the network:
from any other provider (in terms of training, experience, and specialization) not
available within the network;
from a provider not part of a network that is the main source of a service to the member,
provided that the provider is given the same opportunity to become a participating
provider as other similar providers;
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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If the provider does not choose to join the network or does not meet the qualifications,
the member is given a choice of participating providers and is transitioned to a
participating provider within 60 days.
because the only health plan or provider does not provide the service because of moral or
religious objections;
because the member’s provider determines that the member needs related services that
would subject the member to unnecessary risk if received separately and not all related
services are available within the network; and
the State determines that other circumstances warrant out-of-network treatment.
Providers may file an appeal for a payment dispute with the Claims Administration Department.
Providers should submit the following information with the appeal:
Name of provider and provider address
Signed Waiver of Liability statement (sent with the EOP)
Copy of original claim
Remittance notification showing the denial
Any clinical records or other information that explains the provider you should be
reimbursed for the item or service
Member name and date of birth
Kaiser Permanente medical record number
Date(s) of service
Kaiser Permanente assigned claim number
Appeals should be submitted in writing to:
Kaiser Permanente Hawaii – Provider Appeals
Claims Administration Department
ATTN: Provider Appeals
PO Box 378021
Denver, CO 80237-9998
Providers may also file grievances and appeals on behalf of a member. Written consent from the
member or the member’s authorized representative is required. To file a grievance or appeal for
a member, you may call 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY). Members
may also write to Kaiser Permanente at:
Kaiser Foundation Health Plan, Inc.
Appeals and Grievances
711 Kapiolani Blvd.
Honolulu, HI 96813
If a grievance is filed by a provider on behalf of a member or the member's authorized
representative and there is no documentation of a written form of authorization, such as an
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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appointment of representative form, then the provider will be advised about the written consent
requirement in a manner to facilitate timely review of the concern.
Out-of-Plan/Network Referrals
All physicians have at times found the need to consult with another physician regarding their
patient’s care. At Kaiser Permanente, we value the services of our Network Practi tioners who,
in partnership with our own physicians, provide our members with the highest quality of care
available. This section contains the policies and procedures regarding how to refer Kaiser
Permanente members to another practitioner.
Kaiser Permanente provides most services through its own hospital and clinics; through
physicians of HPMG; and to a much lesser extent, through providers contracted through Health
Plan’s Provider Contracting & Relations Department. The Health Plan has entered into an
agreement with HPMG to provide or arrange for physician services for Kaiser Permanente
members, including QUEST Integration. Services provided through contracted providers
account for only 2% of all services provided for Kaiser Permanente members.
When services or items from an outside provider are needed, an authorization request is
submitted and processed through Kaiser Permanente’s Authorization and Referral Management
Department (ARM). Staff consults with the referring physician to ensure all prior authorization
criteria are met. If the requested services meet benefit guidelines, the QUEST Integration
Member will be sent to the appropriate non-Kaiser Permanente medical provider. A relatively
small volume of prior authorizations allows for manual tracking of performance from medical
review, through the authorization decision, and ending with the notification to the member and
provider. Each step of the prior authorization process is monitored to ensure compliance within
the allowable timeframes as described in the QUEST Integration contract. In the rare occasion
that timeframes aren’t met, counseling and education are provided to the staff.
For LTSS services, QI service coordinators will be reviewing and authorizing services. The
authorization will be tracked electronically via our electronic claim system. Referrals for services
provided by non-Plan/non-Network providers must be reviewed and authorized through the
established Plan referral authorization process. This process assures that Members are:
Referred to the appropriate specialty provider;
Referred to the providers who have met our service, quality, and credentialing
requirements;
Eligible for the requested medical service.
The Kaiser Physician-in-Charge is responsible for the final review and authorization of out-of-
plan/network requests, including Behavioral Health and Chemical Dependency requests.
Referrals are authorized for specific services, including frequency and duration of treatment.
Services or care beyond the scope of the initial authorization need additional authorization.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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For contracted and credentialed professional and facility information, please contact the
Community Medical Services at 808-432-7529.
Prior Authorizations
Prior authorization is required as indicated in the ‘QUEST Integration Covered Benefits and
Services’ starting on page 68. Most services within Kaiser Permanente require no prior
authorizations. External referrals are generated in Kaiser’s electronic medical record for the
Authorizations and Referrals Department to review and make a determination. Prior
authorization is required for LTSS/HCBS services and the “at-risk” population.
Call the Kaiser QUEST Integration office at 808-432-5330 for:
Ground transportation when medically necessary (see section below)
Air and ground transportation, meals and lodgings for medically necessary care on
another island or on the mainland
Any member needing LTSS / HCBS
Any member considered ‘At Risk’ (see page 82)
Follow Kaiser’s Prior Authorization process:
Prior authorization must be obtained before service is rendered
No retroactive requests will be processed, except for newborns, state-generated
retroactive enrollments, weekend/holiday/evening discharges, and when members
transition to Kaiser from another QUEST Integration health plan.
Prior Authorizations for Non-Emergency Transportation Services
The QUEST Integration transportation benefit is for medically necessary appointments for
members who have no other means of transportation, who reside in areas not served by public
transportation, or cannot access public transportation due to their disability. The health plan may
use whatever mode of transportation which can be safely utilized by the member.
The most cost-effective means of transportation that best meets the needs of the member’s
specific circumstances will be used when medically necessary as indicated by the Service
Coordinator or PCP as documented in the care plan. Free transportation available to the member
(e.g., friends, relatives, volunteer services, own vehicle, facility serving the member,
consolidation of appointments, etc.) should be explored before other means of paid transportation
are considered unless medically prohibited. Bus tickets may be provided for individual trips.
Bus passes will be considered when the cost of multiple bus tickets exceeds or is expected to
exceed the cost of a bus pass.
Taxi services shall be authorized when a recipient is unable to utilize public transportation or
curb to curb services (Handi-Van) and only between the home of a recipient and to the nearest
appropriate medical facility and back. Side trips are not allowed and will not be paid. In
addition, payment will not be made for waiting time. Taxi services will only be provided after
all other personal transportation options, such as family and friends, have been explored.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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To be authorized, only licensed physicians are allowed to assess and justify the need for taxi
services. Physical and/or mental impairment must be verified by a physician that travel by bus
or Handi-Van would be either hazardous to the patient's health or would compromise his/her
medical condition.
Contact the QUEST Integration Call Center at 808-432-5330 or 1-800-651-2237 (toll-free) for
more information.
How to Submit a Prior Authorization
Submit a prior authorization/referral form contact the following respective department listed
below. You may also submit online via the following link:
http://providers.kaiserpermanente.org/html/cpp_hi/kponlineaffiliate.html
Examples of prior authorizations/referrals:
Prior Authorization: Call the Kaiser QUEST Integration Health Coordinator at:
808-432-5330 or 1-800-651-2237 (toll-free). Fax: 808-432-5260
Adult Day Care Center (ADC)
Adult Day Health Center (ADH)
Assisted Living Facility (ALF) Community Care Management Agency (CCMA)
Community Care Foster Family Home (CCFFH)
Counseling and Training
Environmental Accessibility Adaptations (EAA)
Residential Care Services or Type 1 or Type II Expanded Adult Residential Care Home
(E-ARCH)
Home Delivered Meals
Home Maintenance
Moving Assistance
Non-Emergent Only Transportation
Personal Assistance Service Level I (PA1)
Personal Assistance Service Level II (PA2)
Personal Emergency Response Systems (PERS)
Skilled (or Private Duty) Nursing
Respite Care
Specialized Medical Equipment and Supplies (SMES)
Nursing facility
Lactation counseling beyond six months
Kaiser Authorization Dept.
for Plan Referral
Phone at:
Phone: 808-432-5687
Fax: 808-432-5691
Alt Fax: 808-432-5667
Durable medical equipment (DME) and medical
Hearing aid
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Breast pump (rental beyond six months and all purchases)
Radiology/lab/other diagnostic services: Specialty procedures require prior authorization
Dialysis
Prior authorization is required for all rehabilitation services except for the initial
evaluation
Referral External Sleep Study
Transplant
Contact lenses
Hospice
Transition of Care
Members transitioning to Kaiser Permanente:
If the member is receiving medically necessary covered services one day prior to enrollment to
the health plan, Kaiser Permanente will be responsible for the cost of continuing these
medically necessary services provided by contracted or non-contracted providers without prior
approval. The period of coverage will include the prior period coverage (which is the period
from the eligibility effective date to the data of enrollment into Kaiser QI), as well as any
retroactive enrollment periods. Kaiser Permanente will provide continuation of services for
individuals with SHCN and LTSS for at least ninety (90) days or until the member has received a
health and functional assessment (HFA) by their service coordinator. Claims submitted by non-
Kaiser Permanente providers for medically necessary care during the 45-day transition period
will be reviewed and authorized for payment. Kaiser Permanente will reimburse PCP services
that a member may have accessed during a 45-day period prior to transitioning to a Kaiser
Permanente PCP, even if the prior PCP is not in the Kaiser’s network.
If the member transitioning into Kaiser Permanente is in her second or third trimester of
pregnancy and is receiving medically necessary covered prenatal services the day before
enrollment, Kaiser will be responsible for providing continued access to the prenatal provider,
even if the provider is not part of Kaiser’s network. Kaiser will continue covering prenatal
services through the postpartum period.
Members transitioning from Kaiser Permanente:
Kaiser Permanente will assist the new health plan with obtaining the member’s medical records
and/or other vital information as requested. A release of protected health information form will
be completed before information is sent to the new plan. Kaiser Permanente will cooperate
with the member and the new health plan in transitioning the member into the new health plan.
The Primary Care Physician may be consulted for medical input and a collaborative decision by
the interdisciplinary team will be made to initiate case coordination/management while assisting
a member with the transition of care. Once transition of care is established with the new plan, no
further case coordination will be necessary from the Kaiser QUEST Integration plan.
Kaiser Permanente will be responsible for the care and cost of inpatient services for members
who moves to a different service area in the middle of a month and enrolls in a different health
plan. Responsibility will continue until discharge or level of care change, whichever is first. For
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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non-hospitalized members, the new health plan is responsible from the date of enrollment.
Kaiser Permanente will be responsible for the care and cost of services provided to members
who move to a different service area and remain with Kaiser QUEST Integration .
Pregnant members who are in their second or third trimester and are receiving medically
necessary prenatal services the day before enrollment will be allowed to continue to receive care
from their existing OB/GYN through the post-partum period, even if the provider is not in the
new plan’s network.
Newborns whose mother elects to change health plans after the first 30 days of the newborn’s
auto-assignment into the mother’s health plan (at the time of delivery) will have care
coordination and continuity of care until the newborn is transitioned into the new plan’s network.
Members transitioning when provider terminates from Kaiser:
When a provider terminates from Kaiser, a letter is sent to the member who is assigned to
another physician taking over the PCP’s panel or to a new PCP of the member’s choosing.
However, during the interim, the member is automatically cared for by the other physicians in
the health care team and/or the clinic to ensure continuity of care. The letter is sent to the
member 30 days prior to the effective date of termination or relocation.
Chapter 7: Compliance and Fraud, Waste, and Abuse
Kaiser Permanente (KP) strives to demonstrate high ethical standards in its business practices.
Because contracting providers are an integral part of KP’s business, it’s important that we
communicate and obtain your support for these standards. The Provider Contract Agreement
details specific laws, regulations, and contractual provisions with which you are expected to
comply with.
Compliance with the Law
Providers are expected to comply with applicable State and Federal laws and regulations,
including, but not limited to, the Health Insurance Portability and Accountability Act of 1996
(HIPAA), Title VI of the Civil Rights Act of 1964, and the American with Disabilities Act
(ADA).
Kaiser Permanente Principles of Responsibility
The Kaiser Permanente Principles of Responsibility (“POR”) is the code of conduct for Kaiser
Permanente. Anyone who works for or on behalf of Kaiser Permanente is required to follow
all applicable laws, policies, and this code of conduct. Please click on the attached link, Code of
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
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Ethical Conduct - Kaiser Permanente’s Principles of Responsib i lity.
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Kaiser Permanente Ethics and Compliance Program Description (Compliance
Plan)
The Kaiser Permanente Ethics and Compliance Program includes a fraud, waste, and abuse
plan and provides awareness to promote an ethical environment in compliances with laws and
regulations.
Fraud, Waste, and Abuse (FWA)
Kaiser Permanente will investigate allegations of FWA related to goods and services provided
to Kaiser Permanente or its members and will take corrective action, including, but not limited
to, civil or criminal action where appropriate. The Federal False Claims Act and simil ar state
laws make it a crime to present a false claim to the government for payment. These laws also
protect “whistleblowers” (people who report noncompliance or FWA) from retaliation. Kaiser
Permanente policy prohibits retaliation of any kind against individuals exercising their rights
under the False Claims Act or similar state laws.
It is important to report FWA concerns in a timely manner.
The Kaiser Permanente Compliance Hotline is a convenient and anonymous way to report
suspected wrongdoing without fear of retaliation. The Kaiser Permanente Compliance Hotline
is available 24 hours a day, 7 days a week, at 1-888-774-9100.
Appropriate action is taken to investigate all allegations of noncompliance.
For prevention, detection, and reporting FWA - please click on the attached link, Prevention
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
KP22-016 Provider Manual
Detection and Reporting Fraud, Waste, Abuse (FWA).
Kaiser Permanente recognizes that acting responsibly with our resources is critical to our
success. In addition, the Deficit Reduction Act of 2005 requires Kaiser Permanente to formally
show our resolve in combating fraud, waste, and abuse, especially in the administration of
Federal and State health care programs such as Medicare and Medicaid. The Deficit Reduction
Act requires that we make these policies available for all physicians, employees and you, our
outside network partners.
Compliance with Deficit Reduction Act Requirements: This policy serves as a compendium
of the existing tools that we, along with federal and state agencies and individuals, use to fight
fraud, waste, and abuse in the administration of federal and state health programs in our market.
Examples of these tools include summaries of federal and state laws on false claims and
protection of employees who report suspected violations. It also includes our own existing
policies and procedures for detecting and preventing fraud. Please click on the attached link here,
Compliance with Deficit Reduction Act Requirements Policy.
Fraud, Waste, and Abuse Control: This policy articulates our commitment to control fraud,
waste, and abuse through prevention, detection, correction and reporting of any violation of a
38
Federal or State law, regulatory requirement, contractual obligation or organizational policy or
procedure. Please click on the attached link, Fraud, Waste, and Abuse Control Policy.
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
KP22-016 Provider Manual
Chapter 8: Quality Management Program
Integrated Quality Program
Quality assurance and systems improvement are shared responsibilities of KFHP, KFH, the
Hawaii Permanente Medical Group (HPMG), and affiliates. HPMG delivers medical care in
an exclusive provider relationship in mutual collaboration with the KFHP and KFH. At all
levels of the organization, Health Plan managers partner with physician managers to design,
deliver, measure, and monitor quality care and service across the continuum of care – clinics,
hospital, skilled and intermediate nursing facilities, home health care, affiliated services, and
membership business and support services. The activities summarized in this Regional Quality
Program Description serves to inform internal and external audiences about how the Hawaii
Market is organized to support the organization’s commitment to assessing and improving
performance on a continuous systematic and outcome-oriented basis.
The Hawaii Region Quality Program is a systematic, integrated, widely deployed approach to
planning, implementing, assessing, and improving clinical quality, patient safety, health
outcomes, resource management/stewardship, clinical risk management, outside services, and
service performance. All plans, goals, and initiatives are aligned with the Kaiser Permanente
National Strategy, guided by the Hawaii Market’s mission and vision. Assessing group and
member needs, responding to the voice of the customer, and monitoring quality of care and
service are integrated into the Hawaii Region Quality Program. Also described are the
responsibilities and relationship within the organization including the relationship between the
Kaiser Foundation Health Plan/Hospitals (KFHP/H) Boards of Directors and the Quality and
Health Improvement Committee (QHIC), which oversees quality Kaiser Permanente program-
wide, and our affiliates.
See link – 2024 Quality Progr am Description Hawaii Region
Utilization Management Program
For care delivered by HPMG and Kaiser Foundation Hospital-Moanalua staff, Utilization
Management is based on an approach of advisory Utilization Management. HPMG physicians
work collaboratively with their peers to ensure appropriate treatment plans and utilization of
resources. In most cases, the final decision regarding a member’s treatment plan rests with the
HPMG attending physician. Utilization Management / Continuing Care staff is available to
support physicians in the management of member’s health care needs throughout the care
continuum and provide a variety of services, such as discharge planning, utilization review, care
management and ensuring compliance with internal and external regulatory requirements related
to Utilization Management.
For care delivered by Contract Providers and Practitioners, the approach to Utilization
Management includes an authorization process. For services not available within the HPMG /
39
KFH system, procedures are developed for referrals to Contract Providers to ensure that referrals
are appropriate. Contracted Providers are expected to comply with the Utilization Management
procedures, to continue treatment plans, and to ensure appropriateness of care and resource
management. In cases where Contracted Providers do not comply with HPMG / KFH
procedures, reimbursement for services may be at risk.
See link 2024 Quality Program Description Hawaii Region
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KP22-016 Provider Manual
Guidelines for Patient Medical Records
The medical record shall reflect an accurate, comprehensive record of care planned and/or
provided to a patient. The medical record serves as primary documentation of the health care
process for patients. Health care Providers document clinical data and observations, develop and
communicate plans of care, and record patient and family responses to planned or provided care.
Any Provider who documents health care information in the medical record shall adhere to the
guidelines defined by scope of practice, security classification and job description in providing
care for patients.
DHS personnel or personnel contracted by the DHS shall have access to all records, as long as
access t o the records is needed to perform the duties of the contract and to administer the
QUEST Integration program for information released or exchanged pursuant to 42 CFR
Section 431.300. Practitioners shall provide DHS or its designee(s) with prompt access to
members’ medical records; provide members with the right to request and receive a copy of his
or her medical records, and to request that they be amended, as specified in 45 CFR Part 164,
and allow for paper and electronic record keeping.
All access use and disclosure of member protected health information must be in accordance
with state and federal regulations regarding privacy and confidentiality. Without fail, physicians
and employees are expected to follow the requirements of HIPAA, other laws and Kaiser
Permanente policies on confidentiality, privacy and security.
Providers are required to adhere to the following requirements:
1. All medical records are maintained in a detailed and comprehensive manner that
conforms to good professional medical practice;
2. All medical records are maintained in a manner that permits effective professional
medical review and medical audit processes;
3. All medical records are maintained in a manner that facilitates an adequate system for
follow-up treatment;
4. All medical records shall be legible, signed and dated;
5. Each page of the paper or electronic record includes the patient’s name or ID number;
6. All medical records contain patient demographic information, including age, sex, address,
home and work telephone numbers, marital status and employment, if applicable;
7. All medical records contain information on any adverse drug reactions and/or food or
other allergies, or the absence of known allergies, which are posted in a prominent area
on the medical record;
8. All forms or notes have a notation regarding follow-up care, calls or visits, when
indicated;
40
9. All medical records contain the patient’s past medical history that is easily identified and
includes serious accidents, hospitalizations, operations and illnesses. For children, past
medical history including prenatal care and birth;
10. All pediatric medical records include a completed immunization record or documentation
that immunizations are up-to-date;
11. All medical records contain a history of screenings performed and the findings of those
screenings, along with appropriate follow up actions, as needed, including counseling and
interventions provided as well as referral actions taken;
12. All medical records inclu de the provisional and confirmed diagnosis(es);
13. All medical records contain medication information;
14. All medical records contain information on the identification of current problems (i.e.,
significant illnesses, medical conditions and health maintenance concerns);
15. All medical records contain information about consultations, referrals, and specialist
reports;
16. All medical records contain information about emergency care rendered with a discussion
of requirements for physician follow-up;
17. All medical records contain discharge summaries for: (1) all hospital admissions that
occur while the member is enrolled; and (2) prior admissions as appropriate;
18. All medical records for members eighteen (18) years of age or older include
documentation as to whether or not the member has executed an advance directive,
including an advance mental health care directive;
19. All medical records shall contain written documentation of a rendered, ordered or
prescribed service, including documentation of medical necessity; and
20. All medical records shall contain documented patient visits, which includes, but is not
limited to:
a. A history and physical exam;
b. Treatment plan, progress and changes in treatment plan;
c. Laboratory and other studies ordered, as appropriate;
d. Working diagnosis(es) consistent with findings;
e. Treatment, therapies, and other prescribed regimens;
f. Documentation concerning follow-up care, telephone calls, emails, other
electronic communication, or visits, when indicated;
g. Documentation reflecting that any unresolved concerns from previous visits are
addressed in subsequent visits;
h. Documentation of any referrals and results thereof, including evidence that the
ordering physician has reviewed consultation, lab, x-ray, and other diagnostic test
results/reports filed in the medical records and evidence that consultations and
significantly abnormal lab and imaging study results specifically note physician
follow-up plans;
i. Hospitalizations and/or emergency department visits, if applicable; and
j. All other aspects of patient care, including ancillary services.
See also, Hawaii Legal Guidance Matrix.doc, General Record Retention Requirements under
Hawaii Law, Section II Provider Requirements, E. Ambulatory Surgical Centers (page 16) and
Section IX. HIPAA Compliance (protected health information, page 48)
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KP22-016 Provider Manual
41
Chapter 9: Pharmaceutical Management Procedures
and Drug Formulary
The Kaiser Hawaii Drug Formulary lists medications approved through a scientific review
process by the Pharmacy and Therapeutics (P&T) Committee. Its intent is to enhance the quality
of patient care by promoting safe, effective, and economical drug therapy. The Kaiser Hawaii
Region’s drug formulary is considered a closed formulary, in which listed medications are
usually covered under plan benefits. However, listing of a medication in our drug formulary does
not necessarily mean it is covered under your patient’s prescription drug benefit plan since
prescription benefit coverage varies depending on your patient’s plan.
Drugs covered by QUEST Integration are those prescribed by a physician or other health care
provider licensed for prescription privileges and is on the list of approved drugs and includes
over-the-counter drugs. Drugs must be medically necessary to optimize the member’s medical
condition (including children receiving CAMHD services).
The QUEST Integration benefit also includes:
Medication management and patient counseling is also included.
