INSIDE THIS ISSUE: Practitioner/Provider-Initiated Member Appeals . . . . . . 2

Customer Relations is Here to Help Our Members . . . . 4

Important Provider Line Update . . . . . . . . . . . . . . . . . . . 4

Kaiser Permanente’s Quality Management Program . . . 5

On the Web with Kaiser Permanente . . . . . . . . . . . . . . . . 6

Clinical Practice Guidelines . . . . . . . . . . . . . . . . . . . . . . . 6

Medical Management: Reconsideration Process & Utilization Management (UM) Contacts . . . . 7

Claims Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2011 Plan Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

PROVIDER CONNECTION+Produced by Kaiser Foundation Health Plan of Ohio

FOR NETWORK PROVIDERS OF KAISER PERMANENTEproviders .kp .org/oh

ISSUE 1 | 2011

CLAIM ADMINISTRATION CHANGES FOR ADDED CHOICE® POS AND OUT-OF-AREA PPO PRODUCTSEffective May 1, 2011, the Kaiser Permanente Insurance Company will be transitioning claims administration from Meritain Health Systems to the Kaiser Foundation Health Plan of Ohio Claims Department for dates of service on or after May 1, 2011 .

The impact to you as a result of this change is as follows:

Added Choice® POS Product – You will continue to send claims to Kaiser Permanente, P .O . Box 5316, Cleveland, OH 44101-5316, as noted on the back of the member’s ID card . You may notice a slight change in appearance to your Explanation of Payment since Meritain Health System will no longer appear .

Out-of-Area PPO Product – Several changes related to this transition are as follows:

• For dates of service on or after May 1, 2011, sendclaims to Kaiser Permanente, P .O . Box 6316, Cleveland, OH 44101-5316 .

• Fordatesofserviceprior toMay1,2011,continuetocontact and send claims to Meritain Health Systems .

• Misdirected claims will be returned to your office sothat you can update your records with the new claims submission address .

• IDCardsandExplanationofPaymentwillbemodified.

We anticipate the transition to be as seamless as possible . You can direct any questions to our Kaiser Permanente Customer Relations Department at 1-800-686-7100 .

2

PROVIDER CONNECTION+

APPEAL PROCESS OF PRE-SERVICE DENIALSThe requesting practitioner/provider may submit a written appeal request to the Kaiser Permanente Appeals Unit at the following address:

Kaiser PermanenteAppeals UnitP .O . Box 93764Cleveland, OH 44101-5764Or fax the appeal request to: 216-635-4673

Appeal requests must be received within the same timeframes that are offered to our members . These timeframes are:

• Commercial members (per the Department of Labor[DOL] and the National Committee for Quality Assurance [NCQA]): within 180 calendar days of receipt of the initial adverse determination .

• Medicare members (per the Centers for Medicare andMedicaid Services [CMS]): within 60 calendar days of receipt of the initial adverse determination .

• FederalEmployeemembers(pertheOfficeofPersonnelManagement [OPM]): within six months of receipt of the initial adverse determination .

The Kaiser Permanente Appeals Unit Staff will review the documentation and contact the appealing practitioner/provider for additional information if needed .

The appeal will be reviewed by either the Medical Advisory Council (MAC) for medical necessity denials, or the Benefits Advisory Council (BAC) for benefit denials within 30 calendar days of receipt of the appeal request .

An appropriate physician or behavioral health clinician makes all decisions for medical appropriateness . Physicians participating on the Medical Advisory Council shall not have been involved in the initial determination or be subordinates of a physician involved in the initial determination . For urgently needed services, the appeal will be reviewed by a physician of similar or like specialty as expeditiously as the health condition requires, but no later than 72 hours .

If the initial denial is overturned, the Appeals Unit staff will contact the practitioner/provider and the member in writing within 30 calendar days of the request (telephonically for urgently needed services within 72 hours), and will process the request per department procedures .

