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Class I drug recalls

Accessibility of Utilization Managment Operations

Affirmation statement about incentives

Access to specialty care at your finger tips

New technology

Medical coverage policies

Zolpidem-containing products recommendations

1500 Health insurance claim form

Medical record documentation standards

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networknews

FOR PRACTITIONERS & PROVIDERS OF KAISER PERMANENTE

Produced by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., with the Mid-Atlantic Permanente Medical Group, P.C. Website: providers.kaiserpermanente.org/mas

MARCH 2013

110 Mid-Atlantic Permanente Medical Group Physicians Named Super Doctors®

Kaiser Permanente announced last year that 110 Mid-Atlantic Permanente Medical Group physicians were recognized as Super Doctors® featured in the Washington Post Magazine October 28, 2012 issue.

The annual Super Doctors list, compiled by a peer-group of leading physicians, honors top physicians in dozens of medical specialties from allergy to urology.“Having 110 of our physicians recognized by Super Doctors is a testament to the fact that Mid-Atlantic Permanente Medical Group physicians are experts in their fields of practice and provide outstanding patient care,” said Bernadette Loftus, MD, The Permanente Medical Group’s associate executive director for the Mid-Atlantic States. “It’s an honor for the individual physicians, for the Mid-Atlantic

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Permanente Medical Group and for all of Kaiser Permanente to have so many of our physicians recognized by both their peers as well as the Super Doctors blue ribbon panel.”

“Our Medical Group partners consistently provide superior quality care that ranks us number one in Virginia, Maryland and Washington, D.C.,” said Kim Horn, president, Kaiser Permanente of the Mid-Atlantic States. “The physicians recognized by Super Doctors add to the growing list of local and national accolades our care providers have earned.”

Among the 42 medical specialties reported in Super Doctors’ 2012 list, the 110 Mid-Atlantic Permanente Medical Group physicians honored represent a broad range of specialties including allergy, cardiology, oncology, internal medicine, Ob/Gyn, pediatrics and more.

Here is a complete listing of the Mid-Atlantic Permanente Medical Group physicians recognized by Super Doctors as printed in the Oct. 28, 2012 issue of the Washington Post Magazine:

Allergy • Chang, Betty, Gaithersburg • McNally, Patricia A., Springfield

Cardiology • Biegelsen, Elizabeth S., Largo • Esposito, Aldo, Penderbrook • Golden, John S., Penderbrook • Liu, Yaning L., Penderbrook • Ngwu, Ogundu, Silver Spring• Rashkin, Jason, Penderbrook

Endocrinology • Christie, Catherine M., Springfield • Lee, Taisheng, Falls Church • Movius, Edward G., Gaithersburg

Family Medicine • Cosgrove, Lauren E., Shady Grove • Mackie, Lora E., Ashburn • Page, David E., Woodbridge • Smith, David A., Manassas

Gastroenterology • Butterfield, Betty J., Falls Church • Chowla, Navreet M., Springfield • Winston, Bradley J., Springfield

Hematology • Dogra, Shalini, Fair Oaks • Pandellapalli, Poornima U., Fair Oaks

Infectious Disease • Cameron, Miriam L., Gaithersburg • Doan, Nhat M., Springfield • Bersoff-Matcha, Susan J., Washington • Levy, Charles S., Capitol Hill • Rosenthal, Jonathan H., Springfield • Yoho, David S., Springfield

Internal Medicine • Anderson, Sheila Y., Washington Hospital Center • Boakye, Anthony, Annapolis • Boldt, Leigh, Falls Church • Chen, Vincent C., Springfield • Cooper, Bruce S., Capitol Hill • Corinaldi, Greg A., Springfield • Kin, Jeffrey D., Virginia Hospital Center • Lee, Donna, Falls Church • Malik, Nidhi K., Reston • Nguyen, Hoang-An, Ashburn • Nguyen, Lo-an, Reston • Pak, Seonae, Reston • Rao, Somashekar N., Fair Oaks • Rogart, Rochelle L., Falls Church • Shen, Brian C., Gaithersburg • Tesoriero, Thomas A., Capitol Hill • Van Zoeren, Douglas, Capitol Hill • Weinstein-Mayer, Sherry J., City Plaza

Maternal/Fetal Medicine • Amini, Dennis, Gaithersburg • Lewis, II, Paul E., Kensington