Drugs required to be covered by statute, including antipsychotic medication and
continuation of antidepressant and anti-anxiety medications prescribed by a licensed
psychiatrist or physician duly licensed in the State for a U. S. Food and Drug
Administration (FDA) approved indication as treatment of a mental or emotional
disorder,
Drugs approved by the FDA that are eligible pursuant to the Omnibus Budget
Reconciliation Rebates Act and necessary to treat members for human immunodeficiency
virus, acquired immune deficiency syndrome, or Hepatitis C, or a member needing
transplant immunosuppressive (without the need for a prior authorization).
Practitioners and providers who have questions regarding Kaiser’s Pharmaceutical
Management procedures may call the Pharmacy Administration Department at 808-432-5549.
The formulary approval process ensures that available drugs meet established quality standards
and that adequate information for their optimal use is provided, while limiting the availability of
unsafe, "less than effective," or "ineffective" drugs, and drugs with a high potential for toxicity
or abuse.
The drug formulary also supports cost management by promoting the use of effective but less
costly therapeutic equivalents, reducing the number of therapeutically redundant drugs,
optimizing pharmacy management or drug inventories, and maximizing leverage through the
drug purchasing and bid process.
Non-formulary drugs are drugs not officially accepted for inclusion into our drug formulary. This
includes new drugs not yet reviewed for addition, drugs that have been reviewed but denied
admission to the formulary, or a brand, strength, or dosage form of a formulary drug not stocked
in Kaiser pharmacies.
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KP22-016 Provider Manual
42
Non-formulary drugs are excluded from drug plan coverage unless your patient is allergic to a
formulary drug, fails to respond to formulary drug therapy at maximum doses, or has special
circumstances requiring the use of a non-formulary drug. If your patient meets any or all of these
“medically necessary” conditions for use of a formulary drug, as documented in the patient’s
medical record, your patient may obtain his/her prescription at his/her usually supplemental
charge or receive a refund on a prescription for which they initially paid full price. Non-
formulary drugs are not usually stocked in our pharmacies, therefore, there may be a delay
before such a medication is dispensed or administered.
The formulary can be accessed via the kp.org website here: KPHI Quest Drug Formulary
Kaiser Permanente QUEST Integration: 808-432-5330 or toll-free at 1-800-651-2237 or 711 (TTY)
providers.kaiserpermanente.org
KP22-016 Provider Manual
(kaiserpermanente.org). Formulary (list of covered drugs)
If you do not have access to the internet or have difficulties in accessing the formulary, you may
call Pharmacy Administration Department at 808-432-5854 to request for a hardcopy to be
sent to you.
Chapter 10: Credentialing
This section highlights procedures and policies, such as those regarding credentialing, bioethics,
regulatory reporting, quality of care reporting, and other related information.
Credentialing
As an important part of Kaiser Permanente’s Quality Management Program, all credentialing
and recredentialing activities are structured to assure all practitioners are qualified to meet Kaiser
Permanente’s standards for the delivery of quality healthcare and service to its members.
As stated in the facility services agreements, all providers will remain in compliance with all
applicable facility, local, State and Federal laws, rules and regulations including, but not li mited
to, those (a) regarding licensure, certification and accreditation of acute care hospitals; (b)
necessary for participation in the Medicare and Medicaid programs; and (c) regulating the
operations and safety of acute care hospitals (including all laws, rules and regulations regarding
hazardous substances), and (2) accredited by The Joint Commission (TJC) or any successor and
any other accreditation organization reasonably requested by Kaiser Foundation Hospitals.
The credentialing/recredentialing policies and procedures approved by Kaiser Permanente are
intended to meet the standards outlined by NCQA.
All practitioners wishing to participate in Kaiser Permanente must successfully complete the
credentialing process and must demonstrate their on-going ability to meet credentialing standards
through a triennial recredentialing process. Practitioners are required to provide Kaiser
Permanente with the information needed to review and verify their credentials.
43
The Professional Competency Department is responsible for collecting and verifying
credentialing information while the Credentials and Privileges Committee reviews the completed
credentialing or recredentialing files to determine if the practitioner will be approved for new or
continuing participation in Kaiser Permanente.
Credentialing/Recredentialing Requirements (Practitioners)
These credentialing and re-credentialing requirements apply to all Licensed Independent
Practitioners (LIPs) who provide health care services on behalf of Kaiser Permanente. These
include, but are not limited to MDs, DOs, DPMs, DDSs, NPs, CNMs , PAs, PhDs, PSYs, CRNAs,
LCSWs, ODs, and CNSs for Behavioral Health.
Each practitioner must provide/demonstrate that all the criteria noted below are met:
A completed application which includes practitioner demographics, practice information,
work history, educational background, and a personal attestation to the practitioner’s
physical and mental well-being and the accuracy of the information provided.
A current valid license to practice.
The status of clinical privileges at the hospital designated by the practitioner as the
primary admitting facility, as applicable.
A valid DEA or CDS certificate, as applicable to the specialty.
Appropriate education and training for the practice specialty.
Explanations for any gaps in work history (initial credentialing only).
Evidence of current, adequate professional liability insurance in the amount of
$1,000,000 per occurrence and $3,000,000 aggregate with exceptions only granted upon
complete review.
Acceptable history of malpractice claims experience.
Acceptable performance as recorded in all practice information related to Kaiser
Permanente members.
Full disclosure requirements as identified in accordance with 42 CFR Part 455, Subpart B.
Credentialing/Recredentialing Requirements (Organizational Providers)
These credentialing and re-credentialing requirements apply to organizational providers who
provide health care services on behalf of Kaiser Permanente. Organizational providers are
operations other than Licensed Independent Practitioners (LIPs). Organizational providers
include but are not limited to: acute care hospitals, skilled nursing facilities, free standing
surgical centers, home health/hospice agencies, transitional residential recovery services (TRRS),
dialysis units, psychiatric centers (ambulatory, residential, and inpatient), providers of end-stage
renal disease services, providers of outpatient diabetes self-management training, portable x-ray
suppliers, rural health clinics, federally qualified health centers, designated urgent care clinics,
and Long Term Care Services & Supports (LTSS) providers.
Each provider must provide/demonstrate that all the criteria noted below are met:
A current valid license or certificate issued by the state and or local agency(s) with
jurisdiction (as applicable).
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KP22-016 Provider Manual
44
Evidence of current, adequate professional liability insurance in the amount of
$1,000,000 per occurrence and $3,000,000 aggregate with exceptions only granted upon
complete review.
Evidence of current automobile liability insurance (only applicable to Providers
providing transportation services).
Accreditation or site visit
o
Documentation of current accreditation issued by a Recognized Accrediting Body
along with the most recent accreditation reports.
-OR-
Documentation of a site visit conducted by Centers for Medicare & Medicaid
Services (CMS), Hawaii State Department of Health (DOH) or Community Ties
of America (CTA) within the last three years that demonstrates a standard of
quality acceptable to Kaiser Permanente.
-OR-
Undergo a site visit conducted by Kaiser Permanente staff that demonstrates a
standard of quality acceptable to Kaiser Permanente.
Hawaii's Online Kahu Utility (HOKU) registration
Credentials and Privileges Committee
When all credentialing or recredentialing requirements have been collected and verified, they are
presented to the Credentials and Privileges Committee for review and approval of the
practitioner’s new or continued participation as a contracted practitioner.
Approvals
Practitioners who have been approved for new or continued participation in Kaiser Permanente
are notified by electronic mail within one month of approval.
Denial as Termination of Participation
Practitioners are notified by electronic mail when they are denied participation with Kaiser
Permanente. Depending on the reason for denial a practitioner may have the right to appeal the
decision, please refer to the attached Notice and Fair Hearing Procedure.
Practitioner Rights to Review and Correct Erroneous Credentialing Information
Kaiser Permanente notifies a practitioner when a credentialing verification conflicts with
information provided on the initial or recredentialing application. The practitioner then has the
right to:
review the conflicting verification documentation provided such disclosure is not
prohibited by law, and
submit documentation supporting or clarifying the information provided on the
application.
The conflicting information and the practitioner’s supporting documentation are included in the
practitioner’s credentials file for review by the Credentials and Privileges Committee.
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KP22-016 Provider Manual
45
Confidentiality of Credentialing Information
All information obtained during the credentialing and recredentialing process is considered to be
confidential except as otherwise required by law.
Chapter 11: Claim and Invoice Sub mission
How to send Claims and Invoices to Kaiser Permanente
Send your completed claim, invoice or direct inquiries to the appropriate locations:
For Claim Submission:
Kaiser Foundation Health Plan, Inc.
Hawaii Claims Administration
PO Box 378021
Denver, Colorado 80237
Contact Numbers to Call for Billing Questions:
1-877-875-3805 (Toll-free) or
Kaiser Permanente Hawaii Customer Service for QI Claims 808-432-5330
or toll- free at 1-800-651-2237 or 711 (TTY) 7:45am – 4:30 Monday -Friday
For Invoice Submissions:
Kaiser Permanente Accounts Payable
QUEST Integration
PO Box 178902
Honolulu, HI 96817
OR
Email: [email protected]
It is your responsibility to submit itemized claims for services provided to QUEST Integration
Members in a complete and timely manner and based on chart documentation, in accordance
with your Agreement, this Provider Manual and applicable law.
Methods of Claims Submission
Claims may be submitted by mail or electronically. Whether submitting claims on paper or
electronically, only the UB-04 form will be accepted for facility services billing and only the
CMS-1500 form, which will accommodate reporting of the individual (Type 1) NPI, will be
accepted for professional services billing. Submitting claims that are handwritten, faxed or
photocopied will be subject to processing delay and/or rejection.
When CMS-1500 or UB-04 forms are updated by NUCC/CMS, Kaiser Permanente will notify
Provider when the Kaiser Permanente systems are ready to accept the updated form(s) and
Provider must submit claims using the updated form(s).
Supporting Documentation for Paper Claims
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KP22-016 Provider Manual
46
In general, the Provider must submit, in addition to the applicable billing form, all supporting
documentation and information that is reasonably relevant and necessary to determine payment.
At a minimum, supporting documentation that may be reasonably relevant may include the
following, to the extent applicable to the services provided:
Authorization
Admitting face sheet
Discharge summary
Operative report(s)
Emergency room records with respect to all emergency services
Treatment and visit notes as reasonably relevant and necessary to determine payment
A physician report relating to any claim under which a physician is billing a CPT-4 code
with a modifier, demonstrating the need for the modifier
A physician report relating to any claim under which a physician is billing an “Unlisted
Procedure”, a procedure or service that is not listed in the current edition of the CPT
codebook
Physical status codes and anesthesia start and stop times whenever necessary for
anesthesia services
Therapy logs showing frequency and duration of therapies provided for SNF services
Electronic Data Interchange (EDI)
Kaiser Permanente encourages Providers to submit electronic claims (837I/P transaction).
Electronic claim transactions eliminate the need for paper claims. Electronic Data Interchange
(EDI) is an electronic exchange of information in a standardized format that adheres to all Health
Insurance Portability and Accountability Act (HIPAA) requirements. Kaiser Permanente
requires all EDI claims be HIPAA compliant.
HIPAA Requirements
All electronic claim submissions must adhere to all HIPAA requirements. The following
websites (listed in alphabetical order) include additional information on HIPAA and electronic
loops and segments. HIPAA Implementation Guides can also be ordered by calling Washington
Publishing Company (WPC) at 1-301-949-9740.www.dhhs.gov
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KP22-016 Provider Manual
www.wedi.org www.wpc-edi.com
Claims Submission Timeframes
Claims for services provided to Members should be submitted for payment within ninety (90)
days of such service. However, all claims and encounter data must be sent to the appropriate
address no later than 365 days (or any longer period specified in your Agreement or required by
law) after the date of service or date of discharge, as applicable.
Member Cost Share
Please verify applicable Member Cost Share at the time of service by contacting Member
Services. Members may be responsible to share some cost of the services provided. Member
Cost Share are the fees a Member is responsible to pay a Provider for certain covered services.
CMS-1500 Field Descriptions
47
The fields identified in the table below as “Required” must be completed when submitting a
CMS-1500 (02/12) claim form for processing:
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KP22-016 Provider Manual
Field
Number
Field Name
Required Fields
for Claim
Submissions
Instructions/Examples
1
MEDICARE/ MEDICAID/ TRICARE
/ CHAMPVA/ GROUP HEALT H
PLAN/FECA BLK LUNG/OTHER
Not Required
Check the type of health insu rance coverage applicable
to this claim by checking the appropriate box.
1a
INSURED’S I.D. NUMBER
Required Enter the patient’s Kaiser Permanente Medical
Record Number (MRN)
2
PATIENT’S NAME
Required
Enter the patient’s name. When submitting newborn
claims, enter the newborn ’s first and last name.
3
PATIENT'S BIRTH DATE AND
SEX
Required
Enter the patient’s date o f birth and gender. The
date of
birth must include the mon th, day and FOUR DIGITS
for the year (MM/DD/YYYY) .
Example: 01/05/2006
4
INSURED'S NAM E
Required
Enter the name of the insu red, i.e., policyholder (Last
Name, First Name, and Middle Initial), unless the
insured and the patien t are the same—then the word
“SAME” may be entered.
If this field is completed with an identity different than
that of the patient, also co mplete Field 11.
5
PATIENT'S ADDRESS
Required
Enter the patient’s mailing address and telephone
number. On the first line, enter the STREET
ADDRESS; the sec ond line is for the CITY and
STATE; the third line is for the nine digits ZI P CODE
and PHONE NUMBER.
6
PATIENT'S RELAT IONSHIP TO
INSURED
Required
Check the appropriate box for the patient’s relationship
to the insured.
7
INSURED'S ADDRESS
Required if
Applicable
Enter the insured’s address (STREET ADDRESS,
CITY, STATE, and nine digits ZIP CODE) and
telephone number. When the address is the same as the
patient’s—the word “SAME” may be entered.
8
RESERVED FOR NUCC USE
Not Required
Leave blank.
9
OTHER INSURED'S NAME
Required if
Applicable
When additional insurance coverage ex ists, enter the
last name, f irst name and middle initial of the insured.
9a
OTHER INSURED’S POLICY OR
GROUP NUMBER
Required if
Applicable
Enter the policy and/or group number of the insured
individual named in Field 9 (Other Insured’s Name)
above.
NOTE: For e ach entry in Field 9a, there must be a
corresponding entry in Field 9d.
9b
RESERVED FOR NUCC USE
Not Required
Leave blank.
9c
RESERVED FOR NUCC USE
Not Required
Leave blank.
48
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KP22-016 Provider Manual
Field
Number
Field Name
Required Fields
for Claim
Submissions
Instructions/Examples
9d
INSURANCE PLAN NAME OR
PROGRAM NAME
Required if
Applicable
Enter the name of the “o ther” insured’s INSURANCE
PLAN or program.
10a-c
IS PATIENT’ S CONDITION
RELATED TO
Required
Check “Yes” or “No” to indicate whether employment,
auto liability , or other accident involvement applies to
one or more of the services described in field 24.
NOTE: If “yes” there must b e a correspondin g entry in
Field 14 (Date of Current Illness/Injury).
Place (State) - enter the State po stal code.
10d
CLAIM CODE S (Designated by
NUCC)
Not Required
Leave blank.
11
INSURED’S POLICY NUMBER OR
FECA NUMBER
Required if
Applicable
Enter the insured’s policy or group number.
11a
INSURED’S DATE OF BIRTH
Required if
Applicable
Enter the insured’s date of birth and sex, if different
from Field 3. The date of birth must include the month,
day, and FOUR digits for the year (MM/DD/YYYY).
Example: 01/05/2006
11b
OTHER CLAIM ID (Designated by
NUCC)
Not Required
Leave blank.
11c
INSURANCE PLAN OR PRO GRAM
NAME
Required if
Applicable
Enter the insured’s insurance plan or program name.
11d
IS THERE ANOTHER HEALTH
BENEFIT PLAN?
Required
Check “yes” or “no” to indicate if there is another
health benefit plan. For example, the patient may be
covered under insurance h eld by a spouse, parent, or
some other person.
If “yes” then fields 9 and 9a-d must be completed.
12
PATIENT'S OR AUTHORIZ ED
PERSON'S SIGNATURE
Required if
Applicable
Have the patient or an authorized representative SIGN
and DATE this block unless the signature is on file. If
the patient’s representative signs, then the relationship
to the patient must be ind icated.
13
INSURED'S OR AUT HORIZ ED
PERSON'S SIGNATURE
Required
Have the patient or an authorized representative SIGN
this block unless the signa ture is on file.
14
DATE OF CURRENT ILLNESS,
INJURY, PREGNANCY (LM P)
Required if
Applicable
Enter the date of the current illness or injur y. If
pregn ancy, enter the date o f the patient’s last menstrual
period. The date must in clude the month, day, and
FOUR DIGITS for the yea r (MM/DD/YYYY).
Example: 01/05/2006
15
OTHER DATE
Not Required
Leave blank.
49
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KP22-016 Provider Manual
Field
Number
Field Name
Required Fields
for Claim
Submissions
Instructions/Examples
16
DATES PATIENT UNABLE TO
WORK IN CURRENT
OCCUPATION
Not Required
Enter the “from” and “to” dates that the patient is
unable to work. The dates must include the month,
day, and FOUR DIGITS for the year
(MM/DD/YYYY).
Example: 01/05/2003
17
NAME OF REFERRING
PHYSICIAN OR OTHER SOURCE
Required if
Applicable
Enter the FIRST and LAST NAME of the Kaiser
Permanente referring or Kaiser Permanente
ordering physician.
17a
OTHER ID #
Not Required
17b
NPI NUMBER
Required Enter the NPI number of the Kaiser Permanente
referring provider
18
HOSPITALIZATION DATES
RELATED TO CURRENT
SERVICES
Required if
Applicable
Complete th is block when a medical service is
furnishe d as a result of, or subsequent to, a related
hospitalization.
19
ADDITIONAL CLAIM
INFORMATION (Designated by
NUCC)
Not Required
Leave blank.
20
OUTSIDE LAB CHARGES
Not Required
21
DIAGNOSIS OR NATURE OF
ILLNESS OR INJURY
Required
Enter the diagnosis/condition of the patient, indicated
by an ICD-9 -CM (or its successor, ICD-10) code
number. Enter up to 4 diagnostic codes, in PRIORITY
order (primary, secondary condition).
22
RESUBMISSION
Not Required
23
PRIOR AUTHORIZATION
NUMBER
Required if
Applicable
For ALL inpatient and outpatient claims, enter the
Kaiser Permanente
referral number, if applicable,
for the episode of care being billed
NOTE: this is a 1 0-digit alp hanumeric id entifier
50
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KP22-016 Provider Manual
Field
Number
Field Name
Required Fields
for Claim
Submissions
Instructions/Examples
24A-J
SUPPLEMENTAL I NFORMATION
Required
Supplemental information can only be entered with a
corresponding, completed ser vice line.
The top area of the six service lines is shaded and is the
location for reporting supplemental information. It is
not intended to allow the billing of 12 lines of service.
When reporting additional anesthesia services
information (e.g., begin and end times), narrative
description of an unspecified code, NDC, VP –
HIBCC
codes, OZ – GTIN codes or contract rate , enter the
applicable qualifier and number/code/ information
starting with the first space in the shaded line of this
field. Do not enter a spa ce, hyphen, or other separator
between the qualifier and the number/code/in formation.
The following qualifiers are to be used when reporting
these services.
7 – An esthesia information
ZZ – Narrative description of unspecified code
N4 – National Drug Codes (NDC)
VP – Vendor Product Number Health Ind ustry
Business Communications Council (HIBCC) Labeling
Standard
OZ – Product Number Health Care Uniform Code
Council – Global Trade I tem Number (GTIN)
CTR – Contract rate
24A
DATE(S) OF SE RVICE
Required
Enter the month, day, and year (MM/DD/YY) for each
procedure, service, or su pply. Services must be entered
chronologically (starting with the oldest date first).
For each service date listed/billed, the following fields
must also be entered: Units, Charges/Amount/Fee,
Place of Service, Procedure Code, and corresponding
Diagnosis Code.
IMPORTANT: Do not sub mit a claim with a future
date of service. Claims can only be submitted once the
service has been rendered (for example: durable
medical eq uipment).
24B
PLACE OF SERVICE
Required
Enter the place of service code for each item used or
service performed.
24C
EMG
Required if
Applicable
Enter Y for "YES" or lea ve blank if "NO" to indicate
an EMERGENCY as defined in the electronic 837
Professional 4010A1 implementation guide.
51
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Field
Number
Field Name
Required Fields
for Claim
Submissions
Instructions/Examples
24D
PROCEDURES, SERVICES, OR
SUPPLIES: CPT/HCPCS,
MODIFIER
Required
Enter the CPT/HCPCS codes an d MODIFIERS (if
applicable) reflecting the pr ocedures perfor med,
services rendered, or supp lies used.
IMPORTANT: Enter the anesthesia time, reported as
the “beginning” and “end” times of anesthesia in
military time above the appropriate procedu re code
24E
DIAGNOSIS POINTER
Required
Enter the diagnosis code reference number (pointer) as
it relates the date of service and the procedures shown
in Field 21. When multiple services are performed, the
primary reference number for each service should be
listed first, and other applica ble services should follow.
The ref erence number(s) sho uld be a 1, or a 2, or a 3, or
a 4; or multiple numbers as explai ned.
IMPORTANT: (ICD-9-CM, ( or its successor, ICD-10)
diagnosis codes must be entered in Item Number 21
only. Do not enter them in 2 4E.)
24F
$ CHARGES
Required
Enter the FULL CHARGE for each listed service. Any
necessary payment reductions will be made during
claims adjudication (for example, multiple surgery
reductio ns, maximum allowable limitations, co-pays
etc.).
Do not use commas when reporting dollar amounts.
Negative dollar amounts are not allowed. Do llar signs
should not be entered. Enter 00 in the cents area if the
amount is a whole number.
24G
DAYS OR UNITS
Required
Enter the number of days or units in this block. (For
example: units of supplies, e tc.)
When entering the NDC units in addition to the
HCPCS units, enter the applicable NDC ‘units’
qualifier and related units in the shaded line. The
following qualifiers are to be used:
F2 - International Unit
ML - Milliliter
GR - Gram UN Unit
24H
EPSDT FAMILY PLAN
Not Required
52
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Field
Number
Field Name
Required Fields
for Claim
Submissions
Instructions/Examples
24I
ID. QUAL
Required, if
Applicable
Enter the qualifier of the non-NPI identifier. The Other
ID# of the rendering provider is reported in 24j in the
shaded area. The NUCC defines the following
qualifiers:
0B - State License Number
1B - Blue Shield Provider Number
1C - Medicare Provider Number
1D - Medicaid Provider Number
1G - Provider UPIN Number
1H - CHAMPUS Identification Number
EI - Emplo yer’s Identification Number
G2 - Provider Commerc ia l Number
LU - Location Number
N5 - Provider Plan Network Identification Number
SY - Social Security Number (The social sec urity
number may not be used for Medicare.)