If the initial denial is upheld, the Appeals Unit staff will contact the practitioner/provider and the member in writing within 30 calendar days of receipt of the request (telephonically for urgently needed services within 72 hours), informing them of the rationale for the decision and providing information on any further appeal rights . For Medicare members: if the initial denial is upheld, the case will automatically be forwarded to Medicare’s Independent Review Entity for the final determination .

Contracted practitioners and providers have the right to appeal, on behalf of a member under their care, any decision made by Kaiser Permanente to deny a pre-authorization or a referral based on medical necessity . The following information is an overview of the Kaiser Permanente Provider-Initiated Member Appeal Process . Note: This process pertains to preauthorization denials only. This process does NOT pertain to claims payment disputes that are related to bundling/unbundling, or over- or under-payments.

PRACTITIONER/PROVIDER-INITIATED MEMBER APPEALS

(continued on page 3)

ISSUE 1 | 2011

APPEAL PROCESS OF POST-SERVICE DENIALS (PROVIDER SUBMISSIONS)All providers/practitioners have the opportunity to appeal for denied payment of unauthorized services rendered to members, when the member is not financially responsible for charges incurred . If the member has been billed for services, the member must submit their own appeal request . All provider appeals for payment will be responded to within 90 calendar days from receipt . This process does NOT apply to claims payment disputes .

PLEASE NOTE: Authorization requirements serve as key decision-making criteria in the provider appeal process .

The provider/practitioner may submit a written appeal request to the Kaiser Permanente Appeals Unit . Please feel free to include pertinent clinical information; however, medical necessity is NOT a guarantee for payment for services requiring prior authorization . Send the appeal along with any supporting documentation to:

Kaiser PermanenteAppeals UnitP .O . Box 93764Cleveland, OH 44101-5764You can also fax the information to: 216-635-4673

Appeal requests must be received within the same timeframes as for Pre-Service Appeals (as described above) . The appropriate physician advisor or behavioral health clinician involved in a previous decision will not review the appeal request at a subsequent level .

A decision is made within 90 calendar days of receipt of the appeal request . The practitioner/provider is notified, in writing, when the denial is upheld .

Reprocessing of an overturned claim will be performed within 30 days of the decision and the Explanation of Payment (EOP) will serve as notice of the overturn .

APPEAL PROCESS FOR APPEALS RELATED TO DENIED MEDICARE PART D PRESCRIPTION DRUGS (PRE- OR POST-SERVICE)Prescribing practitioners have the right to appeal any decision made by Kaiser Permanente to deny coverage of a Part D prescription drug benefit . The process for filing an appeal remains the same as under “Appeals Process of Pre-Service Denials” and “Appeals Process of Post-Service Denials .” However, the timeframes for rendering a decision for Medicare Part D appeals are as follows:

• Seven calendar days for standard pre- or post-servicerequests

• 72hoursforexpeditedappealrequests

Additionally, in the event that the decision is to uphold the initial denial, members will be instructed on how to proceed with an external review through Maximus Federal Services . Unlike the automatic submission to Medicare’s Independent Review Entity of all upholds of Part C services, the member must request an external review of Part D denials in writing . The redetermination notice will instruct the member as to the process and timeframe for requesting an external review .

Should you have any questions regarding the Appeal Process, please feel free to contact the Kaiser Permanente Appeals Unit at 440-846-2882, or toll-free at 1-888-479-5333 .

Practitioner/Provider-Initiated Member Appeals (continued from page 4)

3

4

PROVIDER CONNECTION+

CUSTOMER RELATIONS IS HERE TO HELP OUR MEMBERS

Beginning April 1, 2011 Kaiser Permanente members and providers will now be served through a single call center . Combining the current Provider Relations and Customer Relations call centers will allow both members and providers to experience improved and consistent service through the use of technology and more tightly managed call routing . The hours of operation for providers have been expanded from Monday through Friday, 8:45 a .m . to 3:45 p .m ., to Monday through Thursday, 8:15 a .m . to 5 p .m ., and Friday, 9:00 a .m . to 5:00 p .m .