Nephrology • Daquioag, Eleanor, Silver Spring • Mayuga, Ronaldo, Burke

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Neurology • Glor, Daniel, Capitol Hill • Lipps, David C., Penderbrook • McCarthy, Richard, Capitol Hill • Scherokman, Barbara J., Penderbrook • Shamim, Ejaz A., Marlow Heights

Obstetrics/Gynecology • Cooper, Jr., William A., Marlow Heights • Sabi, Farzaneh L., Gaithersburg • Saltzman, Andrew K., Largo • Thompson, Glynn M., Gaithersburg • Tretiak, Mark, Falls Church

Oncology • Ahuja, Neeta, Fair Oaks • Hwang, Leon C., Gaithersburg • So, Matilda, Largo

Ophthalmology • Carlson, Mary Susan D., Falls Church • Keys, Cheryl L., Falls Church • Savage, Howard I., Largo

Otolaryngology • Cheung, Deborah D., Kensington • Morton, Anthony L., Kensington • Patel, Alpen, Towson • Sklarew, Eric C., Kensington • Terris, Mark H., Largo

Pediatrics • Biernoff, Elizabeth T., Capitol Hill • Hellerstein, Ann, Gaithersburg • Koroulakis, Panayiota, Kensington • Moriarty, Susan K., Columbia Gateway • Samuels-Botts, Carol, Largo • Schwartz, Martina, City Plaza • Tamayo, Angela M., Columbia Gateway • Thibodeaux, Brent, Reston • Vander-Walde, Joseph A., Camp Springs

Psychiatry • Price, Susan L., Burke • Sitts, Timothy M., Burke

Pulmonary Medicine • Mayo-Olano, Sheila, Largo • Meller-Azrieli, Fiona F., Woodlawn • Nguyen, Phong, Penderbrook • Tseng, Chun-Ming, Gaithersburg

Radiology • Giacometti, Andrea, Kensington • Long, John A., Kensington

Rheumatology • Coe, Marcia D., Silver Spring • Dalvi, Vrishali, Silver Spring • Fisher, Margaret E., Springfield • Lim, Ivan Y., Capitol Hill • Mehta, Mala B., Penderbrook

Surgery • Sone, Julia H., Colon & Rectal, Springfield • Cardinal, Linda, General, Falls Church • Krolik, Sonya L., General, Largo • Mangalmurti, Chaitanya S., General, Fair Oaks • Cates, Maurice D., Orthopaedic, Rockville • Charles, Lysa M., Orthopaedic, Columbia

Gateway • Chetta, Sidney, Orthopaedic, Falls Church • Hirschhorn, Jessica B., Orthopaedic, Springfield • Horton, Rinelda M., Orthopaedic, Gaithersburg • Jackson, Kenneth W., Orthopaedic, Fair Oaks • Kaplan, Saul J., Orthopaedic, Springfield • Krisztinicz, Thomas I., Orthopaedic, Penderbrook • Krishnan, Shyam, Vascular, Holy Cross Hospital –

POB • Lustgarten, Jacob J., Vascular, Holy Cross

Hospital – POB

Urology • Brems, William K., Kensington • Guarnacci, Steven P., Penderbrook • Katz, Stuart E., Falls Church • Michell, Antonio, Falls Church • Tier, James J., Falls Church

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The Kaiser Permanente Mid-Atlantic States Region’s Pharmacy department supports consistent, reliable and thorough responses to drug recalls to ensure that potentially affected members and prescribing practitioners receive timely notification to prevent adverse drug events.

Provider memos with information on Class I drug recalls and drug market withdrawals for safety

reasons are available on the Pharmacy tab of the Community Provider Portal website providers.kaiserpermanente.org/mas/index.html.

In 4Q2012, several Class I recalls were announced. All potentially affected KPMAS members and providers were contacted.

Class I drug recalls affecting Kaiser Permanente Mid-Atlantic States members

Medication recalled Manufacturer Date of recall Reason for recall

Leucovorin calcium 50 mg/500 mL single dose vials

Bedford Laboratories

October 2012 Discovery of visible crystalline particles (active drug) in some vials.

Pradaxa (dabigatran) 75 mg capsules

Boehringer Ingelheim Pharmaceuticals

November 2012

Due to a potential packaging defect of one lot of medication which may compromise bottle integrity. Dabigatran capsules are hygroscopic and must be dispensed in the manufacturer’s original container to protect it from moisture.

