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California Division provides a claim form for emergency medical services, explaining when and how members must file for reimbursement for emergency care received at non-Kaiser Permanente facilities. The form instructs claimants to complete both sides, attach all itemized bills and supporting documents, and include authorization and signature requirements. 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If there is a balance remaining, after your primary medical plan pays your claim, you may file a claim for Kaiser Foundation Health Plan to pay the difference. Complete the attached Claim for Emergency Medical Services form and mail it along with a copy of your other plan’s paid explanation of benefits. Also attach a copy of all related bills. Please refer to your Evidence of Coverage for additional information on this process.  \nInstructions  \nTo request reimbursement for emergency services received at a non-Kaiser Permanente facility:  \n1. Complete both sides of the attached Claim for Emergency Medical Services form.  \n2. Attach additional information, if applicable, that is requested on the back of the Claim for Emergency Medical Services.  \n3. Detach and keep this instruction sheet and make a copy of the Claim for Emergency Medical Services form for your records.  \n4. Date and sign the form.  \n5. Mail your completed form, along with any bills, to one of the following addresses:  \nFor Southern California Members: For Northern California Members:  \nKaiser Foundation Health Plan, Inc. Kaiser Foundation Health Plan, Inc.  \nClaims Department Claims Department  \nP.O. Box 7004 P.O. Box 12923  \nDowney, CA 90242-7004 Oakland, CA 94604-2923  \nWe will process your claim upon receipt of this completed form. If we need additional information, we will notify you. For information about our time frames for processing your claim, please refer to your Evidence of Coverage.  \nIf you have any questions or need assistance, please call our Member Service Call Center at 1-800-390-3510.  \nKaiser Foundation Health Plan, Inc.  \nCalifornia Division  \nCLAIM FOR EMERGENCY MEDICAL SERVICES   \nMR\\#:   Name:    \nIMPRINT AREA  \nIN ORDER FORYOUR CLAIM TO BE CONSIDERED FOR PAYMENT:  \n• BOTH SIDES OF THIS FORM MUST BE COMPLETED IN FULL.  \n• ALL ITEMIZED BILLS FOR THIS EMERGENCY MUST BE ATTACHED.  \n• THIS FORM MUST BE SIGNED-SEE BELOW.  \n• IN MOST CASES, PAYMENT WILL BE MADE TO PROVIDER(S) UNLESS PROOF OF PAYMENT IS FURNISHED BY THE MEMBER OR PROVIDER(S) .  \n\n| PATIENT NAME | LAST | FIRST | INIT | SEX | BIRTH DATE\u003Cbr>|  |\n| --- | --- | --- | --- | --- | --- | --- |\n\nPATIENT ADDRESS STREET CITY STATE ZIP  \n\n| SUBSCRIBER NAME | LAST | FIRST | INIT | RELATION TO PATIENT | PATIENT DAY PHONE ( ) |\n| --- | --- | --- | --- | --- | --- |\n\nSUBSCRIBER ADDRESS STREET CITY STATE ZIP  \n\n| PLACE OF ILLNESS/INJURY CITY STATE/COUNTRY |  |  | INCIDENT DATE\u003Cbr>|  |  | TIME | ■■ | a. m.\u003Cbr>p.m |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| PLACE OF EMERGENCY CARE CITY STATE/COUNTRY |  |  | TREATMENT DATE\u003Cbr>|  |  | TIME\u003Cbr>■ a. m.\u003Cbr>■ p. m |  |  |\n| IS PATIENT COVERED BY MEDICARE OR OTHER MEDICAL INSURANCE?\u003Cbr>■ Yes ■ No | NAME OF POLICY HOLDER/SUBSCRIBER |  |  |  |  |  |  |  |\n| IF YES, INSURANCE COMPANY NAME ADDRESS TELEPHONE NO. |  |  |  |  | SUBSCRIBER ID NO. |  |  |  |\n| INSURANCE COMPANY NAME ADDRESS TELEPHONE NO |  |  |  |  | SUBSCRIBER ID NO. |  |  |  |\n| IS MEDICAL COVERAGE PART OF THE CAR INSURANCE POLICY?\u003Cbr>■ Yes ■ No |  | NAME OF POLICY HOLDER |  |  |  |  |  |  |\n| IF YES, AUTOMOBILE INSURANCE COMPANY NAME ADDRESS TELEPHONE NO. |  |  |  |  | POLICY NO. |  |  |  |\n\nMEMBER’S DESCRIPTION OF HOW THE EMERGENCY OCCURRED  \nWHY WAS THE PATIENT NOT TREATED AT A KAISER PERMANENTE FACILITY?  \n\n| WAS AN AMBULANCE USED?\u003Cbr>■ Yes ■ No |  | WHO CALLED THE AMBULANCE?\u003Cbr>■ Patient ■ Kaiser Permanente ■ Police/Fire ■ Other (specify)   |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| IF HOSPITALIZED: | ADMIT DATE |  |  | DISCHARGE DATE | IS THE PAT","cbCaikrb1pWffCIq","https://ap.wps.com/l/cbCaikrb1pWffCIq","pdf",102167,"English","# Instructions\n## When to file and required attachments\n# Claim Form (Emergency Medical Services)\n## Patient and subscriber details\n## Emergency care and incident information\n## Coverage, ambulance, hospitalization, and related questions\n## Authorization and signatures\n## Continued section: notification and work-related matters","[{\"question\":\"When must members file a Kaiser emergency medical services claim?\",\"answer\":\"Members must file the claim for Kaiser Foundation Health Plan after their primary medical plan has paid, if there is a remaining balance. The instructions also specify filing for emergency services received at a non-Kaiser Permanente facility.\"},{\"question\":\"What must be completed and attached for the claim to be considered for payment?\",\"answer\":\"Both sides of the form must be completed in full, all itemized bills for the emergency must be attached, and the form must be signed. Payment is generally made to providers unless proof of payment is furnished by the member or providers.\"},{\"question\":\"What additional information is required if the emergency was work-related or caused by a motor vehicle accident?\",\"answer\":\"If the injury is work-related, attach the explanation of payment or denial from the workers’ compensation carrier. If it resulted from a motor vehicle accident, submit a copy of the driver’s auto policy face sheet in effect at the time of the accident and a copy of the member’s auto policy face sheet.\"}]","CLAIM FOR EMERGENCY MEDICAL SERVICES | PDF",1790131146]