When a Claim Must Be Filed
If you are a member of an HMO you must submit a request for payment of benefits for all services you receive from a non-HMO provider. Typically, HMOs only cover services provided by HMO providers. You will need to file a claim for any services, such as services provided during a medical emergency, provided by a non-HMO provider.
You should refer to your Evidence of Coverage or contact your HMO for specific instructions about what information you must supply and when it must be supplied. The time requirements for submitting a request vary by HMO. If you do not provide the information within the required time period, benefits for that health service may be denied or reduced, at the HMO's discretion.
Kaiser EPO
EPO Providers are responsible for submitting claims for their services on your behalf, and claims will be paid directly by the Plan for the services rendered by Kaiser. If an EPO Provider bills you for a Covered Service (other than for Cost Sharing), please call Kaiser's customer service.
For services rendered by Non-EPO providers, where the provider agrees to submit a claim on your behalf, eligible claims payment to the provider will require a valid assignment of benefits. Even if the Non-EPO Provider agrees to bill on your behalf, you are responsible for making sure that the claim is received within 365 days of the date of service and that all information necessary to process the claim is received.
To receive reimbursement for Services you have paid for, you must complete and mail a claim form or (or write a letter) to the Claims Administrator at the address listed in the Legal and Administrative section, within 365 days after you receive services. The claim form (or letter) must explain the Services, the date you received them, where you received them, who provided them, and why you think the Plan should pay for them. Include a copy of the bill and any supporting documents. Your claim form (or letter) and the related documents constitute your claim.
For further information on filing claims, refer to your Kaiser EPO Summary Plan Description.
Time Frames for Responding to Claims
Each plan has specific procedures for addressing claims and appeals. The plan may also require you to respond within specific time frames. The time frames for responding to claims depends on whether the claim is urgent (requiring approval prior to receiving medical care where a delay of treatment could seriously jeopardize life or health) or when the claim is — post service (after the service has been provided), pre-service (before service has been provided) or concurrent care (for extending ongoing treatment previously approved for a specific time period or number of treatments).