Isovue Iodinated Contrast

Bracco Diagnostics November 2012

Presence of visible particles in syringes observed at the end of standard stability studies on retained samples.

Hydrocodone/acetaminophen10 mg/500 mg tablets

Qualitest and Watson Pharmaceuticals

December 2012

Possibility that some tablets may exceed the weight specification and could be super potent for the ingredients hydrocodone and acetaminophen. An unclassified recall was announced for these products in September 2012.

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Accessibility of Utilization Managment OperationsAccessibility is important to our Members and providers. The Kaiser Permanente Utilization Management Department ensures that all Members and providers have access to UM staff, physicians and managers. Table below describes the access and hours of operations for UM services.

UM Department Section Hours of operation Core responsibilities

Utilization Management Operations Center (UMOC), Emergency Care Management

24 hours/day, 7 days/ week, including holidays

• Process transfer requests for Members who need to be moved to a different level of care including emergency rooms, inpatient facilities, and Kaiser Permanente Medical office Buildings

• Enter referrals for all in-patient admissions and Emergency Department notifications received from facilities

• Assist with Repatriations from Hospital to Hospital

• Support all cardiac transfers for level of care needed.

Utilization Management Operations Center: Outpatient, Specialty Referrals and Clinical Research Trials

Monday through Friday, 8 a.m. to 5 p.m.; weekends and holidays, 11 a.m. to 1 p.m., for urgent and emergent referrals only

• Conduct pre-service review of outpatient or inpatient services to include clinical trials

• Weekends and holidays pre-service review of urgent/emergent referrals except clinical research trials

Utilization Management Operations Center: Durable Medical Equipment (DME), Home Care, Rehabilitative Therapy: Physical Therapy, Occupational Therapy and Speech Therapy

Monday through Friday, 8:30 a.m. to 5 p.m.; weekends and holidays: 11 a.m. to 1 p.m., for urgent referrals.

• Conduct pre-service and concurrent review of Home Care, Durable Medical Equipment, Physical Therapy, Occupational Therapy and Speech Therapy, and post-service review

Patient Care Coordinators Non Behavioral Health located at the following affiliated hospitals: • Holy Cross Hospital• Washington Hospital Center• Children’s National Medical Center• Fairfax INOVA Hospital• Virginia Hospital Center• Greater Baltimore Medical Center• St. Agnes Hospital• Suburban Hospital

Monday to Friday, weekends and holidays, 8 a.m. to 4:30 p.m.

• Conduct concurrent review and transition care management

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UM Department Section Hours of operation Core responsibilities

Skilled Nursing Facility (SNF) and Rehabilitation Services

Monday through Friday, 8 a.m. to 4:30 p.m., excluding major holidays

• Conduct concurrent review and transition care management for members in the acute rehab and SNF settings

UM Hospital Services – Behavioral Health located at the following affiliated hospitals:• Virginia Hospital Center• Shady Grove Adventist Hospital• Holy Cross Hospital• Greater Baltimore Medical Center

Monday to Friday, 8 a.m. to 4:30 p.m., excluding major holidays

• Conduct concurrent review and transition care management services of behavioral health service

UM Outpatient Services – Behavioral Health

Monday to Friday, 8:30 a.m. to 5 p.m., excluding major holidays

• Conduct Pre-service and concurrent review of behavioral outpatient services

CareConnect/ Complex Case Management Renal Case Management

Monday through Friday, 8:30 a.m. to 5 p.m., excluding major holidays

• Conduct outpatient medical case management and care coordination for medically complex members and End Stage Renal Disease Members

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KPMAS annually distributes a statement to all members and to all practitioners, providers and employees who make UM decisions, affirming the following: (1) UM decision making is based only on appropriateness of care and service and existence of coverage; (2) KPMAS does not specifically reward practitioners or other individuals for issuing denials of coverage or care; and (3) Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

KPMAS Affirmative Statement distributed to practitioners, providers, staff and members encourages appropriate utilization and discourages underutilization; clearly indicates that it does not use incentives to encourage barriers to care and service; and reminds members, practitioners, providers and employees that KPMAS is prohibited from making decisions regarding hiring, promoting or terminating its practitioners or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits.