Providers will continue to access service by calling 1-800-441-9742 (toll free) . The deaf or hearing impaired may call 216-635-4444 (TTY/TDD) or 1-877-676-6677 (toll free TTY/TDD)

Members will continue to access service by calling 216-621-7100 or 1-800-686-7100 (toll free), or 216-635-4444 or 1-877-676-6677 (toll free TTY/TDD) . Medicare members may call seven days a week, 8 a .m . to 8 p .m ., at 1-800-493-6004 (toll free) or 1-866-513-9966 (toll free TTY/TDD) .

IMPORTANT PROVIDER LINE UPDATE

Kaiser Permanente wants our members to be satisfied with our services, our facilities and our physicians . Customer Relations welcomes any member commentary, compliments or complaints regarding our medical services or administrative procedures . If members are dissatisfied for any reason, they can contact us in writing or by calling Customer Relations at 1-800-686-7100 (toll free) or 1-877-676-6677 (TTY for the deaf, hard of hearing, or speech impaired) .

For written complaints or grievances:

Customer RelationsKaiser Foundation Health Plan of OhioP .O . Box 5309Cleveland, OH 44101

The member, or the member’s authorized representative, must sign all written complaints or grievances . An authorized representative may be any person that the member authorizes in writing to act on his/her behalf .

All complaints or grievances are reviewed by a neutral party, up to and including the President of Kaiser Foundation Health Plan of Ohio, or the President and Executive Medical Director of the Ohio Permanente Medical Group . Customer Relations will acknowledge receipt of complaint or grievance within 5 business days and will respond in writing to formal written complaints or grievances within 30 days . The member will be notified if additional time is required .

For verbal complaints or grievances:

Non-MedicareMonday through Thursday, 8:15 a .m . to 5 p .m ., andFriday, 9:00 a .m . to 5 p .m . at 216-621-7100 or1-800-686-7100 (toll free), 216-635-4444 or1-877-676-6677 TTY/TDD

MedicareCall seven days a week (including holidays) from 8 a .m . to 8 p .m . at 1-800-493-6004 (toll free) or1-866-513-9966 TTY/TDD

Members who call after regular office hours may leave a message, and a representative will return their call the next business day .

Kaiser Permanente of Ohio strives to provide services in a way that embraces all members, including those with limited English language or reading skills . Information pertaining to member complaints or grievances may be available in alternate formats . If your patient has special needs, questions or concerns, they may contact our Customer Relations Department at the phone numbers listed above for additional assistance .

5

ISSUE 1 | 2011

•Qualityandsafetyofclinical care

•Programscope•Yearlyobjectives•Yearlyplannedactivities•Timeframewithinwhich

each activity is to be achieved

•Thestaffmemberresponsible for each activity

•Monitoringofpreviouslyidentified issues

•EvaluationoftheQIprogram

•Qualityofservice

The Senior Quality Council (SQC) is the official quality committee for Kaiser Permanente Ohio . It establishes annual quality priorities, approves and evaluates progress and outcomes of the quality work plan, identifies majororganizational Ohio quality initiatives, provides resources, reviews and recommends policy decisions, institutes needed actions, and ensures follow-up . Every year, a Program Description (PD) and a Program Evaluation (PE) is completed to provide the “big picture” of why a program description is needed, an overview of all the programs, and a summary of progress towards meeting planned goals .

PROGRAM DESCRIPTION The 2011 PD encompasses the Ohio Permanente Medical Group (OPMG) clinical departments including Behavioral Health, ancillary departments, affiliated practitioners and providers, and oversight of delegated activities . It also provides a link to Medical Management, Risk Management and Patient Safety, Legal Counsel, Compliance, Accreditation, Customer Relations, Population Care Management and Prevention, the Medical Group, and the Care Experience initiatives .

PROGRAM EVALUATION The 2011 PE describes completed and ongoing QI initiatives and describes program development, actions that were taken, metrics, trends, and comparative analysis, barriers to progress, and opportunities for improvement .