X5 - State Industrial Accident Provider Number
ZZ - Provider Taxonomy
24J
RENDERING PROVIDER ID #
Required if
Applicable
Enter the non-NPI identifier in the shaded area of the
field, if app licable. Enter the NPI number in the non-
shaded area of the field, if applicable.
Report the Identification Number in Items 24i and 24j
only when different from data recorded in Fields 33a
and 33b.
25
FEDERAL TAX ID NUMBER
Required
Enter the physician/supplier federal tax I.D. number or
Social Security number o f th e billing provider
identified in Field 33. Enter an X in the appropriate box
to indicate which number is being reported. Only one
box can be marked.
IMPORTANT: T he Federal Tax ID Number in this
field must match the information on file with the IRS.
26
PATIENT'S ACCOUNT NO.
Required
Enter the patient’s account number assigned by the
Provider’s accounting system, i. e., patient control
number.
IMPORTANT: This f ie ld aids in patient identification
by the Provider.
27
ACCEPT ASSIGNMENT
Not Required
28
TOTAL CHARGE
Required
Enter the total charges for the services rendered (total
of all the charges listed in Field 24f).
53
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Field
Number
Field Name
Required Fields
for Claim
Submissions
Instructions/Examples
29
AMOUNT PAID
Required if
Applicable
Enter amount paid by othe r payer.
Do not report collections of patient cost share
30
RESERVED FOR NUCC USE
Not Required
Leave blank.
31
SIGNATURE O F PHYSICIAN OR
SUPPLIER INCLUD ING DEGREE S
OR CREDENTIAL S
Required
Enter the signature of the physician/supplier or his/her
representat ive, and the date the form was signed.
For claims submitted electronically, include a computer
printed name as the signature of the health care
Provider or person entitled to reimbursement.
32
SERVICE FACILITY LOCATION
INFORMATION
Required if
Applicable
The name and address of the facility where serv ices
were rendered (if other than patient’s home or
physician ’s office).
Enter the name and add ress information in the
following format:
1st Line – Name
2nd L ine – Address
3rd Line – City, State and Zip Code
Do not use commas, periods, or other punctuation in
the address (e.g., “123 N Main Street 101” instead of
“123 N. Main Street, #101). Enter a space between
town name and state code; do not include a comma.
When entering a 9-digit zip cod e, include the hyphen.
32a
NPI #
Required if
Applicable
Enter the NPI number of the service facility if it is an
entity external to the billing provider.
32b
OTHER ID #
Required if
Applicable
Enter the two-digit qualifier identifying the non-NPI
identifier followed by the ID number of the service
facility. Do not enter a spa ce, hyphen, or other
separator between the qu alifier and number.
33
BILLING PROVIDER
INFO & PH #
Required
Enter the name, address and phone number of the
billing en tity.
33a
NPI #
Required if
Applicable
Enter the NPI number of the billing provider.
33b
OTHER ID #
Required if
Applicable
Enter the two-digit qualifier identifying the non-NPI
number f ollowed by the ID number of the billing
provider. Do not enter a spa ce, hyphen, or other
separator between the qu alifier and number.
If available, please enter your unique provid er or
vendor number assigned by Kaiser Permanente.
54
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UB-04 (CMS-1450) Field Descriptions
55
The fields identified in the table below as “Required” must be completed when submitting a UB-
04 claim form for processing:
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KP22-016 Provider Manual
Field
Number
Field Name
Required
Fields for
Claim
Submissions
Instructions/Examples
1 PROVIDER NAME
and ADDRESS
Required Enter the name and address of the billing
provider which rendered the services being
billed.
2 PAY-TO NAME,
ADDRESS,
CITY/STATE, ID #
Required if
Applicable
Enter the name and address of the billing
provider’s designated pay-to entity.
3a PATIENT CONTROL
NUMBER
Required Enter the patient’s account number assigned by
the Provider’s accounting system, i.e., patient
control number.
IMPORTANT: This field aids in patient
identification by the Provider.
3b MEDICAL /
HEALTH RECORD
NUMBER
Required if
Applicable
Enter the number assigned to the patient’s
medical/health record by the Provider.
Note: this is not the same as either Field 3a or
Field 60.
4 TYPE OF BILL Required Enter the appropriate code to identify the
specific type of bill being submitted. This code
is required for the correct identification of
inpatient vs. outpatient claims, voids, etc.
5 FEDERAL TAX
NUMBER
Required Enter the federal tax ID of the hospital or person
entitled to reimbursement in NN-NNNNNNN
format.
6 STATEMENT
COVERS PERIOD
Required Enter the beginning and ending date of service
included in the claim.
7 BLANK Not Required Leave blank.
8 PATIENT NAME /
ID
Required Enter the patient’s name, together with the
patient ID (if different than the insured’s ID).
9 PATIENT ADDRESS Required Enter the patient’s mailing address.
10 PATIENT BIRTH
DATE
Required Enter the patient’s birth date in MM/DD/YYYY
format.
11 PATIENT SEX Required Enter the patient’s gender.
56
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Field
Number
Field Name
Required
Fields for
Claim
Submissions
Instructions/Examples
12 ADMISSION DATE Required if
Applicable
For inpatient and Home Health claims only,
enter the date of admission in MM/DD/YYYY
format.
13 ADMISSION HOUR Required For either inpatient OR outpatient care, enter the
2-digit code for the hour during which the
patient was admitted or seen.
14 ADMISSION TYPE Required Indicate the type of admission (e.g. emergency,
urgent, elective, and newborn).
15 ADMISSION
SOURCE
Required Enter the code for the point of origin of the
admission or visit.
16 DISCHARGE HOUR
(DHR)
Required if
Applicable
Enter the two-digit code for the hour during
which the patient was discharged.
17 PATIENT STATUS Required Enter the discharge status code as of the
“Through” date of the billing period.
18-28 CONDITION CODES Required if
Applicable
Enter any applicable codes which identify
conditions relating to the claim that may affect
claims processing.
29 ACCIDENT (ACDT)
STATE
Not Required Enter the two-character code indicating the state
in which the accident occurred which
necessitated medical treatment.
30 BLANK Not Required Leave blank.
31-34 OCCURRENCE
CODES AND
DATES
Required if
Applicable
Enter the code and the associated date (in
MM/DD/YYYY format) defining a significant
event relating to this billing period that may
affect claims processing.
35-36 OCCURRENCE
SPAN CODES AND
DATES
Required if
Applicable
Enter the occurrence span code and associated
dates (in MM/DD/YYYY format) defining a
significant event relating to this billing period
that may affect claims processing.
37 BLANK Not Required Leave blank.
38 RESPONSIBLE
PARTY
Not Required Enter the name and address of the financially
responsible party.
39-41 VALUE CODES and
AMOUNT
Required if
Applicable
Enter the code and related amount/value which
is necessary to process the claim.
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Field
Number
Field Name
Required
Fields for
Claim
Submissions
Instructions/Examples
42 REVENUE CODE Required Identify the specific accommodation, ancillary
service, or billing calculation, by assigning an
appropriate revenue code to each charge.
43 REVENUE
DESCRIPTION
Required if
Applicable
Enter the narrative revenue description or
standard abbreviation to assist clerical bill
review.
44 PROCEDURE CODE
AND MODIFIER
Required if
Applicable
For ALL outpatient claims, enter BOTH a
revenue code in Field 42 (Rev. CD.), and the
corresponding CPT/HCPCS procedure code in
this field.
45 SERVICE DATE Required Outpatient Series Bills:
A service date must be entered for all outpatient
series bills whenever the “from” and “through”
dates in Field 6 (Statement Covers Period:
From/Through) are not the same. Submissions
that are received without the required service
date(s) will be rejected with a request for
itemization.
Multiple/Different Dates of Service:
Multiple/different dates of service can be listed
on ONE claim form. List each date on a
separate line on the form, along with the
corresponding revenue code (Field 42),
procedure code (Field 44), and total charges
(Field 47).
46 UNITS OF SERVICE Required Enter the units of service to quantify each
revenue code category.
47 TOTAL CHARGES Required Indicate the total charges pertaining to each
related revenue code for the current billing
period, as listed in Field 6.
48 NON-COVERED
CHARGES
Required if
Applicable
Enter any non-covered charges.
49 BLANK Not Required Leave blank.
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Field
Number
Field Name
Required
Fields for
Claim
Submissions
Instructions/Examples
50 PAYER NAME Required Enter (in appropriate ORDER on lines A, B, and
C) the NAME and NUMBER of each payer
organization from which you are expecting
payment towards the claim.
51 HEALTH PLAN ID Not Required Enter the Plan Sponsor identification number.
52 RELEASE OF
INFORMATION
(RLS INFO)
Required if
Applicable
Enter the release of information certification
indicator(s).
53 ASSIGNMENT OF
BENEFITS (ASG
BEN)
Required Enter the assignment of benefits certification
indicator.
54A-C PRIOR PAYMENTS Required if
Applicable
If payment has already been received toward the
claim by one of the payers listed in Field 50
(Payer) prior to the billing date, enter the
amounts here.
55 ESTIMATED
AMOUNT DUE
Required if
Applicable
Enter the estimated amount due from patient.
Do not report collection of patient’s cost share.
56 NATIONAL
PROVIDER
IDENTIFIER (NPI)
Required Enter the billing provider’s NPI.
57 OTHER PROVIDER
ID
Required Enter the service Provider’s Kaiser-assigned
Provider ID if any
58 INSURED’S NAME Required Enter the insured’s name, i.e. policyholder.
59 PATIENT’S
RELATION TO
INSURED
Required Enter the patient’s relationship to the insured.
60 INSURED’S
UNIQUE ID
Required Enter the patient’s Kaiser Medical Record
Number (MRN).
61 INSURED’S GROUP
NAME
Required if
Applicable
Enter the insured’s group name.
62 INSURED’S GROUP
NUMBER
Required if
Applicable
Enter the insured’s group number. For Prepaid
Services claims enter "PPS".
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Field
Number
Field Name
Required
Fields for
Claim
Submissions
Instructions/Examples
63 TREATMENT
AUTHORIZATION
CODE
Required if
Applicable
For ALL inpatient and outpatient claims, enter
the Kaiser Permanente referral number, if
applicable, for the episode of care being billed.
NOTE: this is a 10-digit alphanumeric identifier
64 DOCUMENT
CONTROL
NUMBER
Not Required Enter the document control number related to
the patient or the claim as assigned by Kaiser
Permanente.
65 EMPLOYER NAME Required if
Applicable
Enter the name of the insured’s (Field 58)
employer.
66 DX VERSION
QUALIFIER
Not Required Indicate the ICD version indicator of codes
being reported.
At the time of printing, Kaiser only accepts ICD-
9-CM diagnosis codes on the UB-04. ICD-10
standards for paper and EDI claims will be
implemented by Kaiser Permanente for
outpatient dates of service and inpatient
discharge dates on/after October 1, 2014.
67 PRINCIPAL
DIAGNOSIS CODE
Required Enter the principal diagnosis code, on all
inpatient and outpatient claims.
67A-Q OTHER
DIAGNOSES
CODES
Required if
Applicable
Enter other diagnoses codes corresponding to
additional conditions that coexist or develop
subsequently during treatment. Diagnosis codes
must be carried to their highest degree of detail.
68 BLANK Not Required Leave blank.
69 ADMITTING
DIAGNOSIS
Required Enter the admitting diagnosis code on all
inpatient claims.
70a-c REASON FOR VISIT
(PATIENT REASON
DX)
Required if
Applicable
Enter the diagnosis codes indicating the patient’s
reason for outpatient visit at the time of
registration.
71 PPS CODE Required if
Applicable
Enter the DRG number to which the procedures
group, even if you are being reimbursed under a
different payment methodology.
72 EXTERNAL CAUSE
OF INJURY CODE
(ECI)
Required if
Applicable
Enter an ICD-9-CM “E-code” (or its successor,
ICD-10 code) in this field (if applicable).
60
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KP22-016 Provider Manual
Field
Number
Field Name
Required
Fields for
Claim
Submissions
Instructions/Examples
73 BLANK Not required Leave blank.
74 PRINCIPAL
PROCEDURE CODE
AND DATE
Required if
Applicable
Enter the ICD-9-CM (or its successor, ICD-10)
procedure CODE and DATE on all inpatient
AND outpatient claims for the principal surgical
and/or obstetrical procedure which was
performed (if applicable).
74a-e OTHER
PROCEDURE
CODES AND
DATES
Required if
Applicable
Enter other ICD-9-CM (or its successor, ICD-
10) procedure CODE(S) and DATE(S) on all
inpatient AND outpatient claims (in fields “A”
through “E) for any additional surgical and/or
obstetrical procedures which were performed (if
applicable).
75 BLANK Not required Leave blank.
76 ATTENDING
PHYSICIAN / NPI /
QUAL / ID
Required Enter the NPI and the name of the attending
physician for inpatient bills or the Kaiser
Permanente physician that requested the
outpatient services.
Inpatient Claims—Attending Physician
Enter the full name (first and last name) of the
physician who is responsible for the care of the
patient.
Outpatient Claims—Referring Physician
For ALL outpatient claims, enter the full name
(first and last name) of the Kaiser Permanente
physician who referred the Patient for the
outpatient services billed on the claim.
77 OPERATING
PHYSICIAN / NPI/
QUAL/ ID
Required If
Applicable
Enter the NPI and the name of the lead surgeon
who performed the surgical procedure.
78-79 OTHER
PHYSICIAN/ NPI/
QUAL/ ID
Required if
Applicable
Enter the NPI and name of any other physicians.
80 REMARKS Not Required Special annotations may be entered in this field.
81 CODE-CODE Required if
Applicable
Enter the code qualifier and additional code,
such as marital status, taxonomy, or ethnicity
codes, as may be appropriate.
61
Form UB-04
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62
Members with Other Insurance
When a member has other health care coverage that is primary to Kaiser Permanente Health
Plan coverage, (such as No-Fault, Worker's Compensation, Medicare), the Practitioner needs to
bill that primary insurance carrier directly.
Kaiser Permanente will review for payment consideration any remaining balance and may
reimburse applicable co-payments and deductibles, if any, of the contractually eligible charges
for the member’s covered benefits.
Remittance Advice
The Remittance Advice Details (RAD) is designed for line-by-line reconciliation of transactions.
Reconciliation of the RAD to providers’ records will help determine which claims are paid or
denied.
Refer to the Remittance Advice Details (RAD) example form for a completed sample of RA.
(See legend below)
1.1 Remittance Advice Details
A. Patient Name H. Contract (Amount Paid)
B. Line of Business (LOB) I. Adjust (Adjustm ent Amount)
C. Service Dates J. Pt share
D. Claim Number (Claims System K. Provider Name (Vendor#)
Number) L. Provider Address
E. Code M. Check#
F. Description N. Check Amount
G. Billed O. Total for Provider
P. Interest Owed
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63
Remittance Advice Report
Remittance Advice
Remittance Detail Report
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KP22-016 Provider Manual
Vendor: K
L Provider Address
City, State Zip code
Vendor: K Provider ID#: 12724188
Vendor ID: K Provider Name:
Check #: M Check Date: 07/01/2015 Check Amount: N
=======================================
=====================================================================
=====================================================================
Ins. Co. Name: KAISER FOUNDATION HEALTH PLAN [1] Check #: M Claim #: D
st me irst ame A Date irth: Month/Day/Year Patient Name: La na , F N - of Bst name, First Name - A Date of Birth: Month/Day/Year Patient Name: La
Patient Acct#:
Member ID: xxxxxx Group:
Service Procedure Before Ben Not Copay/ Exc Ben Patient
Adj After Ben Net Primary
Date /DRG G Billed Disallow Penalty Allowed Covered J Deduct J Coins Amt
Total I Adjust RSN Penalty Withhold Discount Paymnt Codes Ins
======== ======== ======== ======== ========= === ======= = ========
======== ========= ==========
========== ========= ========
========= =
=========
========= ========= =========
5885.00 0.00 0.00 4708.12 0.00 0.00 15.00 0.00 0.00 5885.00 0.00 0.00 4708.12 0.00 0.00 15.00 0.00 5885.00 0.00 0.00 4708.12 0.00 0.00 15.00 0.00 C Service Dates 90999 5885.00 0.00 0.00 4708.12 0.00 0.00 15.00 0.00 0.00 5885.00 0.00 0.00 4708.12 0.00 0.00 15.00 0.00 5885.00 0 5885.00 0.00 0.00 4708.12 0.00 0.00 15.00 0.00 5885.00 0.00 0.00 4708.12 0.00 0.00 15.00 0.00
15.00 0.00 0.00 0.00 1176.88 4693.12 3,23,45, 0.00
C 05/18/15 90999 5885.00 0.00 0.00 4707.76 0.00 0.00 15.00 0.00 15.00
0.00 0.00 0.00 1177.24 4692.76 3,23,45, 0.00
C 05/20/15 90999 5885.00 0.00 0.00 4708.12 0.00 0.00 15.00 0.00 15.00
---------- --------- --------- --------- --------- -------- -------- -------- -------- --------- --- ----
---- -------- ---------- --------- -------- ---------
0.00 0.00 0.00 1176.88 4693.12 3,23,45, 0.00
Claim Totals: 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00
0.00 0.00 0.00 3531.00 O 14079.00 0.00
----------------------------------------
CLAIM EOB SUMMARY
64
Claim Level Code: [23] Payment adjusted, due to impact of prior payor adjudication (Use
only with Group Code OA): Generated by adjudicator Added by retro adjudication process.
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P Interest Amount: 17.36
---------- --------- --------- --------- --------- -------- -------- -------- -------- --------- --- ----
---- -------- ---------- --------- -------- ---------
17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00
0.00
Penalty Amount: 0.00
Total for Processed Claims:
17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00
0.00 0.00 3531.00 14079.00 0.00 0.00 0.00 3531.00 14079.00 0.00
17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00
0.00 0.00 0.00 3531.00 14079.00 0.00
Total for HMO B -*:
---------- --------- --------- --------- --------- -------- -------- -------- -------- --------- --- ----
---- -------- ---------- --------- -------- ---------
17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00
0.00
17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00
0.00 0.00 3531.00 14079.00 0.00 0.00 0.00 3531.00 14079.00 0.00
17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00 17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00
0.00 0.00 0.00 3531.00 14079.00 0.00
Remittance Advice
Remittance Detail Report
Vendor: Vendor Name
Address
City, State Zip Code
Service Procedure Before Ben Not Copay/ Exc Ben Patient
Adj After Ben Net Primary
Date /DRG Billed Disallow Penalty Allowed Covered Deduct Coins Amt
Total Adjust RSN Penalty Withhold Discount H Paymnt Codes Ins
======== ========= ========== ========= ========= ========= =========
========== ========= ======== =========
---------- --------- --------- --------- --------- -------- -------- -------- -------- --------- --- ----
---- -------- ---------- --------- -------- ---------
======== ======== ======== ======== ========= =
Total for Vendor Name *:
=== ======== ========
17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00
0.00 0.00 3531.00 14079.00 0.00
65
Remittance Advice
Remittance Detail Report
Vendor: Name
Address
City, State Zip Code
Service Procedure Before Ben Not Copay/ Exc Ben Patient
Adj After Ben Net Primary
Date /DRG Billed Disallow Penalty Allowed Covered Deduct Coins Amt
Total Adjust RSN Penalty Withhold Discount Paymnt Codes Ins
======== ======== ======== ======== ========= = === ======== ========
======== ========= ========== ========= ========= ========= =========
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========== ========= ======== ========
Total for payee Vendor Name - [Check # M]
---------------
17655.00 0.00 0.00 14124.00 0.00 0.00 45.00 0.00 45.00 0.00
0.00 0.00 3531.00 14079.00 0.00
Total Interest Amount: 298.75
Total Penalty Amount: 0.00
CODES SUMMARY
E Reason Code: [ 3] F Co-payment Amount
Reason Code: [ C] Contracted Rate Payment
Reason Code: [ 45] Chg exceeds fee sched/max allowbl or contrctd/legisltd fee,use only
with Group Codes PR/CO
*** End of Report ***
66
Claims Adjudication Overview
This topic provides a high-level description of the first-pass adjudication business process.
Details of how to perform individual tasks are found in the desk level procedures (DLPs) in this
repository.
Most first pass adjudication for KPClaimsConnect is auto-adjudicated, meaning that the claim is
reviewed and priced by the system without manual claim adjudicator intervention.
Once the claim comes into the system either electronically, through Electronic Data Interchange
(EDI), or manually, through mail room receipts of paper claims, a series of data checks are
performed on the claim to determine whether to pay or deny the claim. See Paper Intake.
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The system looks at many different elements of the claim during auto-adjudication: authorization
exclusions, matching referrals, membership coverage/eligibility, provider selection, contract
pricing, CPT/HCPCS/revenue codes, modifier placement, service dates, claim
billed/allowed/insurance/net amounts.
If there are no questions about these claim elements, the claim will automatically pay or
deny and be released to AP.
If there are questions about one or more of these elements, the system applies a code to
hold or pend the claim for manual review. There could be specific claim types that will
always require review, for example high dollar claims, or there can be combinations of
factors that cause the claim to hold/pend for review.
If the system cannot automatically determine whether to pay or deny the claim based on the data
available, or if there are Federal, State, or regional policy rules that require the claim is reviewed
before it is paid or denied, then the system applies a claim code on the claim to st op the claim
from auto-adjudicating, and routes it to a person to perform an action.
Claim Codes
There are four types of claim codes that are applied to a claim or a line on a claim: pend, hold,
denial, and/or informational. More than one claim code can be applied to a claim or claim service
line. The following table gives a description of the claim code types and their effects on the
claim depending on whether the claim code is applied at the claim level or service line level.
For specific claim codes and applicable DLPs, refer to the Pend/Hold Code Matrix.
Claim Code Applied to Claim Applied to Service Line
Pend/Hold Pends/hol ds the claim for manual review.
Note: The difference between a pend code and a
hold code is on whether they hold a claim when
there is a denial code on the claim. If a denial code
is on the claim with a pend code, the claim will
deny. If a denial code is on the claim with a hold,
Pends/holds the claim for
manual review.
67
the claim will hold for review.