Utilization Management Affirmation Statement

Kaiser Permanente practitioners and health care professionals make decisions about which care and services are provided based on the member’s clinical needs, the appropriateness of care and service, and health plan coverage. Kaiser Permanente does not make decisions regarding hiring, promoting, or terminating its practitioners or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits. The health plan does not specifically reward, hire, promote, or terminate practitioners or other individuals for issuing denials of coverage or care. No financial incentives exist that encourage decisions that specifically result in denials or create barriers to care and services. In order to maintain and improve the health of our members, all practitioners and health professionals should be especially diligent in identifying any potential underutilization of care or service. 01/2013

Affirmation statement about incentives

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Kaiser Foundation Health Plans of the Mid-Atlantic States is proud to provide our Network partners an easy way to access all of Kaiser Permanente’s specialties and an easy way to make a specialty referral.

Kaiser Permanente’s eConsult Line The new number is 301-879-6238The Hours of operation for this line are, Monday – Friday (excluding holidays) 8 a.m. - 5 p.m.The Benefits of the eConsult line to you are:• eConsult is a referral system that enables you to

speak to a Kaiser Referral Authorization Nurse directly and find out which Kaiser specialists you may refer your patient to and when the next available appointment is

• In addition to helping improve our processes for making referrals to specialists,eConsult allows physicians to use telephonic and electronic communication for patient questions that don’t

require a face to face visit. It enables direct booking of referrals, with fewer mouse clicks

• eConsult offers you and your patients, access to Kaiser Permanente’s top physicians and one of the Nation’s best health plans. Consumer Report ranks Kaiser Permanente as having the highest member satisfaction among commercial plans in the Maryland, Virginia and Washington, DC Region and our physicians rank among some of the best. * In Maryland: Kaiser Permanente is ranked the

Best Managed Care Organization by the State of Maryland Health Commission.

* In Virginia: Northern Virginia Magazine listed 90 Kaiser Permanente Doctors in its Best Doctor’s List.

* In Washington, DC: 2012 Washingtonian Magazine: Listed 53 Kaiser Permanente Doctors in its Top Doctor’s List.

Access to specialty care at your finger tips

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By Gregory Alexander, M.D., F.A.A.F.P., Physician Director, Referrals and Medical Policies

The Kaiser Interregional New Technologies Committee (INTC) met and reviewed three new and emerging technologies that are pertinent to the KPMAS delivery system. The following is a brief synopsis that summarizes NEW TECHNOLOGY: Summary of New Technology conclusions regarding the reviews.

Bone morphogenetic protein for spinal fusionINTC brief synopsis:The committee deferred the recommendation on the use of BMP for spinal fusion for further analysis of the KP registry data, results of the Yale University Open Data Access Project, and additional clinical input.

KPMAS coverage position: Evidence at this time is not sufficient to establish a formal evidence based coverage policy.

Intra-articular hyaluronic acid injections (Viscosupplementation) for osteoarthritis of the kneeINTC brief synopsis:There is sufficient evidence that a single course of intra-articular hyaluronic acid injection is not more effective than conventional therapy, including NSAIDS, nonprescription analgesics, exercise, physical therapy and injectable corticosteroids, in improving pain and function.

There is insufficient evidence to determine whether or not repeated treatment using intra-articular hyaluronic acid injections is a medically appropriate treatment option. In addition, evidence

to determine the relative safety and effectiveness of any one HA product versus another is insufficient.

KPMAS coverage position:

Current evidence does not support use of Intra-Articular Hyaluronic Acid (Viscosupplementation) as a treatment of Osteoarthritis of the Knee as it is not superior to conventional therapy.

Repeated treatment of Osteoarthritis of the Knee with Intra-Articular Hyaluronic Acid Injection is considered investigational and experimental and not a covered benefit.

Platelet Rich Plasma for tendinopathy and other indicationsINTC brief synopsis:There is insufficient evidence to determine whether platelet-rich plasma is medically appropriate as a nonsurgical or surgical orthopedic treatment for any patient. The existing evidence is of insufficient quantity and quality.

KPMAS coverage position: Platelet Rich Plasma for Tendinopathy and Other Indications is considered investigational and experimental and therefore is not customarily a covered benefit. Exceptions to non coverage may be considered.

If you would like to receive a hard copy of the Interregional New Technologies Committee (INTC) Summary of Emerging Medical and Surgical Treatment (New Technology) Report, please contact Dr. Gregory Alexander or Dr. Claudia Donovan via the Kaiser Permanente Paging Operator at 1-888-989-1144.