KAISER PERMANENTE’S OHIO QUALITY MANAGEMENT PROGRAM QI PROGRESSKaiser Permanente’s Accreditation Department oversees survey readiness, Healthcare Effectiveness Data and Information Set (HEDIS®) measurement, and improvement activities . Kaiser Permanente’s Ohio HEDIS audit took place March 2011, and our last National Committee for Quality Assurance (NCQA) on-site audit was conducted August 2009 . Based on the findings of the NCQA surveyors, Kaiser Permanente received an “Excellent”

status for both the commercial and Medicare product lines . Any activity that was not completed in 2010 is carried over to the 2011 work plan . OPMG providers and staff track their assigned QI initiatives on a regular basis .

ABOUT THE NATIONAL COMMITTEE ON QUALITY ASSURANCEThe National Committee on Quality Assurance (NCQA) evaluates all resources the organization devotes to the QI program and the associated activities; including staff, data sources, analytic resources, and evidence that Kaiser Permanente is completing Quality Improvement (QI) activities in a competent and timely manner . To meet NCQA’s Quality Improvement Standards, Kaiser Permanente must demonstrate that we are designing sound studies, applying statistical analysis to data, and deriving meaning from the statistical analysis .

NCQA also oversights the annual Healthcare Effectiveness Data and Information Set (HEDIS®) for clinical effectiveness of care measures of performance . Several HEDIS measures of focus improved in 2010 . Kaiser Permanente Ohio exceeded our goals for cancer screening and caring for our diabetic and cardiac patients . Electronic Medical Record tools, such as the Pro-office Encounter (POE) and Best Practice Alerts (BPAs), were instituted and provided clinical staff with the ability to easily identify which tests are needed and then order and advise the member to schedule screenings such as a mammogram, Pap test, or blood work .

Health plan member satisfaction is measured at least annually with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey (Commercial HMO members) and the Member Experience: Tracking, Evaluation, and Opinion Research (METEOR) survey (Commercial and Medicare HMO members) . NCQA uses nine CAHPS measures to determine accreditation points . Although not statistically significant, the 2007 and 2010 Ohio scores improved each year for Health Care Rating, Health Plan Rating, Personal Doctor Rating, and Getting Care Quickly . More details, including competitor comparisons can be found in the 2010 CAHPS report .

To request a CD-ROM or printed hard copy of the “Quality/Medical Management Annual Program Description” and the “Quality Program Annual Evaluation”, contact your Network Associate or the Network Development Department at 1-800-441-9742 .

The Kaiser Permanente Quality Management Program was designed to improve the quality and safety of clinical care and the quality of services provided to our members . The Quality Improvement (QI) program prioritizes quality activities aligned with the region’s Strategic Plan and provides resources in support of achieving the QI work plan . This complies with applicable regulatory and accrediting body requirements . Kaiser Permanente’s QI work plan must address:

KAISER PERMANENTE’S QUALITY MANAGEMENT PROGRAM

6

PROVIDER CONNECTION+

CLINICAL PRACTICE GUIDELINESKaiser Permanente Ohio has developed a wide array of Preventive Care and Clinical Practice Guidelines to support your clinical practice in providing quality care for our members . You can access these guidelines on our website . Clinical Guidelines are located under the “Provider Information” section . Each guideline can be downloaded and printed, as needed .

Clinical Practice Guidelines are updated as changes and additions occur . We will note any guideline updates in this section of the newsletter in future editions and in

the “News and Announcement” section of the provider website at providers.kp.org/oh . If you are not able to access the Preventive Care and Clinical Practice Guidelines online, you may request that hard copies be mailed to your office by calling your Network Associate .

