Claims
Submitting claim forms for care depends on which provider you choose for receiving care. Below, get information about filing a claim after receiving Out-of-Network care and filing a claim for emergency care services.
When to submit claim forms?
In-Network
Get information below about when and how to file a claim
Kaiser Permanente
When you receive care from a Kaiser Permanente Provider, there are virtually no claim forms to complete
When to submit claim forms?
After visiting First Health Choice or First Health Network
When you receive care from First Health Choice or the First Health Network, you usually will not have to file a claim. Your provider will submit a claim to our claims department. First Health Choice and First Health Network providers are not allowed to bill you for any balances for covered services.
If your insurance 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.
For information on Pharmacy claims, please see the Pharmacy section.
Out-of-Network
Any other licensed provider or physician
When to submit claim forms?
After visiting an Out-of-Network Provider
When you receive Out-of-Network care, you will likely need to submit a claim for reimbursement. You are also responsible for paying amounts that are greater than the maximum allowable charge. You may be required to pay the full amount you are billed when you receive care. If so, you will need to submit a Member Reimbursement Form with an itemized bill for reimbursement.
If your insurance 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 up to 12 months from the date you received care, or as soon as reasonably possible.
What you’ll receive from Kaiser Permanente when you file:
Within 30 days of completing the claims processing, you will receive an Explanation of Benefits (EOB) that will detail what you need to pay and what the health insurance 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 for more information.
You’ll need specific information from your service provider.
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.
Access the Member Reimbursement Form
Claim Submission Address:
National Claims Administration Northwest
P.O. Box 370050
Denver, CO 80237-9998
EDI Payer ID: 93079
For information on Pharmacy claims, please see the Pharmacy section.
To find out more about claims:
- Call Customer Service at 1-866-616-0047 (TTY 711).