New technology

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The following medical coverage policies have been updated with changes noted below:

Morbid obesity/bariatric surgery ( DC,Fed, Va)Patient must be nicotine free to start the program. Patient must have a BMI > 40 for 2 years or a BMI of 35-39 for 2 years with a qualifying co-morbidity. Patient needs to undergo a 6 month nutrition program and counseling. Revisions of prior surgical weight loss procedures are reviewed on a case by case basis.

InfertilityThe definition of infertility now includes women plan-ning on using donor sperm, women with known tubal disease, and couples with known male-factor infertili-ty as well as couples who are unable to conceive after a specified time period.. All patients will require the workup as listed (estradiol, LH, FSH, TSH, prolactin) and a HSG. Benefits for advanced reproductive thera-pies have not changed. ICSI (intra-cytoplasmic sperm injection) is now covered under certain conditions if the patient has a benefit for advanced reproductive technologies, eg In Vitro Fertilization.

Spinal cord stimulatorsIndicated for chronic neuropathic pain of the lumbar spine, complex regional pain syndrome and angina after greater than six months of conventional multi-disciplinary medical and surgical pain management treatments.

Ambulance transportationAmbulance transport (ground and air) are covered when patient requires BLS, ACLS, or critical care

support. Ambulettes are available in the area for coordination of care. An example of covered transport would be: discharges from the hospital headed for SNF, for members who are unable to control their upper body/torso.

Breast MRIMedical Coverage Policy was retired. If you have any comments or questions on these updates, please contact:

Claudia K. Donovan, M.D.Physician Manager, Referral ManagementMid-Atlantic Permanente Group11921-B Bournefield WaySilver Spring, MD 20904KP paging line: (703) 359-7460Claudia.K.Donovan@kp.org

If you would like to receive a hard copy of the Medical Coverage Policy, UM criteria or protocol, please contact the Utilization Management Operations Center at 1-800-810-4766 and follow the prompts.

Kaiser Permanente Physician Reviewers are available during business hours 8:00 am to 5:00 p.m., Monday to Friday except holidays to speak with practitioners to discuss pre-service or concurrent medical necessity (adverse) decisions. Please call the Utilization Management Operations Center (UMOC) at 1-800-810-4766 and select the appropriate prompt # or contact the Kaiser Permanente Page Operator at 1-888-989-1144.

Medical coverage policies

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Please use the sample letter format below to update us with any changes you may have through out the year. It is very important that we have the most accurate information when we pull our data for the directory.

Changes may be made by fax to: 301-388-1700 or by mail:

Kaiser Foundation Health Plan of The Mid-Atlantic States, Inc.Provider Contracting & Network ManagementFlr 2 East2101 East Jefferson St.Rockville, MD 20852

If you would like to request a provider directory please contact Member Services at:• For Maryland (301) 468-6000• All other areas outside of Maryland

1-877-777-7902

Keeping the provider directory up to date

<<DATE>>

Tax identification #:Requestor phone #:Effective date of change(s):Requestor:

Reason for the request:

•Addresschange(practicelocationorbilling) *identify whether adding or deleting demographic change •Addingaproviderorpractitionertoanexistinggroupcontract *identify whether adding or deleting provider

If adding or deleting a provider please include:

• First and last name• Sex• Title or degree• NPI number• CAQH number• UPIN or social security number• Primary specialty with secondary specialty if applicable• Practice locations w/ phone and fax numbers• Foreign languages• If urgent care/ will the provider have a panel of Kaiser Permanente patients.

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The FDA now recommends lower doses for zolpidem-containing products based on new information indicating that blood levels in some patients may be high enough the morning after administration to impair activities that require alertness, including driving. Zolpidem is a sedative-hypnotic used in adults for the treatment of insomnia. It is marketed as a generic under various brand-names (i.e., Ambien, Ambien CR, Edluar, Zolpimist, and Intermezzo). Drowsiness is already listed as a common side effect in the drug labels of all insomnia drugs, along with a warning that patients may still feel drowsy the day after taking these products. Patients who take insomnia drugs can experience impairment of mental alertness the morning after use, even if they feel fully awake.

For zolpidem products, data show the risk for next-morning impairment is highest for patients taking the extended-release forms of these drugs (Ambien CR and generics). Women appear to be more susceptible to this risk because they eliminate zolpidem from their bodies more slowly than men.