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Deny Denies the claim.
Note: If the claim has a hold code, it will not auto-
deny. Instead, the claim will hold for review to
determine if the denial stays or will be overwritten.
Denies the service.
Note: A service line may be
denied, but the claim is still
payable with a status of Clean.
These are sometimes referred to
as Clean Denials.
Informationa
l
No effect. Claim code and description may be set
up to print on RA and/or EOB to provide payment
explanation.
No effect. Claim code and
description may be set up to
print on RA and/or EOB to
provide payment explanation.
Note: A claim can have a combination of pend/hold and denial codes applied at the service line
level.
Claim Code Distribution
The claim is assigned to the applicable In Basket pool based on the claim code(s) and will be
reviewed and cleared by users assigned to that pool. The following documents lists provide
reference to how pools are mapped for distribution for each region.
Hawaii Distribution Scheme
Northwest Distribution Scheme
See Resolving Claim Codes.
CRM Process
The person or department receiving the claim may require additional information or may need to
assign a task to a different person or department before they can finalize claims processing.
CRMs can be sent to request action and/or additional information. See Completing Tasks and
Resolving CRM Records.
When Can Members be Billed?
Members do not have any co-payments for covered services.
You cannot bill a member in the following situations:
You fail to follow Kaiser Permanente’s procedures which results in our non-payment to
you
Member is a no-show for a scheduled appointment for covered services.
You may bill a member in the following situations:
Member self-refers to a specialist or other provider within our network without
following Kaiser Permanente’s procedures which results in our non-payment to you.
68
When the member requests and agrees to pay for a non-covered service or self-referrals,
and you obtain prior agreement from the member regarding the cost of the services and
payment terms at the time of service.
Reporting Requirements
As a Medicaid Health Plan, Kaiser QUEST Integration is required to submit a variety of reports
to the State on a schedule.
Some examples include:
Timely access
Over and under utilization
Quality and satisfaction, e.g. HEDIS, CAHPS
Drug utilization
Interpretative services
Member and provider grievances
Suspected fraud and abuse, including child abuse and adult abuse
As a provider, you are required to comply with all requests for information necessary for Kaiser
QUEST Integration that do meet state reporting requirements. This information will also provide
Kaiser Permanente with information about your practice and patients gathered from claims for
process improvement and quality and performance improvement initiatives.
Chapter 12: Kaiser Permanente QUEST Integration
Program Covered Benefits
For more than 35 years, Kaiser Permanente Hawaii Market has had a program of medical care
and outreach service for persons with low income. The program began in 1971 with the
enrollment of 500 public assistance families under a contract with the Hawaii Department of
Human Services (DHS). It continued with federal and state contracts for medical care for
families with low-to-moderate income who were not eligible for public assistance.
In 1994, in an effort to increase access to health care and control the rate of health care
expenditures, the State of Hawaii implemented the Hawaii QUEST program (QUEST). QUEST
Integration is a statewide program that provides medical and behavioral health services using
capitated managed care delivery systems.
QUEST stands for:
Quality Care
Universal Access
Efficient Utilization
Stabilizing Cost
Transforming provision of health benefits to public clients
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Kaiser Permanente has participated in the QUEST program since its inception.
Kaiser Permanente is proud to be a participating health plan in the new QUEST Integration
program serving member starting January 1, 2015. We provide services to Kaiser Permanente
QUEST Integration members on the islands of Oahu and Maui.
How to reach us
The Kaiser Permanente QUEST Integration Call Center assists members and providers. Call
Kaiser Permanente at 808-432-5330 or toll-free at 1-800-651-2237. We’re here from 7:45 a.m.
to 4:30 p.m., Monday through Friday, except holidays. After normal business hours, you may
leave a message on the voice mailbox and someone will call you back as soon as possible, but no
later than 4:30pm the following business day. Members who are deaf, hard of hearing, or speech
impaired may call toll free 711 (TTY). .
Kaiser Permanente identification cards
Kaiser Permanente QUEST Integration members have a Kaiser Permanente Identification
Card
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The QUEST Integration identification card has additional information required by DHS:
Member’s Kaiser Permanente Member Identification Number
Member’s name
Effective date of member’s Kaiser Permanente QUEST Integration coverage
Primary clinic name and telephone number
Third-party liability (TPL) information (not Kaiser Permanente insurance)
QUEST Integration Call Center telephone number
After-hours advice line telephone number
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QUEST Integration Covered Benefits and Services
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Service Description
Primary and Acute Care Services (in alphabetical order)
Cornea Transplants and
Bone Graft Services
Cornea transplants and bone graft services are covered when medically necessary.
Cognitive
Rehabilitation Services
Services provided to cognitively impaired persons, most commonly those with
traumatic brain injury, that assess and treat communication skills, cognitive and
behavioral ability, and cognitive skills related to performing ADLs.
Five cognitive skills areas:
Attention Skills - sustained, selective, alternating, and divided
Visual Processing Skills - acuity, oculomotor control, fields, visual attention,
scanning, pattern recognition, visual memory, or perception
Information Processing Skills - auditory or other sensory processing skills,
organizational skills, speed, and capacity of processing
Memory Skills - orientation, episodic, prospective, encoding, storage,
consolidation, and recall
Executive Function Skills - self-awareness, goal setting, self-initiation, self-
inhibition, planning and organization, self-monitoring, self-evaluation,
flexible problem solving, and metacognition
Approaches include:
Education
Process training
Strategy development and implementation
Functional application
Selected approaches should match the appropriate level of awa reness of
cognitive skills
Some techniques/strategies include:
o Speech/language/communication
o Neuropsychological assessment
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o Compensatory memory techniques
o Executive functions strategies
o Reading/writing skills retraining
Diagnostic Testing Include, but is not limited to:
Screening and diagnostic radiology and imaging
Screening and diagnostic laboratory tests
Other screening or diagnostic radiology or laboratory se rvices
When Medically Necessary
Prior approval is not required for laboratory, imaging, or diagnostic services.
Prior approval is required for:
Magnetic resonance imaging
Magnetic resonance angiogram
Positron emission tomography
Reference lab tests that cannot be done in Hawaii and not specifically billable
by clinical laboratories in Hawaii
Disease-specific new technology lab tests
Genetic tests
Psychological testing
Neuropsychological testing
Cognitive testing
Computerized tomography
Dialysis Provided by:
Medicare-certified hospitals
Medicare-certified end stage renal disease (ESRD) providers
Settings where you can receive dialysis include:
Hospital inpatient
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Hospital outpatient
Non-hospital renal dialysis facility
Member’s home
Dialysis services include:
Equipment
Supplies
Diagnostic testing (including laboratory tests)
Drugs for dialysis treatment approved by Medicare when Medically
Necessary
Hepatitis B surface antigen
Anti-HB testing for patients on hemodialysis
Intermittent peritoneal dialysis
Continuous ambulatory peritoneal dialysis (CAPD)
Alfa-Epoetin (EPO) provided during dialysis
Other drugs related to ESRD
Home dialysis equipment and supplies prescribed by physician
Physician services
Hospital stays for
acute medical conditions requiring dialysis treatments
a patient receiving chronic outpatient dialysis for an unrelated medical
condition
placement, replacement, or repair of the chronic dialysis route.
Durable Medical Durable medical equipment needed to:
Equipment (DME) and
Reduce a medical disability
Medical Supplies
Restore or improve function
Supplies for rent or purchase include:
Oxygen tanks and concentrators
Ventilators
Wheelchairs
Crutches and canes
Eyeglasses
Orthotic devices
Prosthetic devices
Hearing aids
Pacemakers
Medical supplies (surgical dressings, continence, and ostomy supplies)
Foot appliances (orthoses, prostheses)
Orthopedic shoes and casts
Ortho digital prostheses and casts
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Other medically necessary durable medical equipment covered by the Hawaii
Medicaid program
Prior approval is required.
Emergency and Post-
Stabilization Services
Services in an emergency room for emergent conditions. If the condition is
considered non-emergent, you may have to pay for charges related to the visit. Kaiser
Permanente will not deny payment for emergency services sought by a prudent
layperson, even if emergency services are determined not needed and regardless if the
provider is in- or out-of-network.
You are also covered for care that keeps your condition stable after an emergency.
Post-stabilization services include follow-up outpatient specialist care.
If you receive post-stabilization services from a provider outside of Kaiser
Permanente’s network, we will not charge you more than if services were obtained
through an in-network provider.
Early and Periodic
Screening, Diagnostic,
and Treatment
(EPSDT) Services
Routine checkups for children and youth under the age of 21 included (but are not
limited to):
Medical and behavioral health screening
Dental screening and referral to dentist
Diagnostic tests
Immunizations
Preventive care, etc.
Additional services to correct or amend defects of physical,
mental/emotional, and conditions discovered as a result of EPSDT screens
when Medically necessary.
Family Planning
Services
Services for members who are sexually active and of childbearing age:
Education and counseling to make informed choices and understand
contraceptive methods
Emergency contraception and counseling, as indicated
Follow up care and office visits (to help prevent unwanted preg nancies; to
help plan the number of pregnancies; to help plan the time between
pregnancies; or to confirm if you are pregnant)
Pregnancy testing
Family planning drugs, supplies, and devices to prevent unwanted pregnancy
(to include FDA-approved contraceptive methods, sterilization procedures,
and patient education and counseling for all individuals with reproductive
capacity)
Diagnosis and treatment of sexually transmitted diseases
You have the choice to get the above family planning services from Kaiser
Permanente or from an out-of-network provider without a referral from us.
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Other family planning services available to you:
Office visits and diagnostic tests to diagnosis infertility
Sterilization.
Services are voluntary and confidential to Members.
Fluoride Varnish Application by a qualified primary care provider is covered for children between one
and six years of age who have not received topical fluoride treatment by a dentist or
qualified PCP within the past six months.
Qualified PCPs include physicians and nurse practitioners. These qualified PCPs may
delegate under direct supervision to a PA, RN, LPN, or certified medical assistant.
Habilitation Services Habilitative services and devices develop, improve, or maintain skills and functioning
for daily living to developmentally appropriate levels when medically necessary.
Habilitative services and devices include:
Audiology services
Occupational therapy
Physical therapy
Speech-language therapy
Vision services
Augmentative communication devices
Reading devices
Visual aids
Devices used as school-based services or used only for activities at school are not
covered when not medically necessary.
Does not include routine services listed in Vision Services on page 33.
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Service Description
Hearing Services Services include:
Diagnostic services
Screening
Preventive care
Corrective services/equipment/supplies
Service
Age 3
years or
younger
Age 4
years or
older
Under age
21
Age 21
and older
Prior
approval
required
Initial Exam One time a
year
One time
a year
No
Electroacoustic
Exam
4 times
per year
2 times
per year
Fitting/
Orientation/
Hearing Aid
Check
Two times
every three
years
One time
every
three years
Yes
Hearing aid
devices (includes
service/loss/
damage
warranty,
a trial or rental
period
One
hearing aid
per ear
every 24
months
One
hearing aid
per ear
every 24
months
Yes
Services provided by or under the direction of an otorhinolaryngologist or an
audiologist when medically necessary.
Home Health Services Home health services are part-time or intermittent care for the Members who do not
require hospital care provided under the direction of a physician in order to prevent
re-hospitalization or institutionalization.
Services provided at your home by qualified home health agencies include by not
limited to:
Skilled nursing
Home health aides
Medical supplies and DME
Therapeutic services (physical and occupational therapy)
Audiology and speech pathology
Immunizations Receive the following immunizations approved by CDC’s Advisory Committee
including but not limited to type of language:
Influenza
Diphtheria usually combined with Tetanus
Pneumococcal vaccine
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Other vaccines as needed
Inpatient Hospital
Services for Medical,
Surgical,
Maternity/Newborn
Care, and
Rehabilitation
Includes the cost of room and board for inpatient stays.
The services include:
Nursing care
Medical supplies, equipment, and drugs
Diagnostic services, physical therapy, occupational therapy, audiology and
Speech-language pathology services
Other services in this category
When Medically Necessary.
Inpatient Hospital
Maternity/Newborn
Care Services
Women in good health with deliveries that are not complex may
stay in the hospital for up to:
48 hours after a natural birth
96 hours after a cesarean section
The patient and physician may agree to an early discharge.
Medical Services
Related to Dental
Needs
Kaiser Permanente covers dental services to treat medical conditions done in a
medical facility like a hospital when medically necessary.
Also includes:
Referrals
Follow-ups
Coordination
Provision of appropriate medical services related to dental needs (including but not
limited to:
Emergency room treatment
Hospital stays
Ancillary inpatient services
Operating room services
Excision of tumors
Removal of cysts and neoplasms
Excision of bone tissue surgical incisions
Treatment of fractures (simp le and compound)
Oral surgery to repair traumatic wounds surgical supplies
Blood transfusion services ambulatory surgical center services
X-rays
Laboratory services
Drugs
Physician examinations
Consultations
Second opinions
Sedation by physician anesthesiologist
Dental or medical services resulting from a dental condition that are provided in a
medical facility (e.g., inpatient hospital and ambulatory surgical center).
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Includes:
Medical services for adults and children required as part of a dental treatment
Dental procedures by oral surgeons and physicians (primarily plastic surgeons,
otolaryngologists, and general surgeons)
Services by a dentist or physician due to a medical emergency (for example, car accident,
where the services are primarily medical)
Services in relation to oral or facial trauma, oral pathology. Includes, but not limited to
infections of oral origin, cyst and tum or management, and craniofacial reconstructive
surgery, as inpatient basis in an acute care hospital setting.
Services in a private office or hospital-based outpatient clinic for services not medically
necessary or provided by governm ent-sponsored or subsidized dental clinics, and hospital-
based outpatient dental clinics are not covered by Kaiser.
Also see “Covered by Med-QUEST but not by Kaiser Permanente” at the end of
this section.
Nutrition Counseling Types of services for members include:
Diabetes Self-Management Education
Nutrition counseling for obesity
Nutrition counseling for other metabolic conditions (if medically necessary)
Other Practitioner
Services
Other practitioner services by:
Certified nurse midwife services
Licensed APRN services
Family, pediatric, and psychiatric health specialists
Paraprofessionals including peer support specialists
Licensed or certified healthcare provider including:
o Behavioral health providers (psychologists, marriage and family
therapists, mental health counselors, and CSACs)
When services are Medically Necessary
Outpatient Hospital
Services
Outpatient hospital services to prevent, diagnose, or manage the pain of an illness
or injury such as:
Family planning
Medical services related to dental needs
Imaging services
Laboratory studies
Oncology services
Diagnostic testing
Ambulatory surgery services
Physical therapy
Occupational therapy
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Speech therapy
Blood storage and processing
Respiratory services
Audiology services
Cardiology services
Chemotherapy services
Radiation services
Surgeries performed in a freestanding ambulatory surgery center (ASC) or
hospital ASC
Twenty-four (24) hours a day, seven (7) days per week, emergency services
Urgent care services
Medical supplies, equipment, and drugs
Services when Medically Necessary.
Physician Services Services provided by or under the direct supervision of physicians include:
Physical examinations
Screening examinations
EPSDT screenings for children and youth under age 21
Services when Medically Necessary and provided at locations including, but not
limited to:
Physician’s office
Clinic
Private home
Licensed hospital
Licensed skilled nursing or intermediate care facility or
Licensed or certified residential setting
Podiatry (foot and
ankle) Services
Treatment of conditions of the foot and ankle such as:
Professional services, not involving surgery provided in an office or clinic
Diabetic foot care (inpatient and outpatient) not involving surgery
Diagnostic radiology procedures limited to ankle and below
Surgical procedures limited to ankle and below
Foot and ankle care for infection or injury in an office or outpatient clinic
Bunionectomies when the bunion is present with overlying skin ulceration or
neuroma secondary to the bunion.
Pregnancy-Related
Services for Pregnant
Women and Expectant
Parents
Services for the health of the woman and her fetus during the woman’s pregnancy
and up to sixty (60) days post-partum when Medically Necessary.
Services provided for pregnancy and maternity care such as:
Prenatal care
Diagnostic tests (Radiology, laboratory, and other diagnostic tests)
Treatment of missed, threatened, incomplete abortions
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Health education and screening for conditions that could make a pregnancy
“high risk”
Fetal development
Labor and delivery of infant and post-partum care
Diagnostic ultrasound
Fetal stress and non-stress testing
Prenatal vitamins
Screening, diagnosis, and treatment for pregnancy-related conditions, to
include SBIRT, screening for maternal depression, and access to necessary
behavioral and substance use treatment or supports
Lactation counseling – up to six months*
Breast pump rental – up to six months*
Breast pump purchase – requires prior approval
Educational classes on childbirth, breastfeeding, and infant care
Counseling on heal thy behaviors, to include prevention and harm reduction
Inpatient hospital services, physician services, other practitioner services, and
any other services that impact pregnancy outcomes.
Inpatient and outpatient substance use treatment for pregnant and parenting
women and their children.
*May be extended with prior approval.
Prescription Drugs Medications when Medically Necessary to optimize the Member’s medical condition,
including behavioral health prescription drugs for children receiving services from
CAMHD.
Includes:
Prescription drugs and certain over-the-counter drugs which are on the list of
approved drugs and prescribed by your doctor who is license d to prescribe
Medication management and counseling
Medications of non-pulmonary and latent tuberculosis not covered by DOH.
Preventive Services –
Adult
(21 years or older)
Includes:
AAA (abdominal aortic aneurysm) screening for those that meet criteria
Blood pressure
Breast cancer screening
Cervical cancer screening
Chemoprophylaxis
Colorectal cancer screening
Diabetes screening for those that meet criteria
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Health education and counseling
Hepatitis C screening for those that meet criteria
Immunizations
Prostate cancer screening
Rubella serology or vaccine history
Total cholesterol measurements
Tuberculin skin testing
Weight/height measurements
Preventive Services –
Children (Less than 21
years of age)
Includes:
Age-appropriate dental checkup and oral fluoride
Age-appropriate health education
EPSDT services
Hospital stay for normal, term, and healthy newborn
Immunizations
Newborn screening
Other age-appropriate laboratory screening tests
Screening to assess health status
Tuberculin skin testing
For help finding a dentist, call Community Case Management Corporation
(CCMC) at 808-792-1070 or toll-free at l-888-792-1070. CCMC can explain
the covered dental benefits and help you f ind a dentist near you.
Preventive Services –
Pregnant Women
Includes:
Diagnostic amniocentesis, diagnostic ultrasound, fetal stress, and non-stress
Diagnosis of premature labor
Health education and screening
Hospital stays
Prenatal laboratory screening tests
Prenatal visits
Prenatal vitamins, including folic acid
Radiology/Laboratory/
Other Diagnostic
Services
Includes:
Diagnostic and therapeutic radiology and imaging
Screening and diagnostic laboratory test
Other medically necessary diagnostic or therapeutic service
Services may require a prior approval.
Rehabilitation Services Provided to patients who are expected to improve in a reasonable period of time
with therapy provided by licensed physical therapist (PT), licensed occupational
therapist registered (OTR), licensed audiologist, and licensed speech pathologist
respectively. A PT assistant or a certified occupational therapy assistant may be
utilized as long as they are working under the direct supervision of either a PT or
OTR, respectively.
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Services include:
Physical therapy
Occupational therapy
Audiology
Speech-language pathology
Services are limited to those who expect to improve in a reasonable period of time.
Services for children under EPSDT have different requirements
Prior approval is required for all rehabilitation services except for the initial
evaluation.
Sleep Laboratory
Services
Diagnosis and treatment of sleep disorders performed by sleep la bo ratories or sleep
disorder centers.
Sleep laboratory service providers acc redited by the American Acade my of Sleep
Medicine.
Smoking Cessation
Services
Services include:
At least four in-person sessions of at least ten (10) minutes each per quit attempt,
including individual, group, or phone counseling.
Two (2) effective components of counseling, practical counseling (pr oblem-
solving/skills training), and so cial support delivered as part of the treatment, shall be
emphasized.
Counseling services by licensed providers trained on this service. Including: phys ician,
psychologist, clinical social worker in behavioral health, APRNs, Mental Health
Counselors and Certified tobacco treatment specialists under supervision of a licensed
provider.
Medications approved by the U.S. Food and Drug Administration (FDA)
No out-of-pocket cost or co-payment required for these services or medication
No prior approval or step therapy is needed for treatment
Sterilizations and
Hysterectomies
Sterilizations and Hysterectomies for both men and women when the following are
met:
Age 21 years or older at time of consent
Mentally competent
Requires Sterilization Required Consent Form at least 30 calendar days before
the procedure but not more than 180 days between the date of consent and date
of sterilization (except for premature delivery or emergency abdominal surgery)
A Member may consent to be sterilized at the time of premature delivery or
emergency abdominal surgery if at least 72 hours have passed since consent for
sterilization was signed
For premature delivery, the informed consent shall be at least 30 days before the
expected date of delivery. The expected date of delivery shall be provided on the
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consent form
An interpreter is provided when needed and arrangements for Members who are
visually impaired, hearing impaired, or disabled made to communicate the
required information.
Member is not institutionalized (in a prison, mental hospital, or other
rehabilitative facility)
If the Member is incapacitated, then a court order is required, and the require d
amount of time shall pass pursuant to HRS §560:5-609.
Hysterectomies not covered under the following:
For the purpose of making the Member permanently incapable of
reproducing
There is more than one purpose for the hysterectomy, but the primary
purpose is to make the Member permanently incapable of reproducing
It is performed for the purpose of cancer prophylaxis when not medically
needed
Telehealth Services Services include live consultation provided through video or web
conferencing. Services are covered if referred by an in-network provider and if you
may have difficulty using transportation to the provider.
Transportation Services Services include emergency and non-emergency ground and air transportation.
Transportation to and from medically necessary covered medical appointments for:
Members who have no means of transportation
Members who reside in areas not served by public transportation or who cannot
access public transportation
Transportation is also covered when your medical condition requires treatment that
is not available in the area where you are. Travel services include:
Ground and air transportation
Lodging
Meals
Prior approval is required. Includes travel services when medically necessary for the
member and (if needed) one attendant.
Also covered if you do not have access to specialty providers (including but not
limited to psychiatrists and specialty physicians)
Urgent Care Services Care for a medical condition that is serious but not life threatening and n eeds to be
treated within 24 hours.
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Call any Kaiser Permanente clinic for an appoin tment. If the clinic is closed, call the
after-hours advice line at 1-833-833-3333, toll free at 1-800-467-3011, or 711 (TTY).
Urgent care out of area is only covered for members under age 21.
