How to Submit Claims for Reimbursement

Before you submit a medical or pharmacy claim for reimbursement, please sign on to review your coverage, or contact Member Services if you have questions about your benefits.

Reimbursement requests must be received by Kaiser Permanente within 12 months from the date of service.

Pharmacy Service Claims

Medicare Part D Prescriptions

To request prescription reimbursement if you have Medicare Part D, print and complete:

Fill Date Prior to Jan. 1, 2017 (PDF)

Fill Date On or After Jan. 1, 2017 (PDF)

For pharmacy reimbursements, fill out the appropriate form above based on the fill date. Prescriptions filled in 2016 will need to be sent on a separate form than those filled in 2017. Include a brief description of the reason you are making this request for reimbursement and a dispensing list which includes:

  • Patient name and member identification number
  • Fill date
  • Drug name and strength
  • National Drug Code (NDC) number
  • Quantity (such as total number of pills) and supply (number of days)
  • Prescription number
  • Member cost share and amount paid

Mail the completed form to:

For prescriptions filled in 2016:
Kaiser Foundation Health Plan of Washington
Attn: Claims Administration
P.O. Box 34585
Seattle, WA 98124-1585

For prescriptions filled in 2017:
OptumRx
P.O. Box 968021
Schaumburg, IL 60196-8021

Keep a copy of all documents for your records.

All Other Presciptions
(Non-Medicare & Medicare Without Part D)

Print and fill out the following form to request reimbursement for prescriptions. If you have Medicare Part D prescription coverage, see the Medicare section above.

Prescription Claim Form (PDF)

For pharmacy reimbursements, fill out the appropriate form above based on the fill date. Prescriptions filled in 2015 will need to be sent on a separate form than those filled in 2016. Include a brief description of the reason you are making this request for reimbursement and a dispensing list which includes:

  • Member name and identification number
  • Fill date
  • Drug name and strength
  • National Drug Code (NDC) number
  • Quantity (such as total 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.

Mail the completed form to:
OptumRx
PO Box 968022
Schaumburg, IL 60196-8022

After we receive a claim, processing can take four to six weeks. Keep a copy of all documents for your records.

Please be aware, claims sent to the incorrect address or with missing required information may be returned without reimbursement.

Foreign Claims

While traveling outside of the United States, your Kaiser Permanente plan offers coverage for urgent and emergency care, and an inpatient hospital stay following an emergency admission.

If you are admitted following an emergency situation, you or a family member must call the Emergency Notification Line at 1-888-457-9516 or 206-901-6118 within 24 hours following the emergency, or as soon as medically possible.

Medical providers outside the United States usually require you to pay when you receive service and file for reimbursement. To request reimbursement, print and complete:

Member Reimbursement Form for Medical Claims (PDF)

Kaiser Permanente also requires an itemized bill from the provider's office which includes the following:

  • Member name and identification number
  • Date of service
  • Country where services were provided
  • Place of service (doctor’s office, emergency room, urgent care, etc.)
  • A clear description showing 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 (such as euro or peso)
  • Translation of all services rendered
  • Translation of medical records required for inpatient claims

Mail the completed form to:

Kaiser Foundation Health Plan of Washington
Attn: Claims Administration
PO Box 34585
Seattle, WA 98124-1585

For prescription reimbursement following urgent or emergency care, please fill out the appropriate prescription reimbursement form (see Pharmacy Services, above). Prescription reimbursement requires the following information:

  • Member name and member identification number
  • Date of service
  • Country where services were provided
  • U.S. equivalent drug name
  • Strength
  • Quantity
  • Days' Supply

Translating documents: To avoid delays in processing your request, please provide an English translation of your foreign documents and receipts if they are in another language. We will do our best to translate, but if we are unable to, we will send it back to you for translation. Kaiser Permanente does not cover or reimburse for document translation.

After we receive a claim, processing can take up to 60 days. Keep a copy of all documents for your records.

Medical Service Claims

Print and fill out the following form to request reimbursement for medical services (all health plans). Also use this form to request vision claim reimbursement, such as eyeglasses.

Member Reimbursement Form (PDF)

Attach an itemized statement from the provider which includes the following information:

  • Member name and identification number
  • Provider name and address
  • Date of service
  • Place of service (doctor’s office, emergency room, urgent care, etc.)
  • Physician/medical provider’s name
  • Diagnosis (ICD9 or ICD10) and procedure (CPT) codes
  • Itemized charges and proof of payment

You should be able to obtain this information from the provider. Valid proof of payment includes a charge card receipt, a cancelled check, or a statement from the provider showing the services have been paid.

Please note: You only have to include a copy of your Explanation of Benefits (EOB) if Kaiser Permanente is your secondary coverage.

Mail the completed form to:

Kaiser Foundation Health Plan of Washington
Attn: Claims Administration
PO Box 34585
Seattle, WA 98124-1585

After we receive a claim, processing can take up to 60 days. Keep a copy of all documents for your records.

Please be aware, claims with missing required information may be returned without reimbursement.