Data summary:Driving simulation and laboratory studies indicate that zolpidem blood levels greater than approximately 50 ng/mL appear capable of impairing driving to a degree that increases the risk of a motor vehicle accident.

In pharmacokinetic trials of 10 mg immediate release zolpidem, about 15% of women and 3% of men had zolpidem concentrations that exceeded 50 ng/mL approximately 8 hours after the oral dose. After use of 12.5 mg extended-release zolpidem, approximately 33% of women and 25% of men had zolpidem blood concentrations exceeding 50 ng/mL approximately 8 hours after the oral dose. About 5% of patients had blood levels ≥100 ng/mL. After use of 6.25 mgextended-release zolpidem at 8 hours after dosing, about 15% of adult women and 5% of adult men had a zolpidem level of ≥50 ng/mL, whereas for both elderly men and women, about 10% had a similar zolpidem level.

The FDA-recommended changes to zolpidem doses are listed in the table on the next page:

FDA recommends lower doses for zolpidem-containing products

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In general, patients should be prescribed the lowest dose of medication that treats their symptoms. TheFDA hopes that these dose changes will result in lower blood levels the morning after administration and reduce likelihood of impairing activities that require alertness, including driving. The FDA will continue to evaluate the risk of next-morning impairment with other insomnia drugs.

Health care professionals should caution all patients (men and women) who use zolpidem-containing medications about the risks of next-morning impairment for activities that require complete mental alertness, including driving. Inform patients

that impairment from sleep drugs can be present despite feeling fully awake.

Additional information can be found at the following links below:• Drug Safety Communication: www.fda.gov/

Drugs/DrugSafety/ucm334033.htm• Questions and Answers: www.fda.gov/Drugs/

DrugSafety/ucm334041.htm• Consumer Update: www.fda.gov/ForConsumers/

ConsumerUpdates/ucm322743.htm• News Release: www.fda.gov/NewsEvents/

Newsroom/PressAnnouncements/ucm334798.htm

Zolpidem productFDA changes

recommended for women

FDA changes recommended for men Comments

Immediate-release zolpidem products (i.e.,Ambien)

The initial dose for women should be lowered from 10 mg to 5 mg, immediately before bedtime.

Health care professionals should consider prescribing a lower dose of 5 mg for men; In many men, the 5 mg dose provides sufficient efficacy.

For both men and women, the 5 mg dose could be increased to 10 mg if needed; The higher dose is more likely to impair next-morning driving and other activities that require full alertness.

Extended-release zolpidem products (i.e., Ambien CR):

The initial dose for women should be lowered from 12.5 mg to 6.25 mg, immediately before bedtime.

Health care professionals should consider prescribing a lower dose of 6.25 mg in men; In many men, the 6.25 mg dose provides sufficient efficacy.

For both men and women, the 6.25 mg dose can be increased to 12.5 mg if needed; The higher dose is more likely to impair next-morning driving and other activities that require full alertness.

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1500 Health insurance claim formReference Instruction manual – Version 8.0 7/12 change logThe following is a list of changes that have been made to the 8.0 7/12 version of the 1500 Instruction Manual since its release in July 2012. If you would like more information please log on to our website or follow this link: providers.kaiserpermanente.org/html/cpp_mas/claimstoc.html?

No. Location Change1 Item Number 5

Instructions 1st paragraph• Deleted “and telephone number” in the first sentence.• Deleted “and phone number” in the second sentence.

2 Item Number 5 Instructions 5th paragraph

• Added the following as the third sentence. • Phone extensions are not supported.

3 Item Number 7 Instructions 1st paragraph

• Deleted “and telephone number” in the first sentence.• Deleted “and phone number” in the third sentence.

4 Item Number 7 Instructions 4th paragraph

• Added the following as the third sentence. • Phone extensions are not supported.

5 Item Number 17 Instructions 1st paragraph

• Changed the first sentence to read: Enter the name (First name, Middle initial, Last name) followed by the credentials of the professional who referred or ordered the service(s) or supply(ies) on the claim.

6 Item Number 17 Instructions 3rd paragraph

• Changed the first sentence to read: Do not use periods or commas.

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No. Location Change7 Instructions and Examples

of Supplemental Information in Item Number 24 Page 46

• Added the following to Vendor Product Number – Health Industry Business Communications Council (HIBCC): (5010A1: Reporting Vendor Product Number does not exist in 5010A1. The NUCC recommends that this not be reported.)