The following updates were made to the guidelines since January 1, 2011: Cancer: Chemotherapy Induced Febrile NeutropeniaCoronary Artery DiseaseHeadache

Have you signed on to KP Online-Affiliate (OA) lately? Kaiser Permanente monitors all activity of all provisioned users’ accounts, including inactivity . Kaiser Permanente National Privacy, Security and Compliance policies govern all access to member information . Inactive accounts are automatically suspended and user access is blocked due to the confidential nature of the contents within this secure website . This applies to newly-provisioned users who have not activated their accounts as well .

We recommend signing on to OA once a month to keep your account active and available when you need it . Some users place recurring reminders on their calendars, e .g ., “Sign on to KP Online-Affiliate” -- set to recur the first Tuesday of each month . The act of signing on keeps your account in an active state .

If your account has been suspended and you wish to re-establish your access, please call the Provider Line at 1-800-441-9742, option 4, during regular business hours . Ask to speak with the Online-Affiliate Coordinator (OAC) . The process of reactivating your account may take up to two business days .

You will be verbally notified when your account is reactivated . You should then sign on to OA and follow the steps to re-establish your account access . If you need assistance with “Managing your Account”, call the Help Desk at 1-866-331-2089 . Passwords must contain a minimum of eight (8) characters and contain at least one letter and one number .

SECURITY TIME OUTS

Has your OA session prematurely terminated shortly after signing on? There is a “security time out” that will “bump” you from the website and prompt you to sign on again . Please call the Help Desk at 1-866-331-2089 if you experience this problem . Provide the support person with the date and time of the termination, and the feature you were using . Each occurrence is formally reviewed, evaluated and documented . If we can identify the root cause of the random bumping, we can determine how to fix it .

STAFF CHANGES

System administrators at affiliated provider offices are required to inform Kaiser Permanente of OA users who have left your employ or no longer require access . You can call the Provider Line at 1-800-441-9742, option 4, and ask to speak with the Online-Affiliate Coordinator (OAC) to provide notification, or create a “Disenrollment Request” by clicking on the “In Basket” tab and the small arrow to the right of the “New Message” icon . Click on “Disenrollment Request” and enter the person’s name and the effective date of the termination . Click the “Send” button .

ON THE WEB WITH KAISER PERMANENTE

7

ISSUE 1 | 2011

RECONSIDERATION PROCESSAll requests for services that are denied based on medical appropriateness are determined by a board-certified physician . The notice of denial you and the member receive will inform you of the reason for the denial, and your rights to a reconsideration by the physician who made the determination .

If you disagree with the decision, and you would like to discuss the denial with the physician who made the determination, you may contact the Medical Management Department at 1-216-529-5588 option 3, Monday through Friday between 9:00 a .m . and 5:00 p .m . A nurse reviewer will assist you in arranging a peer-to-peer discussion . If the reviewer who made the determination cannot be available within three (3) business days, the reviewer may designate another reviewer . Please note that in accordance with the Ohio Revised Code, you may not pursue a reconsideration without first obtaining the member’s consent .

The decision on the reconsideration will be made within three (3) business days after receipt of the request for the reconsideration . It will be made sooner if the medical condition of the member indicates a need for a more prompt decision . If the issue is not resolved to your satisfaction, and the request for service is still denied, the member may appeal the denial . A reconsideration is not a pre-requisite to the appeal process .

Kaiser Permanente’s internal appeal process includes one level of appeal . Should the member disagree with an adverse determination, the member may seek further appeal through an external review organization . Commercial members must simply notify the Appeal Unit in writing of any decision to seek further appeal . Upheld Medicare adverse determinations are automatically forwarded to the Medicare’s Independent Review Entity by the Appeal Unit . At each step of the way, the member

is guided and directed to ensure they understand the appeal process .

UTILIZATION DEPARTMENT CONTACTSThe physicians and staff of the Medical Management Department are available to answer any other questions you may have regarding:

• Referralandauthorizationprocess

• Medicalappropriatenesscriteria

• Statusofareferral

• Deniedservicerequest

• Otherutilizationmanagementissues

As a contracted network physician, if you wish to speak to a Medical Management staff member regarding specific referral issues, you may call 216-529-5588, and select one of the following phone prompts:

• Option 1: Connects you with a referrals representative in our Medical Management Department .