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Vision Services Routine eye exams and glasses:
Service Under age 21 Age 21 and older
Eye exam* Once in 12 months Once in 24 months
Visual aids**
(Eyeglasses***,
contact lens****,
frames, other parts
of glasses, fittings
and adjustments)
One every 24
months
One every 24
months
*Additional visits may be allowed with prior approval when Me dically Necessary.
**Visual aids must be prescribed by ophthalmologists or optometrists and covered
when Medically Necessary. Individuals under forty (40) years of age require medical
justification for bifocals.
***Replacement and new glasses with significant changes in prescription are covered
within the benefit periods for both adults and children with prior approval.
****Contact lenses are only covered when Medical Necessity is established.
Dispensing of the visual aids begins anew after each twenty-four (24)-month period
since the prior dispensing.
Also covered for all Members:
Prescription lenses
Cataract removal
Prosthetic eyes
Cornea (keratoplasty) transplants provided in accordance w ith the Hawaii
Administrative Rules
Emergency eye medical-condition care covered for all members without prior
approval.
Vision services not included:
Orthoptic training
Prescription fee
Progress exams
Radial keratotomy
Visual training
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Lasik procedure
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Other Facility Services
Hospice Care Provides care to terminally ill patients who are not expected to live more than six
months. Hospice services will be covered in the home, nursing facility or inpatient
settings.
Children under the age of 21 can re ceive treatment to manage or cure disease while
in hospice care.
Nursing Facility Includes:
Skilled Nursing Facility (SNF)
Intermediate Care Facility (ICF)
Subacute level of care in a hos p ital
Behavioral Health Services
Standard Behavioral
Health Services
(includes psychiatric
services and substance
abuse treatment
services)
Includes:
Room and board
Nursing care
Medical supplies
Equipment
Medications
Medication management
Diagnostic services
Professional services
Medically necessary services
Substance abuse treatment services
Use of triage lines or screening systems, telemedicine, e-visits, and/or other
technological solutions covered when applicable.
Covered for the involuntarily committed for evaluation and treatment when
Medically Necessary.
Not covered for Members receiving behavioral health services from the CCS
program.
Ambulatory Mental
Health Services
Includes:
24-hour access line
Mobile crisis response
Crisis stabilization
Crisis management
Crisis residential services
The psychiatric evaluation and treatment of Members criminally committed to
ambulatory mental healthcare settings are covered by the state.
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Medical and standard behavioral health services for Members criminally committed
to ambulatory mental healthcare settings may be billed to Kaiser.
Collaborative Care
Model
Services provided by a prima ry care team consisting of a primary care provider and a
care manager who works in collaboration with a psychiatric consultant, such as a
psychiatrist.
Psychotropic
Medications and
Medication
Management
Medications and medication ma nagement includes:
Evaluation, prescription maintenance of psychotropic medications
Medication management
Counseling
Education
Promotion of algorithms and guidelines
Inpatient Psychiatric
Hospitalizations
Includes
Room/board
Nursing care
Medical supplies
Equipment
Medications and medication management
Diagnostic services
Psychiatric and other behavioral health practitioner services
Ancillary services
Other services
When Medically Necessary.
Psychiatric or
Psychological
Evaluation and
Treatment
Services to evaluate and provide treatment of behavioral health include:
Individual and group counseling and monitoring
Medically Necessary
Alcohol and Chemical
Dependency Services
Inpatient and outpatient substance abuse services.
Provided in a setting accredited according to standards set by the Alcohol and Drug
Abuse Division (ADAD) of the Hawaii S t a t e Department of Health.
Medication-Assisted
Treatment (MAT)
Medications, in combination with counseling and behavioral therapies, to provide a
whole-person approach to the treatment of SUDs.
Medications approved by the FDA and are clinically driven and tailored to meet each
patient’s needs.
Parity in Mental Health
and SUD
Services necessary for compliance with the requirement for parity in mental health
and SUD benefits in 42 CFR Part 438, Subpart K.
SBIRT Early intervention treatment services for persons with SUDs, a nd those at risk for
developing a SUD.
Substance Use
Disorder (SUD)
Treatment
Inpatient and outpatient treatment when Medically Necessa ry. SUD treatment in a
treatment setting accredited by the ADAD.
Includes:
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Medication approved by FDA for SUDs.
Methadone/Levomethadyl acetate services for acute opiate detoxification as
well as maintenance.
Long-Term Services and Supports (LTSS)
Includes Institutional Care as well as well as Home and Community Based Services (HCBS) for aged or
disabled. Individuals need to qualify for all LTSS services. Services may be determined based on a me mber’s
functional assessment documented on the DHS 1147 form and At-Risk Evaluation Form. Members re-
evaluated at least annually. Services may include:
Home delivered meals
Pe rs onal Emergency Response System (PERS)
Pe rs onal care services
Adult day care
Adult day health
Priva te duty nursing
Eligible Population:
At Risk HCBS Member is at risk of deteriorating to the Nursing Facility level of care
Community HCBS
Institutional Services
Acute Waitlisted
SNF/ICF
Skilled Nursing Facility (SNF), or Intermediate Care Facility (ICF) level of care
services provided in an acute care hospital in an acute care hospital bed.
Adult Day Care Center
(ADC)
Supportive care for four or more disabled a dults. Including :
Observation/supervision by center staff
Coordination and use of behavioral, medical, and social care plans, and
implementation of instructions listed in Health Action Plan. Also includes
therapeutic, social, educational, and recreational activities.
Performed by qualified and/or trained individuals only, including family members
and professionals, such as an RN or LPN, from an authorized agency.
Does not include medication administration, tube feedings , and other activities which
require healthcare-related training.
Adult Day Health
Center (ADH)
Organized day program with nursing oversight. Provided to adults with physical
and/or mental conditions. The purpose is to help members to stay in the community
as much as possible.
Provided under supervision of RN.
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Members who require skilled nursing services, will have services provided by an RN
or under the direct supervision of an RN.
Services include:
Emergency care
Dietetic services
Occupational therapy
Physical therapy
Physician services
Pharmaceutical services
Psychiatric or psychological services
Recreational and social activities
Social services
Speech-language pathology
Transportation services.
Assisted Living Facility
(ALF)
Services include:
Personal care
Supportive care (homemaker, chore, PCS, and meal preparation)
Nursing
Help with medication
Payment for room and board is not allowed. Members receiving ALF services shall
be receiving ongoing CCMA services.
Attendant Care Hands-on care, both supportive and health-related in nature, provided to children.
The service includes the Member supervision specific to the needs of a medically
stable, physically disabled child.
Includes:
Skilled or nursing care
Housekeeping activities
Supportive services for the absence, loss, diminution, or impairment of a
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physical or cognitive function.
May be self-directed as personal assistant delegated services.
Community Care
Management Agency
(CCMA)
For members living in Community Care Foster Family Homes and other community
settings, services by a CCMA include:
Nurse delegation to the caregiver
Identifying needed services, supplies, and equipment
Face-to-face monitoring
Use of the health action plan
Assisting the caregiver with undesired effects and/or changes in condition of
members
Community Care
Foster Family Home
(CCFFH)
Services provided in a State-certified private home by a principal care provider who
lives in the home. CCFFH may accept up to three adults each.
Services include:
Personal and supportive care
Homemaker
Chores
Companion services
Nursing
Medication oversight (as permitted under state law)
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Counseling and
Training
Counseling and training serviced provided to the Members, families/caregivers, and
professional and paraprofessional caregivers on behalf of the Member. Provided
individually or in groups. Provided at the Member’s home or an alternative site.
Counseling and training activities include:
Member care training for members, families, and caregivers regarding the
nature of the disease and the disease process
Methods of transmission and infection control measures
Biological, psychological care and special treatment needs/regimens
Employer training for consumer-directed servic es
Instruction about the treatment regimens
Use of equipment specified in the HAP
Employer skills updates as needed to safely maintain the individual and home
Crisis intervention
Supportive counseling
Family therapy
Suicide risk assessments and intervention
Death and Dying counseling
Anticipatory grief counseling
Substance Abuse Disorder counseling
Nutrition assessment and counseling on coping skills to deal with stress
caused by member’s deteriorating functional, medical, mental status
Companion Services Non-medical care, supervision, and socialization prior approved by a service
coordinator and documented in the health action plan.
Environmental
Accessibility
Adaptations (EAA)
Physical changes to the member’s home required by the HAP, Medically Necessary
to ensure the health, welfare, and safety of the member, allowing the member to stay
at home as much as possible. Without these adaptations, the member would require
institutionalization.
Includes:
Installation of ramps and grab-bars
Widening of doorways
Modification of bathroom facilities
Installation of specialized electric and plumbing systems
Window air conditioners may be installed when it is necessary for the health and
safety of the Member.
Not covered:
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Adaptations or improvements to the home that are of general utility and are not of
direct medical or remedial benefit to the individual. Examples include carpeting, roof
repair, central air conditioning, etc.
Adaptations to the total square footage of the home are excluded from this benefit.
All services shall be provided in accordance with applicable state or local building
codes.
Home Delivered Meals Home-delivered meals are provided to individuals who cannot prepare nutritionally-
sound meals without help and need meal services to stay independent in the
community and to prevent institutionalization.
Home-delivered meals are nutritional and delivered to a member’s home. Excludes
residential or institutional settings.
Two meals a day.
Home Maintenance Services to maintain a safe, clean, and sanitary env ironment. Services not included as
a part of personal assistance.
Including:
Heavy-duty cleaning
Minor repairs to essential appliances (to stoves, refrigerators, and water
heaters)
Fumigation or extermination services
For individuals who cannot perform cleaning and minor repairs without assistance
and are assessed, to need the services in order to prevent institutionalization.
Moving Assistance May be provided i n ra re cases for members assessed by Heath Coordination team
and found that the Member needs to move to a new home. For example:
Unsafe deteriorating home
Member is evicted from current home
Member is not able to afford home due to a rent increase
Wheelchair bound member living above the first floor of a multi-story
building without elevator
Home is unable to support the Member’s additional needs for equipment
Moving expenses include packing and moving of belongings
Non-Medical
Transportation
Offered to enable individuals to gain access to community services, activities, and
resources, specified by the HAP. Only when not included in the HCBS service being
accessed. Members living in a residential care setting or a CCFFH are not eligible for
this service. This does not replace medical transportation.
Nursing Facility (NF),
Skilled Nursing Facility
(SNF), or Intermediate
Care Facility (ICF)
Services provided in a nursing facility licensed and certified to provide skilled nursing
and rehabilitative services on a regular basis.
Nursing facility members require assistance 24 hours a day with Activities of Daily
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Living (ADLs) and Instrumental Activities of Daily Living (IADLs) and need care
provided by licensed nursing personnel and paramedical personnel on a regular,
long-term basis.
Services include skilled nursing, health-related care, and rehabilitative services on a
regular basis in an inpatient facility.
Services in a nursing facility include independent and group activities, mea ls and
snacks, housekeeping and laundry services, nursing, and social work services,
nutritional, monitoring, and, counseling, pharmaceutical services, and rehabilitative
services.
Personal Assistance
Service Level I (PA1)
For members who are not living with their family and may need help with their daily
activities.
May be self-directed by the member and include:
Companion services (meal prep, laundry, errands) – prior approval needed.
Homemaker/chore services including:
Routine housecleaning such as sweeping, mopping, dusting, making beds,
cleaning the toilet and shower or bathtub, taking out rubbish
Care of clothing and linen by washing, drying, ironing, mending
Shopping for househo ld supplies and personal essentials (not including
cost of supplies)
Light yard work, such as mowing the lawn
Simple home repairs, such as replacing light bul bs
Preparing meals
Escorting the member to clinics, physician office visits or other trips for
the purpose of obtaining treatment or meeting needs established i n the
health action plan, when no other resource is avai lable
Providing s tandby/minimal assistance or supervision of activities of daily
living such as bathing, dressing, grooming, eating, ambulation/mobility
and transfer
Reporting and/or documenting observations and s ervices provided,
including observation of member self- administered medications and
treatments, as appropriate
Reporting to the assigned provider, supervisor or designee, observations
about changes in the member's behavior, functioning, condition, or self-
care/home management abilities that necessitate a change in service
provided
Personal Assistance
Service Level II (PA2)
For members needing:
Moderate to total assistance with activities of daily living and health
maintenance activities
May be self-directed and consist of the following
Personal hygiene and grooming, including bathing, skin care, oral hygiene,
hair care, and dressing
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Assistance with bowel and bladder care
Assistance with ambulation and mobility
Assistance with transfers
Assistance with medications, which are ordinarily self-administered when
ordered by member's physician
Assistance with feeding, nutrition, meal preparation and other dietary
activities
Assistance with exercise, positioning, and range of motion
Taking and recording vital signs, including bl ood pressure
Measuring and recording intake and output, when ordered
Collecting and testing specimens as directed
Special tasks of nursing care when delega ted by a registered nurse, for
members who have a medically stable condition and who require indirect
nursing supervision as defined in Chapter 16-89, HAR
Proper utiliza tion and maintena nce of member's medical and adaptive
equipment and supplies. Checking and reporting any equipment or supplies
that need to be repaired or replenished
Reporting changes in the member's behavior, functioning, condition, or self-
care abilities which necessitate more or less service
Maintaining documentation of observations and services provided
When personal assistance se rvices Level II activities are the primary services,
personal assistance services Level I activi ties identified on the health action
plan, which are incidental to the care furnished or that are essential to the
health and welfare of the member, rather than the member's family, may also
be provided.
Provided by Home Health Aide, Personal Care Aide, Certified Nurse Aide or Nurse
Aide.
Personal Emergency Elec tronic device with a 24-hour emergency assistance service that helps members
Response Systems get secure immediate help in an emotional, physical, or environmental emergency.
(PERS)
Individually designed to meet the needs and capabilities of the Member and includes
training, installation, repair, maintenance , and response needs.
Access to PERS may be through an electronic device for Members at high risk of
institutionalization to secure help in an emergency. Or the Member may wear a
portable “help” button to allow for mobility. T he response center is staffed by
trained professionals.
Allowable types of PERS items include:
24-hour answering or paging
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Beepers
Med-alert bracelets
Medication reminder services
Intercoms
Life lines
Fire/safety devices, such as fire extinguishers and rope ladders
Monitoring services
Light fixture adaptations (e.g., blinking lights, etc.)
Telephone adaptive devices not available from the telephone company
Other electronic devices or services designed for emergency assistance
Limited to those individuals:
Living alone
Alone for significant parts of the day
Have no regular caregiver for extended periods of time
Who would otherwise require extensive routine supervision
Only provided to Members residing in a non-licensed setting except for an ALF.
Residential Care Services provided in a lic ensed private home by a principle care provider who lives
Services or Type I or in the home.
Type II Expanded
Adult Residential Care Includes:
Home (E-ARCH)
Personal care
Nursing
Homemaker
Chores
Companion services
Medication oversight (provided by a principle care provider who lives in the home)
Residential care is furnished:
In a Type I E-ARCH, five or fewer residents provided that up to six
residents may be allowed at the discretion of DHS to live in a Type I home
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with no more than three residents of whom may be NF LOC
In a Type II E-ARCH, six or more residents, where no more than 20 percent
of the home’s licensed capacity may be individuals meeting a NF LOC who
receive these services in conjunction with residing in the home
Members receiving residential care services shall be receiving ongoing CCMA
services.
Respite Care May be provided on a short-term basis to individuals unable to care for themselves.
Respite may be provided hourly, daily, or overnight in the following locations:
individual’s home or place of residence; CCFFH; E-ARCH; Medicaid-certified NF;
licensed respite day care facility; or other community care residential facility approved
by the State.
Skilled (or Private
Duty) Nursing
For members requiring ongoing nursing care at home or in the community, provided
by licensed nurses.
Services may be self-directed under personal assistance level II/delegated using nurse
delegation procedures as outlined in HRS §457-7.5 and the Health Plan Manual.
Specialized Medical
Equipment and
Supplies (SMES)
Refers to the purchase, rental, lease, warranty costs, assessment costs, installation,
repairs, and removal of devices, controls, or appliances, as specified in the health
action plan that enable individuals to increase and/or maintain their abilities to
perform ADL, or to perceive, control, participate in, or communicate in the
environment in which they live.
Services include but are not limited to:
Items necessary for life support
Specialized infant car seats
Modification of parent-owned motor vehicle to accommodate the child, e.g.
wheelchair lifts
Intercoms for monitoring the child's room
Shower seat
Portable humidifiers
Electric utility bills specific to electrical life support devices (e.g., ventilator,
oxygen concentrator)
Medical supplies
Heavy duty items including but not limited to patient lifts or beds that exceed
$1,000 per month
Rental of equipment that exceeds $1,000 per month such as ventilators
Emergency back-up generators specific to electrical life support devices
(ventilator, oxygen concentrator); and
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Miscellaneous equipment such as customized wheelchairs, specialty orthotics,
and bath equipment that exceeds $1,000 per month.
Items reimbursed shall be in addition to any medical equipment and supplies
furnished under the MSP and shall exclude those items which are not of direct
medical or remedial benefit to the individual.
Specialized medical equipment and supplies shall be recommended by the Member’s
PCP.
Subacute Facility
Services
Members do not require acute care but need more intensive skilled nursing.
Services provided in:
A licensed nursing facility
A licensed and certified hospital
Community Integrated Services (CIS)
To be eligible, you need to be eighteen (18) years of age or older to be eligible. Also, you must meet the
following to qualify for CIS:
1. Be chronically homeless, or
2. Currently homeless and have one of the qualifying health condit ions listed below, or
3. Living in an institution and cannot leave without stable housing and have one of the qualifying health conditions
listed below, or
4. Living in public housing and at risk of being kicked out and have one of these qualifying health conditions:
A mental health disorder affecting one or more major life activities, or
Diagnosed with substance us e dis order, or
Have a chronic physical or complex health needs, or
Go to the emergency department or inpatient hospital often.
CIS is divided into three categories: (1) pre-tenancy services, (2) tenancy services, and (3) other housing and
tenancy support services.
Pre-tenancy services Include:
Screening and assessments
Developing housing support assistance plan
Searching for housing
Preparing and submitting applications
Identifying needs for start-up
Identifying equipment, technology, and other changes needed
Reviewing safety of housing
Moving assistance
Housing crisis plan
Tenancy services Include:
Identifying and assisting with behavioral management
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Educating you about roles and responsibilities of tenant/landlord
Coaching you how to develop and maintain relationships with
landlords/property managers
Teaching you how to resolve disagreement with your landlords/neighbors
Connecting you with supportive groups to help prevent you from being
kicked out of your home
Housing recertification process
Updating/maintaining housing ass istance and crisis plans
Developing skills for daily living and maintaining your home
Coordinating Service care
Managing housing crisis
Community Transition
Services
Include:
Case Management Services:
o Moving into stable housing
o Assessing the unit’s and Member’s readiness for move-in
o Assisting the Member in obtaining furniture and commodities
Housing Quality and Safety Improvement Services.
o Repairs or remediation for issues such as mold or pest infestation if
cost effective method of addressing occupant's health condition, as
documented by a health care professional, and not covered under any
other program.
Legal Assistance.
o Connecting to expert community resources to address legal issues
impacting housing and health, such as assistance with breaking a lease
due to unhealthy living conditions.
Securing House Payments.
o Provide a one-time payment for security deposit and/or first month's
rent provided that such funding is not available through any other
program. Once for each Member, except for State determined
extraordinary circumstances such as a natural disaster.
Other Services
Certification of
Physical/Mental
Impairment
Coverage for evaluations and re-evaluations of disabilities.
Advance Care Planning Voluntary advance care planning services between a provider and the Member with
or without completing relevant legal forms as described in 42 CFR §438.3.(j).
Hospice Care A program that provides care to terminally ill patients who are not expected to live
more than six months. A participating hospice provider shall meet Medicare
requirements.
Children under the age of twenty-one years may receive treatment to manage or cure
their disease while concurrently receiving hospice services.
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Inpatient
Palliative
Care
Palliative care focuses on providing total care to our members
with chronic, potentially life limiting illness. The care focuses on
the physical, spiritual, emotional, and social needs of the member
and family. Our goal is to relieve suffering in all its
manifestations. We provide this care through an interdisciplinary
team including physician, nurse, social worker, and chaplain.
Palliative care focuses on symptoms management and alleviating
the stress and suffering of a chronic illness.
Members with life
limiting illness in
hospital setting
Prior Authorization
required.
Medical
Respite
When a member is discharging from the hospital and has lingering
medical needs but does not have stable housing, Kaiser
Permanente contracts with providers for medical respite housing
which includes case management services.
Members with
medical need for
follow-up care and
unstable housing
Prior Authorization
required
Aqua
Therapy
We offer aqua or hydrotherapy to members in need of physical
therapy during recovery from injury or to manage chronic pain
when they cannot tolerate land-based physical therapy (PT) and
meet medical necessity criteria. Aqua therapy takes place in a salt-
water based, heated pool with expert physical therapists.
At physician
discretion for
members who
cannot tolerate
land-based PT
Prior Authorization
required
Remote
Monitoring
Technology
Kaiser Permanente provides blood pressure cuffs, pulse
oximeters, and glucose monitors to some members with chronic
conditions. In some cases, the devices are integrated with KPHC
and automatically feed readings into the member's health record.
At physician
discretion
Prior Authorization
required
Behavioral
Health Self-
care Apps
Kaiser Permanente offers members free access to : Calm and
myStrength online behavioral health applications to help with
mild-to-moderate depression, anxiety, and sleep issues. They are
also high quality, secure, and confidential.
The Ginger app provides 1-on-1 emotional support by text —
available 24/7
All Kaiser
Permanente
members
https://healthy.kaise
rpermanente.org/ha
waii/health-
wellness/mental-
health/tools-
resources/digital
Lifestyle
Medicine
Program
Kaiser Permanente's Lifestyle Medicine Program offers a wide
variety of classes, coachinq, and other resources to improve
members' health and wellbeing. Classes range from weight loss,
All Kaiser
Permanente
members
100
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providers.kaiserpermanente.org
KP22-016 Provider Manual
nutrition, and exercise to sleep, hygiene, and unlimited attempts at
smoking cessation. It also includes individual health coaching for
all members.
https://kpinhawaii.o
rg/our-services
https://kpinhawaii
.org/our-services
Covered by DHS Med-QUEST but not by Kaiser Permanente
Some services are not covered by your medical plan. Members can get these services in other
ways.