8 Instructions and Examples of Supplemental Information in Item Number 24 Page 46

• Added the following to Product Number Health Care Uniform Code Council – Global Trade Item Number (GTIN): (5010A1: Reporting Product Number does not exist in 5010A1. The NUCC recommends that this not be reported.)

9 Instructions and Examples of Supplemental Information in Item Number 24 Page 46

• Add the following to the qualifier VP: (5010A1: Reporting Vendor Product Number does not exist in 5010A1. The NUCC recommends that this not be reported.)

10 Instructions and Examples of Supplemental Information in Item Number 24 Page 46

• Add the following to the qualifier OZ: (5010A1: Reporting Product Number does not exist in 5010A1. The NUCC recommends that this not be reported.)

11 Instructions and Examples of Supplemental Information in Item Number 24 Page 47

• Under the heading “Additional Information for NDC Reporting”, added the following as the fourth paragraph: When reporting compound drugs, a statement of ingredients may be required to be attached to the claim.

12 Instructions and Examples of Supplemental Information in Item Number 24 Page 48-49

• Deleted examples for Vendor Product Number (1) and Product Number (2).

13 Appendix A Rendering Provider Definition

• Changed the Rendering Provider definition to read: Rendering Provider 5010 837P The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider’s information here. Future versions of 837P The Rendering Provider is the individual who provided the care. In the case where a substitute provider (locum tenens) was used, that individual is considered the Rendering Provider. The Rendering Provider does not include individuals performing services in support roles, such as lab technicians or radiology technicians.

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Kaiser Permanente is committed to providing you and your family with quality health care services. In a spirit of partnership with you, here are the rights and responsibilities we share in the delivery of your health care services.

MEMBER RIGHTS As a member of Kaiser Permanente, you have the right to:1. Receive information that empowers you to be

involved in health care decision making. This includes your right to:a. Actively participate in discussions and

decisions regarding your health care options.b. Receive and be helped to understand

information related to the nature of your health status or condition, including all appropriate treatment and non-treatment options for your condition and the risks involved - no matter what the cost is or what your benefits are.

c. Receive relevant information and education that helps promote your safety in the course of treatment.

d. Receive information about the outcomes of health care you have received, including unanticipated outcomes. When appropriate, family members or others you have designated will receive such information.

e. Refuse treatment, providing you accept the responsibility and consequences of your decision.

f. Give someone you trust the legal authority to make decisions for you if you ever become unable to make decisions for yourself by completing and giving us an Advance Directive, a durable power of attorney for health, living will, or other health care treatment directive. You can rescind or modify these documents at any time.

g. Receive information about research projects that may affect your health care or treatment. You have the right to choose to participate in research projects.

h. Receive access to your medical records and any information that pertains to you, except as prohibited by law. This includes the right to ask us to make additions or corrections to your medical record. We will review your request based on applicable state and federal law to determine if the requested additions are appropriate. If we approve your request, we will make the correction or addition to your protected health information. If we deny your request, we will tell you why and explain your right to file a written statement of disagreement. You or your authorized representative will be asked to provide written permission before your records are released, unless otherwise permitted by law.

Member rights and responsibilities: our commitment to each other

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2. Receive information about Kaiser Permanente and your plan. This includes your right to:a. Receive the information you need to choose or

change your Primary Care Physician, including the name, professional level, and credentials of the doctors assisting or treating you.

b. Receive information about Kaiser Permanente, our services, our practitioners and providers, and the rights and responsibilities you have as a member. You also can make recommendations regarding Kaiser Permanente’s member rights and responsibility policies.

c. Receive information about financial arrangements with physicians that could affect the use of services you might need.

d. Receive emergency services when you, as a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed.

e. Receive covered urgently needed services when traveling outside Kaiser Permanente’s service area.

f. Receive information about what services are covered and what you will have to pay and to examine an explanation of any bills for services that are not covered.

g. File a complaint, grievance or appeal about Kaiser Permanente or the care you received without fear of retribution or discrimination, expect problems to be fairly examined, and

receive an acknowledgement and a resolution in a timely manner.