•Option 3: Connects you with a precertificationrepresentative in our Medical Management Department .

Kaiser Permanente’s Medical Management staff is available from 9 a .m . to 5 p .m . Monday through Friday (excluding holidays) .

For questions specific to non-formulary or criteria restricted medications, please call Kaiser Permanente Pharmacy Utilization Management directly at 216-265-4408 or 1-877-265-4408 .

MEDICAL MANAGEMENT: Reconsideration Process & Utilization Management (UM) Contacts

8

PROVIDER CONNECTION+

ELECTRONIC FUNDS TRANSFER PAYMENT REQUIRED FOR ELECTRONIC DATA INTERCHANGE (EDI) SUBMITTERSStarting October 16, 2010, the State of Ohio requires that Kaiser Permanente pay contracted providers electronically when claims are submitted electronically . If you are not set-up for Electronic Funds Transfer (EFT) payment, please complete and return the EFT provider set-up form . The EFT form can be found on the Kaiser Permanente Community Provider website at providers.kp.org/oh . Select the Forms section Claims and Payment forms EDI EFT Authorization Agreement . You may also contact our Network Development Department to obtain a form at 1-800-441-9742 option 4 .

Complete this document and mail a signed copy to our EDI Coordinator with the required attachments .

EDI Coordinator, Kaiser Permanente 14600 Detroit Avenue, 7th Floor Lakewood, OH 44107

ELECTRONIC REMITTANCE ADVICE (835 TRANSACTIONS):If you would also like to receive more detail about your EFT payments, please sign up to receive electronic remittance advice (835) transactions . The remittance advice request form can be found on the Kaiser Permanente Community Provider website at providers.kp.org/oh . Select the Forms section Claims and Payment forms EDI Electronic Claims Remittance Set-up Form . You may also contact our Network Development Department at 1-800-441-9742 option 4 to obtain a form .

Complete the request form and email or mail it to our EDI Coordinator at the address above . The 835 set-up can usually be completed (without any further requests for information) in five to seven business days .

BENEFITING FROM AVAILITY 276 TRANSACTIONSWe encourage Plan providers to sign up for Availity, one of the nation’s leading health information networks, which offers a convenient, multi-payer Web portal to Ohio providers . The portal offers the following transactions for Kaiser Permanente

of Ohio: eligibility and benefits verification, claim status inquiries, and claims submissions . This is a free service for area providers . For more information regarding this network, including an online demonstration, visit availity.com .

One of Kaiser Permanente’s partners in service, Anesthesia Associates of Painesville, enrolled with Availity a few months ago . The staff report that the Availity Web portal service has been beneficial to their office and it is very easy to use . The group monitors their claims’ status on a regular basis by using the 276 claims status inquiry . Staff also uses the Availity Web portal to validate secondary insurance by typing in the patient’s social security number and performing a search . With Kaiser Permanente members, they type in the patient’s Medical Record Number to verify member eligibility and benefits . (Interviewed 1/27/11)

EDI CLAIMS Electronic claims submission (EDI) continues to grow at Kaiser Permanente . Since electronic claims do not have to be scanned or manually keyed, turnaround times for claims processing have improved . Submitting your claims electronically also saves you time .

SUBMITTING SECONDARY CLAIMS VIA EDIKaiser Permanente of Ohio welcomes electronic “commercial” secondary claims submissions . To process the claims correctly, we need the detail of the primary payment . Therefore, we require that providers adhere to the Coordination of Benefit (COB) guidelines specified in the HIPAA Implementation Guide section 1 .4 .2 . The claim must reportallapplicableclaimleveladjustmentamounts(Loop2320)aswellasservicelineleveladjustmentamounts(Loop2430) . Claims without this information will have to be denied and further information will be requested . Please note that Kaiser Permanente of Ohio is already accepting Medicare crossover claims . So, you do not need to send us your secondary Medicare claims .