Dental care: The DHS, not Kais er Permanente, covers dental se rvices. Some limitations
and prior authorization may apply.
Dental Services are now available to eligible members over the age of 21. Some limitations and
prior authorization may apply. Effective January 1, 2023, c overed services include the following:
Services Description and Limitation
Preventative Services
Comprehensive Oral Evaluation – Once every 5 years
Periodic screening examinations - 2 per year
Prophylaxis - 2 per year
Topical fluoride or fluoride varnish - 2 per year
Diagnostic and
Bitewing x-rays - 2 per year
Radiology Services
Full series x-rays – 1 every 5 years
Periapical x-rays
Biopsies of oral tissue
Endodontic Therapy
Root canal therapy on permanent molars
Services
Restorative Services
Amalgams on primary and permanent posterior teeth
Composites on anterior and posterior teeth
Pin and/or post reinforcement
Cast cores
Recement inlays and crowns
Stainless steel crowns
Oral Surgery
Periodontal Therapy
Scaling and root planning – one every 24 months
Services
Prosthodontic Service
Complete Upper and Lower Dentures – one every 5 years
Partial Dentures – one every 5 years
Denture relines -- one every 2 years
Repairs
Emergency and
Gingivectomy, for gingival hyperplasia
Palliative Treatment
Other medically necessary emergency dental services
101
For help finding a dentist, call Community Case Management Corporation (CCMC) at 808-
792-1070 or toll-free at 1-888-792-1070. CCMC can explain the covered dental benefits
and help you find a dentist near you..
Elective abortions or intentional termination of pregnancy (ITOP): Intentional
terminations of pregnancy (ITOP) are not covered by Kaiser Permanente. They are
covered by the Med-QUEST Division (MQD). You wil l need authorization. Your provider
shall contact MQD’s Clinical Standards Office (CSO), on ITOP requests. MQD can also
arrange transportation.
State of Hawaii Organ and Tissue Transplant (SHOTT) Program: DHS provides
transplants through the SHOTT program. Covered transplants must be non-experimental,
non-investigational for the specific orga n/tissue and speci fic medical condition being
treated. These transplants may include liver, heart, heart-lung, lung, kidney, kidney-panc reas,
and allogenic a nd autologous bone marrow transplants. In addition, children may be
covered for transplants of the small bowel with or without liver. Children and adults must
meet specific medical criteria as determined by the State and the SHOTT program
contractor. We can help with a referral to the SHOTT Program when it is medically
appropriate.
Services from other agencies in the community:
Early Intervention Program (EIP) provides services for chil dren 0 – 3 years of age with
special needs . Services are provided in places where a child lives, learns, and grows. Parents
and/or caregivers are coached on how to help their c hild succeed in their envi ronment.
Services covered include: Assistive Technology, occupational therapy , physical therapy,
psychology services , special ins truction, speech-language pathology, and vision services. For
more information, call 808-594-0066.
Honolulu Community Action Program (HCAP) – Head Start
This is a federal program to help prepare children ages 3 – 5 years old for school. Some of
the programs offered are part-day or full-day centers, home-based, Head Start DOE
combined classrooms, and family activities. To a pply, or for more information, ca ll 808-847-
2400.
Women, Infant and Children (WIC) - This program helps low-income, nutritionally at-
risk pregnant women, new moms, and chil dren under age 5 with he althy foods, nutrition
education, scree ning and referrals to other health, welfare, and social programs. Some of the
healthy foods are milk, eggs, cheese, ce real, peanut butter, fruits, veg etables, and infant food.
For more information, call 808-586-8175 on Oahu or 1-888-820-6425.
Tuberculosis Control Program: This program is for the diagnosis, treatment,
identification, prevention, and appropriate therapy of tuberculosis. For more information,
call the Tuberculosis Control Branch at 808-832-5731.
Hansen's Disease Community Program: This program is for patients with Hansen’s
Disease. The program provides treatment, education, assistance to family members and
health care providers, and helps patients obtain services. For more information, ca ll the
Hansen’s Disease Branch at 808-733-9831.
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102
Community Care Services (CCS) Behavioral Health Program (provided by Ohana
Health Plan): A dult Members eighteen (18) years or older with a diagnosis of serious
mental illness (SMI) or serious a nd pe rsistent me ntal illness (SPMI) may be eligible for
additional behavioral health service from the CCS program. Specialized behavioral health
services include inpatient and outpatient therapy, tests to monitor the member’s response to
therapy, and intensive case management. For more information, call 1-888-846-4262.
Services for Individuals with Developmental Disabilities/Intellectual Disabilities
(DD/ID): The DOH Developmental Disability Division (DOH/DDD) provides
intermediate care facility/ID services to some individuals. Kaiser Permanente and
DOH/DDD coordinate activities for people with DD/ID. For more information, call 808-
586-5840.
Support for Emotional and Behavioral Development (SEBD) for children: Behavioral
health services are available for children/youth less than twenty-one (21) with diagnosis of
emotional and behavioral developme nt disorders. T he Department of Health, through its
Child and Adolescent Mental Health Division (CAMHD) SEBD program provides
behavioral health services, including transportation, to children and adolescents ages 3
through 20 who need intensive behavioral health services. To find out more, call one of the
Family Guidance Centers listed below.
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Family Guidance
Center Address Phone Number Fax Number
Pearl City Office Central Oahu Family Guidance Center (COFGC)
860 Fourth Street, 2nd Floor
Pearl City, Hawaii 96782
808-453-5900 808-453-5940
Family Court
Liaison Branch
(FCLB)
Hawaii Youth Correctional Facility
42-470 Kalanianaole Hwy. Building 03
Kailua, Hawaii 96734
808-266-9922 808-266-9933
Honolulu Honolulu Oahu Family Guidance Center
(HOFGC)
3627 Kilauea Avenue, Room 401
Honolulu, Hawaii 96816
808-733-9393 808-733-9377
Leeward Oahu Leew ard Oahu Family Guidance Center (LOFGC)
601 Kamokila Blvd., Room 355
Kapolei, Hawaii 96707
808-692-7700 808-692-7712
Kaneohe Office Central Oahu Family Guidance Center (COFGC)
45-691 Keaahala Road
Kaneohe, Hawaii 96744
808-233-3770 808-233-5659
Maui Maui Family Guidance Centers (MFGC)
270 Waiehu Beach Road, Suite 213
Wailuku, Hawaii 96793
808-243-1252 808-243-1254
103
Services that are typically NOT covered under the QU EST Integration
Program
Personal care items such as shampoos, toothpaste, toothbrushes, mouth washes, denture
cleansers, shoes, slippers, clothing, laundry services, baby oil, sanitary napkins, diapers for
babies, soaps, lip balm, bandages, and contact lens solution
Non-medical items such as books, telephones, beepers , radios, linens, clothing, television
sets, computers, air conditioners, air purifiers, fans, household items, motor vehicles or
furnishings
Experimental and/or investigative services, procedures, drugs, devices, and treatments; drugs
not approved by the Federal Drug Administration (FDA)
Treatment of complications resulting from previous cosmetic, ex perimental or investigative
services, or other services that are not covered
Treatment of baldness, including hair transplants and topical medications, wigs, and
hairpieces
Treatment of persons confined to public institutions
All medical and surgical procedures, therapies, supplies, drugs, and equipment for the
treatment of sexual dysfunction or inadequacies
Penile or testicular prostheses and related services
Reversal of sterilization, in vitro fertilization, artificial insemination, sperm banking
procedures, fertilization by artificial means, and all procedures and drugs to treat infertility or
enhance fertilization
Bereavement counseling, employment counseling, primal therapy, long-term character
analysis, marathon group therapy, and/or consortium
Routine foot care, treatment of flat feet
Swimming lessons, summer camp, gym membership, and weight control classes
Beds – lounge beds, bead beds, water beds, day beds, ove rbed tables, bed li fters, bed boards,
bed side rails if not an integral part of a hospital be d
Contact lenses for cosmetic purposes, bifocal contact lenses
Oversized lenses, blended or progressive bifocal lenses, tinted or absorptive lenses (except
for aphakia, alb i nism, g laucoma, medical photophobia) trifocal lenses (except as a specific
job requirement), spare glasses
Refractive eye surgery
Physical exams and/or psychological evaluations as a requirement for employment or as a
requirement for continuing employment (e.g., truck and taxi drivers’ licensing)
Physical exams and/or psychological evaluations as a requ irement for drivers’ licenses or for
the purpose of securing life and other insurance policies or plans
Organ transplants not meeting the guidelines established by the Medicaid program and organ
transplants not specifically identified as benefits
Biofeedback, acupuncture, chi ropra ctic services, naturopathic services, faith healing,
Christian Science services, hypnosis, massag e treatment (by masseurs), and any other form of
self-care or self-help training and any related diagnostic testing
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104
Ambulance wait time, physician wait time, standby services, telephone consultations,
telephone calls, writing of prescriptions, stat charges
Treatment of pulmonary tuberculosis that is covered by DOH
Treatment of Hansen’s Disease that is covered by DOH
Topical application of oxygen
Orthoptic training
Travel medicine
OPTIFAST programs and supplements, bariatric classes, and supplies
Emergency Services
Definitions:
Emergency Medical Condition – A medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in placing the health of the individual (or, with respect to a pregnant woman,
the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily
functions, or serious dysfunction of any bodily organ or part. An emergency medical condition
shall not be defined based on lists of diagnoses or symptoms.
Emergency Services – Any covered inpatient and outpatient services that are furnished by a
provider that is qualified to furnish services and that are needed to evaluate or stabilize an
emergency medical condition.
Emergency services from non-Kaiser Permanente practitioners are covered ONLY if the
services meet the prudent layperson standard and the services were immediately required
because it was an unforeseen illness or injury and the delay caused by coming to a Kaiser
Permanente facility would have resulted in death, serious impairment to bodily functions,
serious dysfunction of a bodily organ or part, or placed the health of the individual in serious
jeopardy. Continuing or follow up care from non-Kaiser Permanente providers is not covered,
except for post-stabilization care while waiting to transfer care to Kaiser Permanente.
If a member is admitted to a non-Kaiser Permanente facility, the member or a family member
must notify Kaiser Permanente within 48 hours after care begins (or as soon as reasonably
possible) by calling the phone number on the back of their Kaiser Permanente identification
card.
Urgent Care: Urgent care is defined as care for a sudden and unforeseen illness or injury which
is required to prevent serious deterioration of the member’s health and which cannot be delayed
until the member is medically able to safely return to the Hawaii Service Area to receive care
from a Kaiser Permanente practitioner (if outside the Hawaii Service Area), or to travel to a
Kaiser Permanente facility.
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105
When members are in need of urgent care, please contact the nearest clinic. After hours, call the
Kaiser Permanente After Hours Advice Nurse (1-800-467-3011 from Neighbor Islands or 808-
432-7700 from Oahu).
QUEST Integration Health Coordination
Kaiser Permanente will identify those members who may be candidates for health coordination.
For members new to Kaiser Permanente and subject to initial assessment requirements and
timeframes, the determination of need for LTSS will be included in that assessment.
Health coordination assignments will be determined by the LTSS Manager or someone on
his/her behalf when the cases are received. Specifically, those who qualify for Health
Coordination fall into seven (7) categories:
1. Adults with SHCN and EHCN
2. Children with SHCN and EHCN
3. Members receiving HCBS
4. Members choosing Self-Direction
5. Institutional LOC members residing in an institutional setting
6. Dual eligible
7. Community Integration Services (CIS)
While Medical Group physicians have ultimate responsibilit y as t he manager of his or her panel
of patients, an additional health coordination support system is available for eligible QUEST
Integration members. This system focuses on the use of licensed social workers, registered
nurses, and para-professional staff to:
Coordinate the timely access and use of medically necessary services.
Direct and, as needed, assist QUEST Integration enrollees in their use of the Kaiser
Permanente system to obtain services
Outreach to QUEST Integration new member enrollees to familiarize them with the
Kaiser Permanente health plan, link them to a Primary provider, and inform them of
their benefits (preventative care, EPSDT, SHCN, EHCN, Chronic disease management,
community resources, etc.).
Assist with discharge planning for hospital patients.
Track QUEST Integration enrollees' compliance with prescribed treatment and assist
their compliance by coordinating necessary patient education.
Assist the provider to outreach to the QUEST Integration enrollee for urgent matters in
the clinic or at the enrollee's home.
Refer members to other programs or agencies when care coordination services are not
available at Kaiser
The PCP in conjunction with his or her support staff will be responsible for ensuring that
recipients receive adequate information to permit them to make medically informed decisions
about their health care needs.
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106
QUEST Integration service coordinators and support staff are located in the “hub” Kaiser
Permanente clinics on the islands of Oahu and Maui. Communication through the electronic
medical record allows all providers and support staff to have immediate access to pertinent
medical and social information. Physicians, QUEST Integration service coordinators and
support staff are supported by established systems within Kaiser Permanente to direct the
QUEST Integration member toward selected preventive services, track patients' scheduled
appointments and, when necessary, remind them about the need to fulfill the visit.
Referrals to QUEST Integration staff may be made by calling 808-432-5330 or 1-800-651-2237
(toll-free).
Services for children
Regular medical visits are very important to keep children as healthy as possible and reduce the
spread of disease. Children’s regular visits, examinations, immunizations (shots), and screening
tests are included in well-child care at no cost.
For members under age 21, the QUEST Integration program provides these preventative services
in a program called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). Children
will be examined periodically to check for any illness. Checkups are needed more often in the
child’s first years and less often as he or she grows older (see examination and vaccine schedule
on page 16). Some children look healthy but have hidden health problems. Screening tests, such
as blood tests, give the doctor information about the child’s health. If any health problems are
found, the doctor looks for the cause, makes a diagnosis, and orders treatment.
These medically necessary services, including behavioral therapy for children, are provided at no
cost to you. The behavioral therapies include intensive behavioral therapy for children with
autism spectrum disorder (ASD), including applied behavioral analysis (ABA) for the treatment
of children with an ASD diagnosis.
Reminders of the next EPSDT appointment will be made by phone and email through kp.org.
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Here is what to expect at the child’s EPSDT checkups:
Height, weight, and blood pressure checks
Eye exams
Hearing tests
Lab tests
Immunizations
Screening for lead, tuberculosis (TB) and other conditions
Mental and physical assessment
Screening for behavioral health issues or substance abuse
Review of medications (including fluoride and multivitamins)
Referrals to specialist or dentist, if needed
Health education and guidance about the child’s health care
Education and guidance for the child’s growth and development
107
Information regarding accessing care, such as appointments, advice nurse, or after-hours
care
The schedule on the next page may be used to remind parents when to make appointments for
their child. Parents should let the child’s health care provider know if the child is ill or taking
medicines (such as steroids) that may suppress their immuni ty. This schedule may change based
on the child’s health care needs. Please check with the child’s health care provider.
Physical exams are advised once yearly from age 2 – 6 years, then once every other year. More
exams may be needed depending on the child’s health care needs. Rotavirus vaccine for 2 and 4
months of ages only. TB risk assessment will be done with each physical exam starting from 2
years of age and annually up to 17 years of age. The TB skin test will only be done if the risk
assessment is positive.
YOUR HEALTHY CHILD’S EXAMINATION AND VACCINE SCHEDULE
AGE
APPOINTMENT
TYPE
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VACCINE TYP E
2-3 days
Physical exam
Hepatitis B (HepB) administered at birth
2–3 weeks Physical exam
Catch up immunizations if needed
2 months Physical exam with shots
Diphtheria-Tetanus-acellular Pertussis (DTaP), Haemophilus
Influenza B (Hib), Polio, Pneumococcal Conjugate Vaccine
(PCV), HepB, Rotavirus
4 months Physical exam with shots
DTaP, Hib, Polio, PCV, Rotavirus, Hep B if part of combo
vaccination
6 months Physical exam with shots
DTaP, Hib, Polio, PCV, HepB
9 months
Physical exam
Catch up immunizations if needed
12–13 months Physical exam with shots
TB risk assess ment if indicate d at 12 months of age (TB skin test
done if risk assessment positive), Hepatitis A, Measles-Mumps-
Rubella (MMR), Varicella
15 months Physical exam with shots
DTaP, Hib, PCV
18 months Physical exam with shots
Hepatitis A
23
–
24
months
Physical
exam
Catch
up
immunizations
if needed
3 years Physical exam with shots
MMR, Varicella
4 years Physical exam with shots
DTaP, Polio
5 years Physical exam with shots
DTaP, Polio (if not done at age 4 years)
6 years
Physical
exam
Catch
up
immunizations
if needed
108
7–13 years Physical exam with shots
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KP22-016 Provider Manual
Physical done yearly. 9 years: Human Papillomavirus (HPV) series
of two doses for both girls and boys; 11- 12 years: Tetanus-
Diphtheria-acellular Pertussis (Tdap); Meningococcal
14–20 years
Physical exam with shots
Physical done yearly. Meningococcal booster. Catch up vaccines if
needed
All persons ages 6 months and older should receive annual flu vaccination
Definitions
Abuse -– Any of the following:
Practices (fiscal, business, or medical) that are not sound and cost more;
Payments to providers for services not medically necessary;
Payments to providers for services that do not meet professional standards for health care
in a managed care setting;
Payments to providers for services not in the contract for duties for health care in a
setting;
Events or medical practices of providers that are not sound.
Activities of Daily Living (ADLs) – Activities a person performs on a daily basis, for self-care,
such as:
feeding,
grooming,
bathing,
dressing and
toileting.
Acute Care – Medical care provided under the direction of a physician at a hospital for a
condition requiring inpatient care and having a relatively short duration.
Adult - All members age of twenty-one (21) years or older for coverage benefit purposes only.
Adult Day Care Center – A licensed facility that is maintained and operated by an individual,
organization, or agency for the purpose of providing regular care which includes supportive care
to four (4) or more disabled adults.
Adult Day Health Center – A licensed facility that provides organized day programs of
therapeutic, social, and health services for adults with physical or mental impairments, or both.
Members requiring nursing oversight or care. For the purpose of restoring or maintaining, to the
fullest extent possible, their ability for remaining in the community.
109
Adult group - Individuals who obtain Medicaid eligibility in accordance with Hawaii
Administrative Rules, 17-1718.
Advance Directive - A written instruction, such as a living will or durable power of attorney for
health care, recognized under State law relating to provision of health care when the individual
is incapacitated.
Adverse Benefit Determination - Any one of the following:
The denial or restriction of a requested service, including the type or level or service,
requirements for medical necessity, appropriateness, setting, or effectiveness of a covered
benefit. The reduction, suspension, or termination of a previously authorized service;
The denial, in whole or part, of payment for a service;
The failure to provide services in a timely manner, as defined in Section 40.230
(availability of providers);
The failure of the health plan to act within prescribed timeframes regarding the standard
resolution of grievances and appeals;
The denial of an enrollee's request to dispute a financial liability, including cost sharing,
copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.
For a rural area member or for islands with only one health plan or limited providers, the denial
of a member’s request to obtain services outside the network:
o From any other provider (in terms of training, experience, and specialization)
not available within the network;
o From a provider not part of a network that is the main source of a service to the
member, provided that the provider is given the same opportunity to
become a participating provider as other similar providers;
o If the provider does not choose to join the network or does not meet the
qualifications, the member is given a choice of participating providers and is
transitioned to a participating provider within 60 days;
o Because the only health plan or provider does not provide the service because
of moral or religious objections;
o Because the member’s provider determines that the member needs related
services that would subject the member to unnecessary risk if received separately
and not all related services are available within the network; and
o The State determines that other circumstances warrant out-of-network treatment.
Aged, Blind, or Disabled (ABD) – A category of eligibility under the State Plan for persons
who are aged (sixty-five [65] years of age or older), legally blind, and/or disabled.
Ambulatory Care - Preventive, diagnostic and treatment services provided on an outpatient
basis by physicians, nurse practitioners, physician assistants and other PCPs.
Annual Plan Change Period – A period when an eligible individual is allowed to change from
one participating health plan to another participating health plan.
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Appeal - A review by the health plan and State Administrative Appeal of an adverse benefit
determination.
Appointment – A face-to-face interaction between a provider and a member. This does include
interactions made possible using telemedicine but does not include telephone or e-mail
interaction.
Assisted Living Facility – A licensed facility that consists of a building complex offering
dwelling units to individuals and services to allow residents to maintain an independent assisted
living lifestyle. The facility shall be designed to maximize the independence and self-esteem of
limited-mobility persons who feel that they are no longer able to live on their own.
Attending Physician – A medical doctor (MD) or a doctor of osteopathy (DO), authorized to
practice medicine and surgery by the State, who orders and directs the services required to meet
the care needs of a Medicaid Member. The attending physician may be a physician from a group
practice who is designated as the primary physician or an alternate physician that has been
delegated the role of the attending physician by the Member’s initial attending physician during
the physician’s absence. At the time he or she elects to receive hospice care, the attending
physician has the most significant role in the determination and delivery of the individual’s
medical care.
Authorized Representative – A person who can make care- related decisions for a member who
is not able to make such decisions alone. A representative may, in t he following order of priority,
be a person who is:
A court-appointed guardian of the person;
A spouse or other family member (parent) as designated by the member or the State
according to HRS 327 E-5; or
Any other person who is not court-appointed, not a spouse or other family member who
is designated as the member’s healthcare representative according to HRS 327 E-5.
Auto-Assignment – The process utilized by DHS to enroll Members into a Health Plan, using
predetermined algorithms, who (1) are not excluded from Health Plan participation and (2) do
not proactively select a Health Plan within the DHS-specified timeframe. Also, the process of
assigning a new Member to a primary care physician chosen by the Health Plan, pursuant to the
provisions of this Contract.
Behavioral Health Services – The full continuum of services from screening to specialty
treatment services to support individuals who have mental health and substance use needs,
including those with mild to moderate conditions, emotional disturbance, mental illness, or
substance use conditions.
Benchmark – A target, standard, or measurable goal based on historical data or an
objective/goal.
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Beneficiary – An individual who has been determined eligible and is currently receiving
Medicaid.
Benefit Year – A continuous twelve (12)-month period generally following an open enrollment
period. In the event the contract is not in effect for the full benefit year, any benefit limits shall
be pro-rated.
Benefits - Those health services that the member is entitled to under the QUEST Integration
program and that the health plan arranges to provide to its members.
Breast and Cervical Cancer Program – A program implemented by the State of Hawaii,
Department of Health (DOH) to detect breast and cervical cancer or pre-cancerous conditions of
the breast or cervix. Enrolled individuals receive treatment in the QI program when referred by
DOH.