3. Receive professional care and service. This includes your right to:a. See plan providers, get covered health care

services and get your prescriptions filled within a reasonable period of time and in an efficient, prompt, caring, and professional manner.

b. Have your medical care, medical records and protected health information handled confidentially and in a way that respects your privacy.

c. Be treated with respect and dignity. d. Request that a staff member be present as a

chaperone during medical appointments or tests.

e. Receive and exercise your rights and responsibilities without any discrimination based on age, gender, sexual orientation, race, ethnicity, religion, disability, medical condition, national origin, educational background, reading skills, ability to speak or read English, or economic or health status including any mental or physical disability you may have.

f. Request interpreter services in your primary language at no charge.

g. Receive health care in facilities that are environmentally safe and accessible to all.

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MEMBER RESPONSIBILITIESAs a member of Kaiser Permanente, you have the responsibility to:

1. Promote your own good health:a. Be active in your health care and engage in

healthy habits. b. Select a Primary Care Physician. You may

choose a doctor who practices in the specialty of Internal Medicine, Pediatrics, or Family Practice as your Primary Care Physician.

c. To the best of your ability, give accurate and complete information about your health history and health condition to your doctor or other health care professionals treating you.

d. Work with us to help you understand your health problems and develop mutually agreed upon treatment goals.

e. Talk with your doctor or health care professional if you have questions or do not understand or agree with any aspect of your medical treatment.

f. Do your best to improve your health by following the treatment plan and instructions your physician or health care professional recommends.

g. Schedule the health care appointments your physician or health care professional recommends.

h. Keep scheduled appointments or cancel appointments with as much notice as possible.

i. Inform us if you no longer live or work within the Plan service area.

2. Know and understand your plan and benefits:a. Read about your health care benefits

and become familiar with them. Detailed information about your plan, benefits and covered services is available in your Evidence of Coverage. Call us when you have questions or concerns.

b. Pay your plan premiums and bring payment with you when your visit requires a copayment, coinsurance or deductible.

c. Let us know if you have any questions, concerns, problems or suggestions.

d. Inform us if you have any other health insurance or prescription drug coverage.

e. Inform any network or nonparticipating provider from who you receive care that you are enrolled in our Plan.

3. Promote respect and safety for others: a. Extend the same courtesy and respect to

others that you expect when seeking health care services.

b. Assure a safe environment for other members, staff, and physicians by not threatening or harming others.

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Medical record documentation standards are based on and adopted from several risk management and quality improvement sources. Medical record documentation is required to report pertinent facts, findings, and observations about an individual’s physical or mental health history (including present illnesses and/or chronic conditions and past medical, surgical and social histories), examinations, tests, treatments, and outcomes.

The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. Payers have a contractual obligation to enrollees and may require reasonable documentation that services are consistent with coverage provided.

Validation may include the following information:• Location of service.• Medical necessity and appropriateness of

diagnostic and/or therapeutic services.• Services provided have been correctly

coded and reported based on supporting documentation in the medical record.

Kaiser Permanente of Mid-Atlantic States has adopted the following medical record documentation standards:

1. All entries are legible.2. All entries are authenticated by the author with

signature, credentials and date of entry.3. Medication allergies and adverse reactions are

prominently listed or noted as “none” or “NKA.”4. There is an immunization summary for patients

18 years and younger. 5. There is a problem list w/significant illnesses and

conditions listed in the medical record. 6. Chronic conditions and significant illnesses are

listed.

7. Past surgical history is documented or noted as “none” on the problem list or face sheet.

8. Family history is documented or noted as “none” on the problem list or face sheet.

9. For patients 14 years and older, there is documentation of the following in either the progress note or face sheet. a. Alcohol use or lack thereofb. Substance use or lack thereofc. Tobacco use or lack thereofd. Sexual behavior

10. There is a chief complaint documented for each encounter visit.

11. There is a history of present illness documented for each encounter visit.

12. There is an examination documented in the progress note relevant to the chief complaint.

13. There is a treatment plan documented for each encounter visit.

14. Follow-up instructions are documented in the encounter and include follow-up instructions and time frame for follow-up.

15. For laboratory orders written during the encounter, the results indicate signature and date of ordering provider’s review.

16. Radiology orders written during the encounter being reviewed, the results indicate signature and date of ordering provider’s review.

17. If a referral or order for services (procedure or diagnostic testing-internal or external) is requested during the encounter being reviewed, there is a written report or results from the consultant/provider in the record.

18. If a consultation is requested, there is a written summary report reflecting the practitioner review with date of review and signature.

19. Abbreviations used within the encounter are listed on the approved “Abbreviation List” located in the physician’s office.

Medical record documentation standards

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