SUBMITTING CLAIMS FOR DUALLY COVERED MEMBERSWhen a Kaiser Permanente member is covered under two Kaiser Permanente benefit plans, please submit the claim once . Our Claims Operations team will pay under both plans

CLAIMS CORNER

(continued on page 9)

9

ISSUE 1 | 2011

so you will receive remittance advice and payment under both the primary and secondary Kaiser Permanente coverage .

PREPARING FOR THE FUTURE On January 16, 2009, Health and Human Services announced the final rules for the 5010 Transactions sets for electronically submitted claims and the ICD-10 code sets . Kaiser Permanente has started testing 5010 transaction sets and the ICD-10 codes on schedule . We will be testing with our national clearinghouses throughout 2011 .

We are on track for full compliance by December 31, 2011 .

TO SET UP ELECTRONIC CLAIMS SUBMISSION (837 TRANSACTIONS): Contact your EDI clearinghouse to submit claims to Kaiser Permanente of Ohio through one of our contracted clearinghouses using the appropriate Payer ID . There’s no need for you to contact Kaiser Permanente to begin submitting your claims via EDI . We’re ready to accept electronic claims whenever you submit them .

Claims Corner (continued from page 8)

NATIONAL CLEARINGHOUSES

PAYER ID FOR KAISER PERMANENTE OF OHIO

TRANSACTIONS CONTACT

QuadaxContact clearinghouse directly

Professional claims (837P),Institutional claims (837I),Remittance Advices (835)

Quadax .com

RelayHealth RH007

Professional claims (837P),Institutional claims (837I),Remittance advices (835),Eligibility & benefits inquiry (270)

RelayHealth .com

Ingenix NG007Professional claims (837P),Remittance advices (835)

Ingenix .com

Emdeon 34092Professional claims (837P),Institutional claims (837I),Remittance Advices (835)

Emdeon .com

Capario KS005 Professional claims (837P) Capario .com

Availity n/a

Professional claims (837P),Institutional claims (837I),Remittance advices (835),Eligibility & benefits inquiry (270)Claims status inquiry (276)

Availity .com

Through the Availity Web portal you can submit claims, receive remittance advice, and inquire as to member eligibility and claims status .

For more information, please contact the Kaiser Network Development Department at 1-800-441-9742, option 4 .

QUESTIONS…If you have any questions, please contact Network Development at 1-800-441-9742 option 4, or refer to the “Claims” section on the Community Provider website at providers.kp.org/oh .

If you have questions about setting-up remittance advices or EFT with Kaiser Permanente of Ohio, please e-mail the EDI Coordinator at OH-EDI-Coordinator@kp.org .

10

PROVIDER CONNECTION+

2011 PLAN CHANGES

Effective January 1, 2011 for all Added Choice Point-of-Service (POS) members:

The Tier 1 pharmacy network was narrowed to 10 Kaiser Permanente’s pharmacies and 8 contracted retail pharmacies (includes two MetroHealth pharmacies) . This

change does not affect HMO members. POS members

are still be able to use the same pharmacies as before, but

are responsible for their Tier 2 copay at pharmacies that

are no longer part of Tier 1 . For more information, please

see the “Pharmacy” section of providers.kp.org/oh .

The New Year brings in plan changes for many of our members . Sometimes the member’s employer makes changes, and in some cases we make changes to our plans for business reasons .

In 2010 we began implementing changes to our Added Choice® Point-of-Service (POS) plans in order to make our pharmacy cost trend more sustainable for our organization, our members, and our employer group customers .

For2011wecontinuedtoadjustthePOSplansaswellasourOut-of-Area(OOA)PPOplans(plansfor employer groups within our service area that have employees who live outside the service area) . Here is a brief overview of the changes:

(continued on page 11)

Starting January 1, 2011 as Point-of-Service (POS) and Out-of-Area (OOA) PPO groups renew:

• KaiserPermanente’sformularywillapplywhenmemberspurchase drugs at MedImpact pharmacies .

