Claims

When to submit Claim forms

After visiting a PPO Provider:

• When you receive care from a PPO Provider with First Choice Health, First Health Network, or Cigna Healthcare^SM PPO Network¹ you usually will not have to file a claim. Your PPO Provider generally completes and submits claim forms. Your PPO Provider is not allowed to bill any balances for covered services.

After visiting a Non-participating Provider:

• When you receive care from a Non-participating Provider, you will likely need to submit a claim for reimbursement. You may be required to pay the full amount you are billed when you receive care. If so, you will need to submit a claim form with an itemized bill for reimbursement.
• When using a Non-participating Provider or facility, you will be responsible for the amount you are billed above the maximum allowable charge set out in your Evidence of Coverage (EOC) — this is referred to as balance billing. These charges billed directly by your Non-participating Provider do not apply to your deductible or out-of-pocket maximum.

If your plan has an annual deductible:

• Reimbursement is based on how much you have already paid toward your deductible and any remaining charges for which you are responsible, such as coinsurance.

Filing claims for emergency care services:

• If you receive emergency care services and need to submit claims for reimbursement, you must submit itemized bills for claims related to these services within 12 months, or as soon as reasonably possible.
• To submit a medical claim for reimbursement, complete this Member Reimbursement Form and mail to:

Kaiser Permanente National Claims Administration – Northwest
P.O. Box 370050
Denver, CO 80237-9998

What you’ll receive from Kaiser Permanente when you submit a claim:

• Within 30 days, you will receive an Explanation of Benefits (EOB) that will detail what you need to pay and what the health plan will pay. An EOB statement is not a bill from your medical insurance plan administrator. It is an informational statement to keep you informed of any claims processed under your insurance plan.

If you file a claim:

• You have up to 12 months from the date you received care to submit your claim.
• Kaiser Permanente will review the claim and decide what payment or reimbursement may be owed to you.
• Care must be medically necessary. Refer to your Evidence of Coverage (EOC) for more information.

What if my claim is denied?

• It is your right to file an appeal if you disagree with a decision not to pay for a claim. Read your Evidence of Coverage for more information.

Claim submission address:

Kaiser Permanente National Claims Administration – Northwest
P.O. Box 370050
Denver, CO 80237-9998

1. The Cigna Healthcare PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna Healthcare PPO for Shared Administration.
Cigna Healthcare is an independent company and not affiliated with Kaiser Foundation Health Plan, Inc., and its subsidiary health plans. Access to the Cigna Healthcare PPO Network is available through Cigna Healthcare’s contractual relationship with the Kaiser Permanente health plans. The Cigna Healthcare PPO Network is provided exclusively by or through operating subsidiaries of The Cigna Group, including Cigna Health and Life Insurance Company. The Cigna Healthcare name, logo, and other marks are owned by Cigna Healthcare Intellectual Property, Inc.