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Payer playbook · CA

Kaiser Permanente

Kaiser Foundation Health Plan, Inc. (and Kaiser Foundation Health Plan of California, Inc. for the California region) · Kaiser Foundation Health Plan, Inc. · NAIC 94362

01

Where to send the appeal

Verified addresses and inbound channels. We refresh on every release.

Fax
+1-866-457-3303
Provider portal
https://providers.kaiserpermanente.org/info_assets/cpp_cod/cod_disputes_appeals.htmlaccepts appeals
Mailing address
Kaiser Permanente — Provider Disputes / Member Services Appeals National Claims Administration P.O. Box 7064 Pasadena, CA 91109-7064
02

Response timeline

The clocks that matter. Miss them and you escalate to the state insurance commissioner.

First-level response
45 days
Second-level response
30 days
Provider appeal window
365 days
State prompt-payment window
30 days
Expedited pathway
72 hours
03

Codes worth fighting

Based on outcome data across our payer corpus.

Known win codes
  • CO-97
  • CO-18
  • CO-4
  • CO-167
  • PR-2
Known difficult codes
  • CO-50
  • CO-29
  • CO-109
  • CO-204
04

Modifier behavior

The denials this payer applies on modifier-bearing claims. The rebuttal language is part of the Denial OS letter generator and not published here.

Modifier 59

Distinct Procedural Service

Kaiser's claims-processing engine for out-of-network emergency / urgent care claims (the primary appeal use case) applies CMS-aligned NCCI edits; modifier 59 denials usually signal documentation gaps rather than policy disputes.

Recommended rebuttal language is part of the Denial OS letter engine — start a free appeal to see it in context.

Modifier 25

Significant, Separately Identifiable E/M Service

Same-day E/M with procedure denials are infrequent in Kaiser appeals because most routine care is internal; when they occur on out-of-network ED claims, documentation requirements are above CPT baseline.

Recommended rebuttal language is part of the Denial OS letter engine — start a free appeal to see it in context.
05

Interest statute

The legal basis for charging interest when payment runs late.

California Health & Safety Code §1371.35 (Knox-Keene Health Care Service Plan Act — claim payment timelines for HMO products: 30 working days for clean claims, 15% per annum interest on late clean-claim payments) / California Insurance Code §10123.13 (PPO/indemnity prompt-pay)

Knox-Keene Act applies (CA HMOs regulated by DMHC).

You have the playbook. Now write the letter.

Paste your EOB and Denial OS generates the appeal in five minutes — citing the contracted rate, the modifier rebuttal, and the deadline statute that matches this exact payer.

Start your appeal