Care Team – A team of healthcare professionals from different professional disciplines who
work together to manage the physical, behavioral health, and social needs of the Member.
Centers for Medicare & Medicaid Services (CMS) – The United States federal agency which
administers the Medicare program and, working jointly with state governments, the Medicaid
program, and the SCHIP.
Child and Adolescent Mental Health Division (CAMHD) - A division of the State of Hawaii
Department of Health that provides behavioral health services to children ages three (3) through
twenty (20) who require support for emotional or behavioral development.
Children - All members under the age of twenty-one (21) years of age for coverage benefit
purposes only.
Children’s Health Insurance Program (CHIP) or State Children’s Health Insurance
Program (SCHIP) – A joint federal-state healthcare program for uninsured, targeted, low-
income children, established pursuant to Title XXI of the Social Security Act that is
implemented as a Medicaid expansion program in Hawaii.
Chronic Condition – Any on-going physical, behavioral , or cognitive disorder. Including
chronic illnesses, impairments and disabilities. There is an expected duration of at least twelve
(12) months with resulting functional limitations, reliance on compensatory mechanisms and
service use or needs beyond what is normally considered routine.
Claim - A bill for services, a line item of services, or all services for one member within a bill.
Code of Federal Regulations (CFR) – The codification of the general and permanent rules and
regulations published in the Federal Register by the executive departments and agencies of the
federal government of the United States.
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Cold-Call Marketing – Any unsolicited personal contact, whether by phone, mail, or any other
method, by the Health Plan with a potential Member, Member, or any other individual for
marketing.
Community Care Foster Family Home (CCFFH) - A home that is certified by the State DOH
to provide an individual with twenty-four (24) hour a day living accommodations and home and
community-based services (HCBS).
Community Care Management Agency (CCMA) - An agency that is involved with
locating,
coordinating and
monitoring services to residents in community care family homes or members in E-
ARCHs and assisted living facilities.
A health plan may be the owner of a community care management agency.
Community Care Services (CCS) – A behavioral health program administered by DHS. CCS
provides eligible adult Members specialized behavioral health services to severe mental illness
(SMI) and severe and persistent mental illness (SPMI).
Community Health Worker (CHW) – A frontline public health worker who is a trusted
Member of and/or has a close understanding of the community served to facilitate access to
services and improve the quality and cultural competence of service delivery. A CHW serves as
an integral Member of the care team, providing in-home visits, accompanying Members to
provider visits as needed, and assisting Members with healthcare needs.
Community Integration Services (CIS) – Pre-tenancy supports and tenancy sustaining
services that support individuals to be ready and successful tenants in housing that is owned,
rented or leased to the individual.
Pre-Tenancy services help to identify the individual’s needs and preferences. Also,
assists in the housing search process, and provides help to arrange details of the move.
Tenancy services help with independent living maintaining. Includes:
o tenant/landlord education,
o tenant coaching and
o assistance with community integration and inclusion to help develop natural
support networks.
Community Paramedic (CP) – An advanced paramedic that works to increase access to
primary and preventive care and decrease use of emergency departments, which in turn decreases
healthcare costs. Among other things, CPs m ay play a key role in providing follow–up services
after a hospital discharge to prevent hospital readmission. CPs can provide health assessments,
chronic disease monitoring and education, medication management, immunizations and
vaccinations, laboratory specimen collection, hospital discharge follow–up care, and minor
medical procedures. CPs work under the direction of an Ambulance Medical Director.
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Community Transition Services (CTS) – A pilot program within the CIS benefit. This program
is designed to address eligible beneficiaries’ specific health determinants to improve health
outcomes and lower healthcare costs. CTS program benefits include transitional case
management services, securing house payments, housing quality, safety improvement services,
and legal assistance. CTS program benefits are authorized by CMS and shall be provided to all
beneficiaries who meet CIS eligibility criteria on a voluntary basis.
Comprehensive Risk Contract – A risk contract that covers comprehensive services including,
but not limited to inpatient hospital services, outpatient hospital services, rural health clinic
services, federally qualified health center (FQHC) services, laboratory and x-ray services, early
and periodic screening, diagnostic, and treatment (EPSDT) services, LTSS, and family planning
services.
Conspicuously Visible – Individuals seeking services from, or participating in, the health
program or activity could reasonably be expected to see and be able to read the information that
is sufficiently conspicuous and visible as defined by HHS Office of Civil Rights at 45 CFR
§92.8(f)(1).
Consumer Assessment of Healthcare Providers and Systems (CAHPS®) – A comprehensive
set of surveys that ask consumers and patients to report on and evaluate various aspects of
quality of their healthcare. The acronym CAHPS is a registered trademark of the Agency for
Healthcare Research and Quality (AHRQ).
Contract – The contract between the Health Plan and DHS to provide medical services. The
written agreement between DHS and the contractor that includes the Competitive Purchase of
Service (AG Form 103F1 [10/08]), General Conditions for Health and Human Services
Contracts (AG Form 103F [10/08]), any special conditions and/or appendices, this RFP,
including all attachments and addenda, and the Health Plan’s proposal.
Contract Services – The services to be delivered by the contractor that are designated by DHS.
Contractor – Successful applicant that has executed a contract with DHS.
Co-Payment – The amount that a Member shall pay, usually a fixed amount of the cost of a
service.
Cost-Neutral – When the aggregate cost of serving people in the community is not more than
the aggregate cost of serving the same (or comparable) population in an institutional setting.
Covered Services - Those services and benefits to which the member has a right to under
Hawaii’s Medicaid programs.
Critical Access Hospital (CAH) – A hospital designated and certified as a CAH under the
Medicare Rural Hospital Flexibility Program.
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Cultural Competency – A set of interpersonal skills that allow individuals to increase their
understanding, appreciation, acceptance, and respect for cultural differences and similarities
within, among and between groups and the sensitivity to know how these differences influence
relationships with members. This requires a willingness and ability to draw on community- based
values, traditions and customs, to devise strategies to better meet culturally diverse member
needs, and to work with knowledgeable persons of and from the community in developing
focused interactions, communications and other supports.
Days - Unless otherwise specified, the term "days" refers to calendar days .
Dental Emergency - An oral condition that does not include services aimed at restoring or
replacing teeth and shall include services for relief of dental pain, remove serious infection, treat
serious injuries to teeth or supportive structures of the oral-facial complex.
Department of Health, Developmental Disabilities Division (DOH-DDD) – The DOH-DDD
provides services for persons with intellectual and/or developmental disabilities (I/DD). Most
services provided are through the Medicaid 1915(c) HCBS Waiver for individuals with I/DD to
support these participants to live in their homes and communities through services that promote
each person’s self-determination, health, community integration, and safety (Section 1915(c) of
the Social Security Act).
Department of Human Services (DHS) – Department of Human Services, State of Hawaii.
Department of Health and Human Services (DHHS) – United States Department of Health
and Human Services.
Director – The administrative head of the department of human services unless otherwise
specifically noted.
Dual Eligible – Member eligible for both Medicare and Medicaid.
Dual Eligible Special Needs Plan (D-SNP) – A dual eligible special needs plan that enrolls
beneficiaries who are entitled to both Medicare (Title XVIII) and Medicaid (Title XIX Medical
Assistance from a State Plan). D-SNPs are defined in the federal regulations at 42 CFR §422.2
and authorized at Section 1859 of the Social Security Act.
Durable Medical Equipment (DME) – Medical equipment that is ordered by a doctor for use in
the home. These items shall be reusable, such as walkers, wheelchairs, or hospital beds. DME is
paid for under both Medicare Part B and Part A for home health services.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) – EPSDT services aim to
identify physical or mental defects in individuals and provide healthcare, treatment, and other
measures to correct or ameliorate any defects and chronic condition discovered in accordance
with Section 1905r of the Social Security Act. EPSDT includes services to:
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Seek out individuals and their families and inform them of the benefits of prevention and
the health services available;
Help the individual or family use health resources, including their own talents, effectively,
and efficiently; and
Ensure the problems identified are diagnosed and treated early before they become more complex
and their treatment more costly.
Effective Date of Enrollment – The date as of which a participating health plan is required to
provide benefits to an Member.
Eligibility Determination - An approval or denial of eligibility for medical assistance, as well as
a redetermination or termination of eligibility for medical assistance. .
Emergency Medical Condition – The sudden onset of a medical condition that manifests itself
by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or
symptoms, substance abuse) such that a prudent layperson, who possesses an average knowledge
of health and medicine, could reasonably expect the absence of emergency services or immediate
medical attention to result in:
Placing the health of the individual (or with respect to a pregnant woman, the health of the
woman, or her unborn child) in serious jeopardy;
Serious impairment of body functions,
Serious dysfunction of any bodily functions;
Serious harm to self or others due to an alcohol or drug abuse emergency;
Injury to self or bodily harm to others; or
With respect to a pregnant woman who is having contractions:
o That there is inadequate time to affect a safe transfer to another hospital before
delivery; or
o That transfer may pose a threat to the health or safety of the woman or her unborn
child.
Emergency Medical Transportation – Ambulance services for an emergency medical
condition.
Emergency Room Services – Emergency services provided in an emergency room.
Emergency Services – Covered inpatient and outpatient services that are needed to evaluate or
stabilize an emergency medical condition that is found to exist using a prudent layperson
standard.
Encounter – A record of medical services rendered by a provider to a Member enrolled in the
Health Plan on the date of service.
Encounter Data – A compilation of encounters.
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Enrollment - The process by which an individual, who has been determined eligible, becomes a
member in a health plan, subject to the limitations specified in the DHS Rules.
Enrollment fee - The amount a Member is responsible to pay that is equal to the spenddown
amount for a medically needy individual or cost share amount for an individual receiving long-
term care services. A resident of an intermediate care facility for I/DD or a participant in the
Medicaid waiver program for individuals with developmental disabilities or intellectual
disabilities are exempt from the enrollment fee.
Excluded Services – Healthcare services that health plan does not pay for or cover.
Expanded Adult Residential Care Home (E-ARCH) – A licensed facility that provides
twenty-four (24) hour living accommodations. There is a fee. For adults unrelated to the family.
The member requires at least minimal assistance in the: activities of daily living, personal care
services, protection, and healthcare services. And who may need the professional health services
provided in an intermediate care or skilled nursing facility . There are two types of expanded
care ARCHs in accordance with Section 321-15.62, HRS:
Type I – home allowing five (5) or fewer residents provided that up to six (6) residents
may be allowed at the discretion of the department to live in a type I home, with no more
than three (3) nursing facility level residents; and
Type II – home allowing six (6) or more residents with no more than twenty percent
(20%) of the home’s licensed capacity as nursing facility level residents.
Expanded Health Care Needs (EHCN) – A Member that has complex, costly health care needs
and conditions, or who is at risk of developing these conditions is immi nent. The Members that
meet EHCN criteria are considered to be highly impactable and likely to benefit from health
coordination services (HCS).
Federal Financial Participation (FFP) – The contribution that the federal government makes to
State Medicaid programs.
Federal Poverty Level (FPL) – The federal poverty level (FPL) updated periodically in the
Federal Register by the Secretary of Health and Human Services under the authority of 42 USC
§9902(2), as in effect for the applicable budget period used to determine an individual’s
eligibility in the medical assistance programs.
Federally Qualified Health Center (FQHC) – An entity that has been determined by the
Secretary of the DHHS to meet the qualifications for an FQHC, as defined in Section
1861(aa)(4) of the Social Security Act.
Federally Qualified Health Maintenance Organization (HMO) – An HMO that CMS has
determined is a qualified HMO under Section 1310(d) of the Public Health Service Act.
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Fee-for-Service (FFS) – A method of reimbursement based on payment for specific services
rendered to an individual eligible for coverage under Med-QUEST.
Financial Relationship – A direct or indirect ownership or investment interest (including an
option or non-vested interest) in any entity. This direct or indirect interest may be in the form of
equity, debt, or other means and includes an indirect ownership or investment interest no matter
how many levels removed from a direct interest or a compensation management with an entity.
Fraud - An intentional deception or misrepresentation made by an individual with the
knowledge that the deception could result in some unauthorized benefit to the individual or some
other individual. It includes any act that constitutes fraud under applicable federal or state laws.
Grievance - An expression of dissatisfaction from a Member, Member’s representative, or
provider on behalf of a Member about any matter other than an adverse benefit determination.
Grievance Review - A State process for the review of a denied or unresolved grievance by a
Health Plan, including instances where the aggrieved party is dissatisfied by the proposed
resolution.
Habilitation Devices – Devices that support the provision of Habilitation Services in inpatient
and/or outpatient settings. Habilitation devices include but are not limited to:
Mobility devices, such as whe e lchairs, motorized scooters, walkers, crutches, canes, prosthetic
devices, orthotic braces, and other orthotic devices.
Devices that aid hearing loss, including hearing aids, cochlear implants (pediatric and adult), and
hearing assistive technology.
Devices that aid speech include DME, and augmentative and alternative communication devices,
such as voice amplification systems.
Prosthetic eyeglasses and prosthetic contact lenses for the management of a congenital anomaly
of the eye.
Dental devices (not for cosmetic purposes).
Habilitative/Habilitation Services – Healthcare services that help to keep, learn, or improve
skills and functioning for daily living. Examples include therapy for a child who is not walking
or talking at the expected age. These services may include physical and occupational therapy,
speech-language pathology, and other services for people with disabilities in a variety of
inpatient and/or outpatient settings.
Health Action Plan (HAP) – A person-centered individualized plan that is developed with the
Member and/or authorized representative based on the SHCN, expanded health care needs
(EHCN), or LTSS assessment conducted by the Health Coordinator. A HAP includes, but is not
limited to, the following: LTSS assessment conducted by the Health Coordinator. A HAP
includes, but is not limit ed to, the following:
Person-centered goals, objectives, or desired outcomes;
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A list of all services and interventions required (Medicaid and non-Medicaid), the amount, the
frequency and duration of each service, and the type of provider to furnish each service.
A description how all clinical and non-clinical healthcare-related needs and services will be
coordinated, including coordination with outside entities providing supports for the Member.
For Members receiving HCBS, the HAP shall be developed consistent with 42 CFR §441.301(c).
The HAP is regularly reviewed, updated, and agreed upon by the Member or authorized
representative with the entity providing health coordination.
Healthcare Professional – A physician, podiatrist, optometrist, psychologist, dentist, physician
assistant, physical or occupational therapist, speech-language pathologist, audiologist, registered
or practical nurse, licensed clinical social worker, nurse practitioner, or any other licensed or
certified professional who meets the State requirements of a health care professional.
Healthcare Provider – Any individual or entity that is engaged in the delivery of health care
services and is legally authorized to do so by the State.
Health Information Exchange (HIE) – HIE allows doctors, nurses, pharmacists, other
Healthcare Providers and patients to appropriately access and securely share a patient’s vital
medical information electronically—improving the speed, quality, safety and cost of patient care.
Health Insurance – A contract that requires the health insurer to pay some or all of healthcare
costs in exchange for a premium.
Health Maintenance Organization (HMO) – See Managed Care Organizations.
Health Plan - Any health care organization, insurance company, accountable care organization,
health maintenance organization, or managed care organization that provides covered services on
a risk basis to enrollees in exchange for capitated payments.
Health Plan Manual – DHS manual contains operational guidance, policies, and procedures
required of the Health Plan participating in QI. It will clarify reporting requirements and metrics
used by DHS to oversee and monitor the Health Plan's performance. The Health Plan Manual, as
amended or modified, is incorporated by reference into the Contract.
Health Professional Shortage Area (HPSA) – An area designated by the United States DHHS’
Health Resources and Services Administration (HRSA) as being underserved in primary medical
care, dental, or mental health providers. These areas can be geographic, demographic, or
institutional in nature.
Health Insurance Portability and Accountability Act (HIPAA) – The Health Insurance
Portability and Accountability Act that was enacted in 1996.
Home and Community Based Services (HCBS)- Long-term care services provided to an
individual residing in a community setting who is certified by DHS to be at the nursing facility
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level of care (LOC) and would be eligible for care provided to an individual in a nursing facility
or a medical facility receiving nursing facility LOC.
Hospital - Any licensed acute care facility in the service area to which a member is admitted
receiving inpatient services pursuant to arrangements made by a physician. Acute care hospitals
may additionally be designated as CAHs, as defined by the Medicare Rural Hospital Flexibility
Program.
Hospital Outpatient Care – Care in a hospital that usually does not require an overnight stay.
Hospital Services - Except as expressly limited or excluded by this agreement, those medically
necessary services for registered bed patients that are generally and customarily provided by
licensed acute care general hospitals in the service area and prescribed, directed, or authorized by
the attending physician or other provider.
.
Hospitalization – Care in a hospital that requires admission as an inpatient for an overnight stay.
An overnight stay for observation could be outpatient care.
In Lieu of S ervice (ILS) – Under the federal Medi caid managed care rules (42 CFR 438.3[e][2]),
ILS substitute for services or settings covered in a state plan because they are a cost-effective
alternative. The actual costs of providing the ILS are included when setting capitation rates, and
they also count in the numerator of the medical loss ratio. ILS, however, can only be covered if
the State determines the service or alternative setting is a medically appropriate and cost-
effective substitute or setting for the State Plan service; if beneficiaries are not required to use the
ILS; and if the ILS is authorized and identified in the contract with Medicai d managed care plans.
Incentive Arrangement – Any payment mechanism under which a Health Plan may receive
funds for meeting targets specified in the contract; or any payment mechanism under which a
provider may receive additional funds from the Health Plan for meeting targets specified in the
contract.
Indian – The term “Indians” or “Indian”, unless otherwise designated, means any person who is
a Member of an Indian tribe, as defined in this §2.6, except that, for the purpose of 25 USC
§§1612 and 1613, such terms shall mean any individual who:
irrespective of whether he or she lives on or near a reservation, is a Member of a tribe,
band, or other organized group of Indians, including those tribes, bands, or groups
terminated since 1940 and those recognized now or in the future by the State in which
they reside, or who is a descendant, in the first or second degree, of any such Member; or
is an Eskimo or Aleut or other Alaska Native; or
is considered by the Secretary of the Interior to be an Indian for any purpose; or
is determined to be an Indian under regulations promulgated by the Secretary of Hea lth and
Human Services.
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Indian Health Care Provider (IHCP) means a health care program operated by the Indian
Health Service (IHS) or by an Indian tribe, tribal organization, or urban Indian organization
(otherwise known as an I/T/U) as those terms are defined in Section 4 of the Indian Health Care
Improvement Act (25 USC §1603).
Indian Tribe – The term “Indian tribe” means any Indian tribe, band, nation, or other organized
group or community, including any Alaska Native village or group or regional or village
corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85
Stat. 688) (43 USC §1601 et. seq.), which is recognized as eligible for the special programs and
services provided by the United States to Indians because of their status as Indians.
Inquiry – A contact from a Member that questions any aspect of a Health Plan, subcontractor, or
provider’s operations, activities, or behavior, or requests disenrollment, but does not express
dissatisfaction.
Institutional or nursing facility level of care (NF LOC)-The decision that a member needs the
services of nurses in an setting to deliver the ’s planned treatment for total care. These services
can be provided in the home or in programs. And is cost-neutral. Also, it is the least limiting
option to care in a hospital or nursing home.
Instrumental Activities of Daily Living (IADLs) – Activities related to independent living.
Includes:
preparing meals,
running errands to pay bills or
pick up medication,
shopping for groceries or personal items, and
performing light or heavy housework.
Kauhale Online Eligibility Assistance (KOLEA) System – The State of Hawaii certified
system that maintains eligibilit y information for Medicaid and other medical assistance
beneficiaries. Kauhale means community in Hawaiian.
Long-Term Services and Supports (LTSS) –
Services provided to a Member in an inpatient medical facility receiving NF LOC or to a resident
of a NF LOC. These facilities include assisted living facilities, expanded adult care homes,
community care foster family homes, nursing facilities, and sub-acute units.
Managed Care – A comprehensive approach to the provision of healthcare that combines
clinical services and administrative procedures within an integrated, coordinated system to
provide timely access to primary care and other necessary services in a cost-effective manner.
Managed Care Organization (MCO) – An entity that has, or is seeking to qualify for, a
comprehensive risk contract under the final rule of the BBA and that is: (1) a federally qualified
HMO that meets the requirements under Section 1310(d) of the Public Health Service Act; (2)
any public or private entity that meets the advance directives requirements and meets the
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following conditions: (a) makes the service it provides to its Medicaid members as accessible (in
terms of timeliness, amount, duration, and scope) as those services that are available to other
non-Medicaid members within the area served by the entity and (b) meets the solvency standards
of 42 CFR Section 438.116 and Section 432-D-8, HRS.
Marketing – Any communication from a Health Plan to a Member or any other individual that
can reasonably be interpreted as intending to influence the individual to enroll in the particular
Health Plan, or dissuade them from enrolling into, or dis-enrolling from, another Health Plan.
Marketing Materials – Materials that are produced in any medium by or on behalf of a Health
Plan and can reasonably be interpreted as intending to market to potential Members.
Medicaid - A federal/state program authorized by Title XIX of the Social Security Act, as
amended, which provides federal matching funds for a Medicaid program for members of
federally aided public assistance and Supplemental Security Income (SSI) benefits and other
specified groups. Certain minimal populations and services must be included to receive FFP;
however, states may choose to include certain additional populations and services at State
expense or if CMS approved receive FFP.
Medical Expenses – The costs, excluding administrative costs, associated with the provision of
covered medical services under a Health Plan.
Medical Facility – A means a facility which:
Is organized to provide medical care, including nursing and convalescent care;
Has the necessary professional personnel, equipment, and facilities to manage the
medical, nursing, and other health needs of the individuals on a continuing basis in
accordance with accepted standards;
Is authorized under state l aw to provide medical care;
Is staffed by professional personnel who have clear and definite responsibility to t he inst itution
in the provision of professional medical and nursing services including adequate and continual
medical care and supervision by a physician, sufficient RN, or licensed practical nurse (LPN)
supervision and services and nurse aid services to meet nursing care needs, and appropriate
guidance by a physician on the professional aspects of operating the facility.
Medical Necessity – Procedures and services, as determined by DHS, which are considered to
be necessary and for which payment will be made. Medically-necessary health interventions
(services, procedures, drugs, supplies, and equipment) shall be used for a medical condition.
