Before you submit a claim for reimbursement, review your coverage, or contact Member Services at 1-888-901-4636 (TTY 711), Monday through Friday, 8 a.m. to 5 p.m.
You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If your primary care provider determines that you need Medicare-required medical care that is not available within our network, your primary care provider will obtain plan authorization for you to see an out-of-network provider. Copay Primary & Specialty Care Visit copay 4. Urgent Urgent Care copay 5. Emergency Emergency Room visit copay 6. Group # Employer / Purchaser Group number 7. Effective Date Month, day and year the Member’s benefit period began. Generic/Brand Rx Pharmacy Copays. Indicates copays for Generic/Brand at either Kaiser. The emergency copay is waived if admitted to the hospital within 24 hours for the same condition or if admitted directly to the hospital as an inpatient. Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. Jefferson St., Rockville, MD ML1027 MAS 7/1/20-12/31/21.
Reimbursement requests must be received by Kaiser Permanente within 12 months from the date of service.
Pharmacy service claims
Medicare Part D prescriptions
Member reimbursement drug claim form (PDF)
Kaiser Emergency Contact
Mail the completed form to:
OptumRx
P.O. Box 650287
Dallas, TX 75265-0287
All other prescriptions: non-Medicare & Medicare without Part D
Prescription claim form (PDF)
Mail the completed form to:
OptumRx
P.O. Box 650334
Dallas, TX 75265-0334
For all pharmacy service claims
Include a brief description of the reason you are making this request for reimbursement and a dispensing list that includes:
- Member name and ID number
- Fill date
- Drug name and strength
- National Drug Code (NDC) number
- Quantity (number of pills) and supply (number of days)
- Prescription number
- Cost and amount paid
If you make frequent requests for pharmacy reimbursement, submit those on a quarterly basis or more frequently.
After we receive a claim, processing can take 4 to 6 weeks. Claims sent to the incorrect address or with missing required information may be returned without reimbursement. Claims processed at pharmacies not in the plan network, including some federal facilities, will be reviewed for a reasonable need to obtain outside of the pharmacy network.
Medical service claims
Member reimbursement form (PDF)
Mail the completed form to:
Claims Processing
Kaiser Permanente
P.O. Box 30766
Salt Lake City, UT 84130-0766
For all medical service claims
Attach an itemized statement from the provider that includes:
- Member name and ID number
- Provider name and address
- Date of service
- Place of service (doctor's office, emergency room, urgent care)
- Provider's name
- Diagnosis (ICD10) and procedure (CPT) codes
- Itemized charges and proof of payment
Valid proof of payment includes a charge card receipt, a canceled check, or a statement from the provider showing the services have been paid.
Note: You only have to include a copy of your Explanation of Benefits if Kaiser Permanente is your secondary coverage.
After we receive a claim, processing can take up to 60 days.
Claims with missing required information may be returned without reimbursement.
Foreign claims
When you are traveling outside of the United States, your plan offers coverage for urgent and emergency care, and an inpatient hospital stay following an emergency admission.
Kaiser Emergency Copay
If you are admitted for an emergency, you or a family member must call the Emergency Notification Line at 1-888-457-9516 or 206-630-3413 within 24 hours after admission. Medical providers outside the United States usually require you to pay when you receive service and file for reimbursement.
Member reimbursement form for medical claims (PDF)
Mail the completed form to:
Claims Processing
Kaiser Permanente
P.O. Box 30766
Salt Lake City, UT 84130-0766
For all foreign medical service claims
We require an itemized bill from the provider's office that includes:
- Member name and ID number
- Date of service
- Country where services were provided
- Place of service (doctor's office, emergency room, urgent care)
- Description of the medical condition you were seen or treated for and the services provided
- Practitioner's name
- Total billed charges
- Proof of payment
- Verification of the type of currency used by the country where the services were rendered
- If possible, provide foreign documents and receipts translated in English. If you are unable to, Kaiser Permanente will translate at no cost.
For prescription reimbursement following urgent or emergency care
Fill out the appropriate prescription reimbursement form (see Pharmacy Services, above). Prescription reimbursement requires:
- Member name and ID number
- Date of service
- Country where services were provided
- U.S. equivalent drug name
- Strength
- Quantity
- Days' Supply
After we receive a claim, processing can take up to 60 days.
Emergency medical conditions may require transportation by a licensed ambulance. If you think you have an emergency medical condition, call 911 or go to the nearest hospital. To better coordinate your emergency care, we recommend that you go to a Kaiser Permanente hospital if it is reasonable to do so, given your condition or symptoms. Please refer to Your Guidebook to Kaiser Permanente Services for the location of Kaiser Permanente hospitals that provide emergency care.
An emergency medical condition is a medical or psychiatric condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in any of the following: serious jeopardy to your health, serious impairment in your bodily functions, or serious dysfunction of any bodily organ or part.
Note: This information is subject to change as contracts renew. Please refer to your Evidence of Coverage for the latest coverage information, including copayments, and for information about filing a claim to obtain reimbursement of emergency ambulance services.
This information is not a contract and may not answer all your questions. For up-to-date information about your emergency and ambulance coverage (including extensions), consult your Evidence of Coverage.