- The drugs listed on the HMO, POS, and OOA formularies are identical . The Medicare formulary will continue to be a separate list .

- POS members do not use the formulary exception process that HMO members use; they can simply purchase the nonformulary drug using their nonformulary coverage .

• Dispenseaswritten(DAW)editswillbeimplemented.

- If the member or physician requests a brand drug and a generic equivalent exists, the member will pay the brand copay plus the difference between the cost of the brand drug and the generic drug .

What does all this mean?In summary, for all Kaiser Permanente members with any kind of plan, you can help them save money by:

•Prescribinggenerics

•Prescribingmedicationsontheformulary

•EncouraginguseofKaiserPermanentepharmacies

•Encouraging use of the Kaiser Permanente DirectMail Pharmacy

Thank you for all that you do to provide great care for our members .

Lower member prices on certain generic drugs in 2011 Please note that Kaiser Permanente pharmacies are again offering lower prices on certain generic drugs in 2011 . The new reduced prices are a dollar lower than the reduced prices of 2010 . The generic medications included treat chronic conditions such as asthma, hypertension, high cholesterol, diabetes, and depression .

The price reductions are in response to an increasing number of national retailers, such as Walmart and Target, lowering the cost of generic prescriptions . The

following reduced member rates are valid January 1 through December 31, 2011:

• $8for30-daysupply• $10for60-daysupply• $12for90-daysupply

As always, when members refill a prescription at a Kaiser Permanente pharmacy, they’ll pay the lowest price available, whether it’s their standard copayment or the new generic price . For more information about the program, please see the “Pharmacy” section of providers.kp.org/oh or call our Pharmacy Service Center at 216-524-5003 .

Mail-Order Pharmacy Use Could Improve Patients’ Medication Adherence

Researchers from the University of California, Los Angeles and Kaiser Permanente’s Division of Research in Oakland, California found that patients with diabetes, high blood pressure, or high cholesterol who ordered their medications by mail were more likely to take them as prescribed by their doctors than did patients who obtained them from a local pharmacy . The study, “Mail-Order Pharmacy Use and Adherence to Diabetes-Related Medications,” is published online in the American Journal of Managed Care (www.ajmc.com) .

Using mail order can also save patients time and money . Depending on the member’s direct mail prescription drug benefit, a two-month supply of maintenance medications may be purchased for one copayment (some benefit plans offer up to a three-month supply for one or two copayments) . There’s no need to drive to a pharmacy or wait in line, and shipping is free .

When possible, please encourage your Kaiser Permanente patients to use Kaiser Permanente’s Direct Mail Pharmacy . Please be sure to write the prescription for a 90-day supply, preferably with refills . For more information about the program, please see the “Pharmacy” section of providers .kp .org/oh or call our provider line for the Direct Mail Pharmacy at 216-749-8409.

11

ISSUE 1 | 2011

2011 plan changes (continued from page 10)

PROVIDER CONNECTION+

Important Provider Line Update

Clinical Practice Guidelines

Members Rights and Responsibilities

In this issue:

and more...

Patricia D. Kennedy-ScottRegional President, Kaiser Foundation Health Plan of Ohio

Ronald Copeland, MD President & Medical Director, OPMG

Carolyn HightowerVice President, Health Plan Administration and Strategy

Vanessa RogalDirector, Network Development & Performance

Karen SuhyNetwork Manager

Kim McKenzieEditor

Kaiser PermanenteNetwork Development Department1001 Lakeside Ave ., Suite 1200Cleveland, Ohio 44114

Published by the Network Development & Performance Department at Kaiser Permanente . Please contact our Network Development and Performance Department at 1-800-441-9742 or fax us at 216-479-5550 with comments, questions or suggestions for future issues .

Provider Connection

NONPROFIT ORGUS POSTAGE PAIDCLEVELAND OH

PERMIT NO. 3116