There shall be sufficient evidence to draw conclusions about the intervention’s effects on health
outcomes. The evidence shall demonstrate that the intervention can be expected to produce its
intended effects on health outcomes. The intervention’s beneficial effects on health outcomes
shall outweigh its expected harmful effects. The intervention shall be the most cost-effective
method available to address the medical condition. Sufficient evidence is provided when
evidence is sufficient to draw conclusions, if it is peer-reviewed, is well-controlled, directly or
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indirectly relates the intervention to health outcomes, and is reproducible both within and outside
of research settings.
Medical Office – Any outpatient treatment facility staffed by a physician or other healthcare
professional licensed to provide medical services.
Medical Services - Except as expressly limited or excluded by the contract, those medical and
behavioral health professional services of physicians, other health professionals and paramedical
personnel that are generally and customarily provided in the service area and performed,
prescribed, or directed by the attending physician or other provider.
Medical Specialist – A physician, surgeon, or osteopath who is board certified or board eligible
in a specialty listed by the American Medical Association, or who is recognized as a specialist by
the participating healthcare plan or managed care health system.
Medicare - Means the healthcare insurance program for the aged and disabled administered by
the Social Security Administration under title XVIII of the Social Security Act.
Medicare Special Savings Program Members – Qualified severely impaired individuals,
medical payments to pensioners, qualified Medicare beneficiaries, specified low-income
Medicare beneficiaries, qualifying individuals and QDWIs who may be eligible to receive
assistance with some Medicare cost sharing.
Medication-Assisted Treatment (MAT) - Treatment for opioid use disorder combining the use
of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral
therapies.
Medication-Assisted Treatment (MAT) Medications – The FDA has approved several
different medications to treat alcohol and opioid use disorders. MAT medications relieve the
withdrawal symptoms and psychological cravings that cause chemical imbalances in the body.
Medications used for MAT are evidence-based treatment options and do not just substitute one
drug for another.
Opioid Dependency Medications - Buprenorphine, methadone, and naltrexone are used to
treat opioid use disorders to short-acting opioids such as heroin, morphine, and codeine,
as well as semi-synthetic opioids like oxycodone and hydrocodone. These MAT
medications are safe to use for months, years, or even a lifetime. As with any medication,
consult your doctor before discontinuing use. Source: Medication-Assisted Treatment
(MAT) | SAMHSA
Opioid Overdose Prevention Medication - Naloxone is used to prevent opioid overdose
by reversing the toxic effects of the overdose. According to the World Health
Organization (WHO), naloxone is one of a number of medications considered essential to
a functioning health care system.
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Source: Medication-Assisted Treatment (MAT) | SAMHSA
Medication-Assisted Treatment (MAT) Providers – For more information on how to become
a MAT Provider, please visit SAMHSA - Substance Abuse and Mental Health Services
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Administration website here https://www.samhsa.gov/.
Contracted Federal Opioid Treatment Programs (OTP) are licensed by Department of Health.
Med-QUEST Division (MQD) – The offices of the State of Hawaii, Department of Human
Services, which oversees, administers, determines eligibility, and provides medical assistance
and services for state residents.
Member – An individual who has been designated by the Med- QUEST Division to receive
medical services through the QUEST Integration program as defined in Section 30.300 and is
currently enrolled in a QUEST Integration health plan. See also Enrollee.
Model of Care (MOC) – A quality improvement tool used to ensure the unique needs of each
Member enrolled in a special needs plan (SNP) are identified and addressed. In 2010, the ACA
designated the NCQA to execute the review and approval of SNPs’ MOC based on standards and
scoring criteria established by CMS. NCQA assess MOC from SNPs according to detailed CMS
scoring guidelines.
National Committee for Quality Assurance (NCQA) – An organization that sets standards,
develops HEDIS measures, and evaluates and accredits Health Plans and other MCOs.
Native Hawaiian – Refers specifically to people of native Hawaiian descent.
Neighbor Islands (neighbor island s) – Islands in the State of Hawaii other than Oahu – Hawaii
Island, Maui, Lanai, Molokai, Kauai, and Niihau.
Network – A group of doctors, hospitals, pharmacies, and other healthcare experts hired by a
health plan to take care of its Members.
New Member - A member (as defined in this section) who has not been enrolled in a health plan
during the prior six (6) month period.
Non-Participating Provider – A provider who does not have a contract with any health insurers
or plans to provide services to Members.
Nurse Delegation – In accordance with the current HAR §16-89-100, the ability of a RN to
delegate the special task for nursing care to an unlicensed assistive person.
Nursing Facility (NF) – A freestanding or a distinct part of a facility that is licensed and
certified to provide appropriate care to individuals referred by a physician. Such individuals are
those who need twenty-four hour a day assistance with the normal ADL, need care provided by
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licensed nursing personnel and paramedical personnel on a regular, long-term basis, and may
have a primary need for twenty-four hours per day of skilled nursing care on an extended basis
and regular rehabilitation services.
Operational Effectiveness Program - A quality assurance program for Health Plan operations.
Overpayment - A QUEST Integration (Medicaid) overpayment is a payment that exceeds the
allowed payment for services specified in the QUEST Integration contract.
Paraprofessional – An unlicensed, licensed, or certified healthcare team Member that provides
person centered care, patient engagement, community resources, and culturally-competent care.
A paraprofessional may include a medical assistant, community health worker, a peer support
specialist or other specific titles, and provides basic healthcare services in settings s uch as
hospitals, health clinics, physical offices, nursing care facilities and patient homes.
Participating -
When referring to a Health Plan it means a Health Plan that has entered into a contract with DHS
to provide Covered Services to Members. When referring to a Healthcare Provider it means a
Provider who is employed by or who has entered into a contract with a Health Plan to provide
Covered Services to Members. When referring to a facility it means a facilit y that has entered
into a contract with a Health Plan for the provision of Covered Services to Members.
Participating Provider – A provider who has a contract with health plans to provide services.
Patient-Centered Medical Home (PCMH) – A system of care designed to meet the needs of
the whole patient. The model utilizes a team-based approach, but the PCP is responsible for the
continuity and coordination of a patient’s care.
Patient Protection and Affordable Care Act of 2010 (ACA) – Federal legislation that, among
other things, puts in place comprehensive health insurance reforms.
Peer Support Services – Peer support services are provided by a Peer Support Specialist
certified by Adult Mental Health Division of the DOH. Peer support services are coordinated
within the needs and preferences of the Member in achieving the specific, individualized goals
that have measurable results and are specified in the care, service, or treatment plan.
Peer Support Specialist – An individual who uses their lived experience of recovery from
mental illness, addiction, and/or chronic disease management, plus skills learned in formal
training, to deliver services that promote recovery, health, and resiliency. Peer support specialists
are certified by Adult Mental Health Division (AMHD) as a part of the Hawaii certified peer
specialist program or a program that meets the criteria established by AMHD and shall complete
ongoing continuing education requirements. Additionally, they shall be supervised by a mental
health professional, as defined by the State.
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Performance Improvement Project (PIP) – Quality improvement initiatives undertaken by
Health Plans in accordance with 42 CFR §438.240(d) that are designed to achieve, through
ongoing measurements and interventions, significant improvement, sustained over time, in
clinical and non-clinical care areas that are expected to have a favorable effect on health
outcomes and Member satisfaction.
Person-Centered Planning – As defined in 42 CFR §441.301(c)(1)-(3).
Personal Assistance – Care provided when a member, member’s parent, guardian or legal
employs hires and oversees a personal assistant. The health plan will this person. This is based
on watching of the member and the personal assistant during the actual delivery of care. The
Documentation of this certification will be kept in the member’s individual plan of care.
Physician – A licensed Doctor of Medicine or Doctor of Osteopathy.
Physician – A licensed Doctor of Medicine or Doctor of Osteopathy.
Physician Services – Services provided by an individual licensed under state law to practice
medicine.
Plan – A benefit provided by employers, unions, or other group sponsors to pay for healthcare
services.
Post-Stabilization Services – Covered services related to an emergency medical condition that
are provided after a member is stabilized in order to maintain the stabilized condition or to
improve or resolve the member’s condition.
Preauthorization – A decision by a Health Plan that a healthcare service, treatment plan,
prescription drug, or DME is medically necessary. Sometimes called prior authorization, prior
approval or precertification. A Health Plan may require preauthorization for certain services
prior to Members receiving them, except in an emergency. Preauthorization does not guarantee
the Health Plan will cover the cost.
Prepaid Plan – A Health Plan for which premiums are paid on a prospective basis, irrespective
of the use of services.
Prescription Drug – Drugs and medications that, by law, require a prescription.
Prescription Drug Coverage – Health plan that helps pay for prescription drugs and
medications.
Prescription Monitoring Program (PMP) – The purpose of the program is to improve patient
care and stop controlled substance misuse. PMPs use formulary controls, provider-directed
interventions such as education, screening, and intervention programs to decrease inappropriate
utilization. Additionally, PMPs include a patient review and restriction program that can limit
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use by Members who are seeking multiple controlled substance prescriptions from different
providers, often from multiple pharmacies, within a short period of time.
Presumptive Eligibility – Initial Medicaid eligibility given to a potential Member for a specified
period of time prior to the final determination of their eligibility.
Preventive Services (Adult Health) – Services that can prevent or detect illnesses and disease
in earlier, more treatable stages, thereby significantly reducing the risk of illness, disability, early
death, and medical costs. Examples include screening and preventive services identified in
recognized clinical practice guidelines such as those published by the United States Preventive
Services Task Force, the Centers for Disease Control and Prevention (CDC), HRSA’s women’s
preventive services guidelines, and DOH’s guidelines on screening for tuberculosis. Additional
examples of adult preventive services include:
Immunizations;
Screening for common chronic and infectious diseases and cancers;
Clinical, non-clinical, and behavioral interventions to manage chronic disease and reduce
associated risks and complications;
Support for self-management of chronic disease;
Support for self-management for individuals at risk of developing a chronic disease;
Screening for pregnancy intention as appropriate;
Counseling to support healthy living;
Support for lifestyle change when needed; and
Screening for behavioral health conditions
Preventive Services (Pediatrics and Adolescent Health) – Services that can prevent or detect
illnesses and disease in earlier, more treatable stages, thereby significantly reducing the risk of
illness, disability, early death, and medical costs. This includes evidence-based screening and
preventive interventions such as those recognized in Bright Futures guidelines issued by HRSA
and the CDC, all screening, assessment, and preventive services covered by EPSDT, and DOH
screening guidelines for tuberculosis. Additional examples of preventive se rvices include:
Immunizations;
Screening for common chronic and infectious diseases and cancers;
Clinical, non-clinical, and behavioral interventions to manage chronic disease and reduce
associated risks and complications;
Support for self-management of chronic disease;
Support for self-management for individuals at risk of developing a chronic disease;
Screening for pregnancy intention as appropriate;
Counseling to support healthy living;
Support for lifestyle change when needed; and
Screening for behavioral health and developmental conditions.
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Primary Care – Outpatient care to include: prevention, treatment of acute conditions, and
management of chronic conditions. Primary care is often first contact care of the same complaint.
May result in diagnostic testing and treatment, appropriate consultation or referral and includes
coordination and continuity of care.
Primary Care Provider (PCP) - A practitioner selected by the Member to manage the
Member's utilization of health care services who is licensed in Hawaii and is:
A physician, either an MD or a DO, and shall generally be a family practitioner, general
practitioner, general internist, pediatrician or obstetrician-gynecologist (for women,
especially pregnant women) or geriatrician;
An APRN-Rx. PCPs have the responsibility for supervising, coordinating, and providing
initial and primary care to enrolled individuals and for initiating referrals and maintaining
the continuity of their care; or
A physician’s assistant recognized by the State Board of Medical Examiners as a licensed
physician assistant.
Prior Period Coverage – The period from the eligibility effective date as determined by DHS
up to the date of enrollment in a Health Plan.
Prior Period Performance Rate – The actual score on a specific performance measure for the
prior reporting period.
Private Duty Nursing (PDN) – PDN is a service provided to individuals requiring ongoing,
long-term maintenance nursing care at home or in the community (in contrast to home health or
part time, intermittent skilled nursing services under the Medicaid State Plan [MSP]). The
service is provided by licensed nurses (as defined in HRS, Chapter 457) within the scope of state
law, consistent with physician’s orders, and in accordance with the Member’s HAP. PDN
services may be self-directed under personal assistance level II/delegated using nurse delegation
procedures as outlined in HRS §457-7.5.
Private Health Insurance Policy – Any health insurance program, other than a disease-specific
or accident-only policy, for which a person pays for insurance benefits directly to the carrier
rather than through participation in an employer or union sponsored program.
Protected Health Information (PHI) – As defined in the HIPAA Privacy Rule, 45 CFR Section
160.103.
Provider - Any licensed or certified person or public or private institution, agency, or business
concern authorized by DHS to provide healthcare, services, or supplies to individuals receiving
medical assistance.
Provider Grievance – An expression of dissatisfaction made by a provider as described in
§8.4.B.
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Provider Preventable Conditions (PPC) – Provider-preventable conditions are conditions that
meet the definition of a healthcare-acquired condition or other provider-preventable conditions.
A healthcare-acquired condition (HAC) means a condition occurring in any inpatient hospital
setting, identified as a HAC by the Secretary under Section 1886(d)(4)(D)(iv) of the Act; other
provider-preventable condition may include conditions that have been found based upon a
review of medical literature by qualified professionals to be reasonably preventable through the
application of procedures supported by evidence-based guidelines, and have a negative
consequence for the Member. At a minimum, other provider-preventable conditions include
wrong surgical or other invasive procedure performed on a patient; surgical or other invasive
procedure performed on the wrong body part; or surgical or other invasive procedure performed
on the wrong patient.
QUEST Integration (QI)- QUEST Integration is the managed care program that provides
healthcare benefits, including long-term services and supports, to individuals, families, and
children; the program serves both non-aged, blind, or disabled (non-ABD) individuals and ABD
individuals, with household income up to a specified federal poverty level (FPL). This is the
demonstration project developed by DHS.
Rehabilitative/Rehabilitation Services – Healthcare services that help Members keep, get back,
or improve skills and functioning for daily living that have been lost or impaired because
Members were sick, hurt, or disabled. These services may include physical and occupational
therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of
inpatient and/or outpatient settings.
Rehabilitation Devices – Devices that support the provision of rehabilitation services in
inpatient and/or outpatient settings. Rehabilitation devices include but are not limited to:
Mobility devices, such as wheelchairs, motorized s cooters, walkers, crutches, canes,
prosthetic devices, orthotic braces, and other orthotic devices.
Devices that aid hearing loss, balance or tinnitus disorders, including hearing aids, aural
rehabilitation with cochlear implants for both pediatric and adult, and hearing assistive
technology.
Devices that aid speech include DME, speech-generating equipment, and augmentative
and alternative communication devices, such as voice amplification systems.
Cognitive aids to assis t with memory, attention, and other challenges with cognition.
Prosthetic eyeglasses and prosthetic contact lenses for the management of trauma to the
eye or ophthalmologic disease.
Dental devices, excluding devices for cosmetic purposes).
Resident of Hawaii – A person who resides in the State of Hawaii or establishes his or her intent
to reside in the State of Hawaii.
Risk Share – The losses or gains associated with Health Plan costs or savings related to
expected healthcare expenditures that are shared between the Health Plan and DHS. A Health
Plan may separately enter into risk share arrangements with providers.
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Rural Health Center (RHC) – An entity that meets the qualifications for an RHC, as defined in
Section 1861(aa)(2) of the Social Security Act.
Rural Providers – Primary medical care, dental, or mental health Providers who serve in a
HRSA-designated HPSA. HRSA-designated HPSA can be found using the following website:
http://hpsafind.hrsa.gov/.
Self-Direction – A service delivery option under LTSS HCBS. Personal assistance services
provided for an LTSS Member when the Member, Member’s parent, guardian, or legal
representative employs and supervises a personal assistant. The personal assistant is certified by
the Health Plan as able to provide assistance with ADL and/or IADL provided as an alternative
to nursing facility placement to persons with a physical disability. Documentation of this
certification will be maintained in the Member’s individual plan of care.
Service Area – The geographical area defined by zip codes, census tracts, or other geographic
subdivisions, i.e., island that is served by a participating Health Plan as defined in its contract
with DHS.
Severe Mental Illness (SMI) – A mental disorder which exhibits emotional or behavioral
functioning that is so impaired as to interfere substantially with a person’s capacity to remain in
the community without treatment or services of a long-term or indefinite duration. This mental
disability is severe and persistent, encompassing individuals with SMI, SPMI, or requiring
support for emotional and behavioral development (SEBD), resulting in a long-term limitation of
a person’s functional capacities for primary ADL such as interpersonal relationships,
homemaking, self-care, employment, and recreation.
Significant Change – A change that may affect access, timeliness, or quality of care for a
Member (i.e., loss of a large provider group, change in benefits, change in Health Plan operations,
etc.) or that would affect the Member’s understanding and procedures for receiving care.
Skilled Nursing (SN) – Skilled nursing is a service provided to individuals requiring home
health or part time, intermittent skilled nursing services under the MSP (in contrast to ongoing,
long-term nursing care) at home or in the community. The service is provided by licensed nurses
(as defined in HRS Chapter 457) within the scope of state law, consistent with physician’s orders
and in accordance with the Member’s HAP.
Skilled Nursing Care – A LOC that includes services that can only be performed safely and
correctly by a licensed nurse (either a RN, a LPN, or APRN).
Social Determinants of Health (SDOH) – Conditions in which people are born, grow, live,
work, and age that shape health. Socio-economic status, discrimination, education, neighborhood
and physical environment, employment, housing, food security and access to healthy food
choices, access to transportation, social support networks and connection to culture, as well as
access to healthcare are all determinants of health. Hawaii state law recognizes that all state
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agency planning should prioritize addressing these determinants to improve health and wellbeing
for all, including Native Hawaiians.
Special Health Care Needs (SHCN) – A Member that has chronic physical, behavioral,
developmental, or emotional conditions that require health-related services of a type or amount
that is beyond what is required of someone of their general age.
Special Treatment Facility – A licensed facility that provides a therapeutic residential program
for care, diagnoses, treatment, or rehabilitation services for individuals who are socially or
emotionally distressed, have a diagnosis of mental illness or substance abuse, or who have a
developmental disability or intellectual disability (DD/ID).
Specialist – A physician specialist focuses on a specific area of medicine or a group of patients
to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-
physician specialist is a provider who has more training in a specific area of healthcare.
State - The State of Hawaii.
State Fiscal Year (SFY) – The period July 1 through the following June 30 of consecutive
calendar years.
State Plan – The document approved by DHHS that defines how Hawaii operates its Medicaid
program. The State Plan addresses areas of state program administration, Medicaid eligibility
criteria, service coverage, and provider reimbursement.
Stepped Care – The concept of Stepped Care is that individuals can move up or down a
continuum of services as needed and that treatment level and intervention will be paired with the
individual’s level of acuity to provide effective care without overutilization of resources. The
goal is to meet individual need at the lowest level possible while ensuring high-quality results
which allows the system to use limited resources to their greatest effect on a population basis.
Sub-Acute Care – A LOC that is needed by an individual not requiring acute care, but who
needs more intensive skilled nursing care than is provided to the majority of patients in a SNF.
Substance Abuse and Mental Health Services Administration (SAMHSA) – The agency
within DHHS that leads public heath efforts to advance the behavioral health of the nation.
SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s
communities.
Substance Use Disorder (SUD) – SUDs occur when the recurrent use of alcohol and/or drugs
causes clinically significant impairment, including health problems, disability, and failure to
meet major responsibilities at work, school, or home.
Support for Emotional and Behavioral Development (SEBD) – A program for behavioral
health services for children and adolescents administered by CAMHD.
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Telehealth – As defined by HRS §346-59.1, the use of telecommunications services to
encompass four modalities: store and forward technologies, remote monitoring, live consultation,
and mobile health; and which shall include but not be limited to real-time video conferencing-
based communication, secure interactive and non-interactive web-based communication, and
secure asynchronous information exchange, to transmit patient medical information, including
diagnostic-quality digital images and laboratory results for medical interpretation and diagnosis,
for the purpose of delivering enhanced healthcare services and information while a patient is at
an originating site and the Healthcare Provider is at a distant site. Standard telephone contacts,
facsimile transmissions, or email text, in combination or by itself, does not constitute a telehealth
service for the purposes of this definition.
Temporary Assistance to Needy Families – Time-limited public financial assistance program
that replaced Aid to Families with Dependent Children that provides a cash grant to qualified
adults and children.
Third Party Liability (TPL) – Any person, institution, corporation, insurance company, public,
private or governmental entity who is or may be liable in contract, tort or otherwise by law or
equity to pay all or part of the medical cost of injury, disease or disability of a member or to
Medicaid.
Transitions of Care – The movement of Members between healthcare practitioners, settings,
and home as their conditions and care needs change. For example, a Member might receive care
from a PCP or specialist in an outpatient setting, then transition to a hospital physician and
nursing team during an inpatient admission before moving to another care team at a SNF.
Urgent Care - The diagnosis and treatment of medical conditions which are serious or acute but
pose no immediate threat to life or health. Requires medical attention within 24 hours.
Utilization Management Program (UMP) - The requirements and processes established by a
health plan to ensure members have equitable access to care, and to manage the use of limited
resources for maximum effectiveness of care provided to members.
Value-Added Services – Under the federal Medicaid managed care rules (42 CFR
§438.3[e][1][i]), services that are not covered under the State Plan, but that a Health Plan
chooses to spend capitation dollars on to improve quality of care and/or reduce costs. Value-
added services seek to improve quality and health outcomes, and/or reduce costs by reducing the
need for more expensive care. The cost of value-added services cannot be included in the
capitation rates; it can, however, be included in the numerator of the MLR if it is part of a quality
initiative.
Value-Based Payment (VBP) – An approach to payment reform that links provider
reimbursement to improved performance or that aligns payment with quality and efficiency. This
form of payment holds Healthcare Providers accountable for both the cost and quality of care
they provide. VBP strives to reduce inappropriate care and to identify and reward the highest
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performing providers. VBP may include but not be limited to different reimbursement strategies
such as FFS with incentives for performance, capitation payment to providers with assigned
responsibility for Member care, or a hybrid model.
Waste – Overutilization of services or other practices that do not improve health outcomes and
result in unnecessary costs. Generally not caused by criminally negligent actions but rather the
misuse of resources.
Whole-Person Care – Whole-person care addresses the health, behavioral health, psycho-social,
and social services needs of a Member in a person-centered manner with the goals of improved
health outcomes and more efficient and effective use of resources.
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