Letters to Providers

The following letters contain updated Kaiser Permanente policy information or clinical reminders. Letters are in a print-friendly PDF format and will be available for two years.


National Drug Code (NDC) billing requirements (PDF)
Effective February 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will require the billing of the National Drug Code (NDC) associated with the drug administered during a visit.

Manipulative services — AT modifier requirement (PDF)
Effective February 1, 2021, codes 98940, 98941 and 98942 must be billed with the Acute Treatment (AT) modifier to identify that the service was medically necessary acute treatment, as opposed to maintenance therapy.

Threshold decrease for pre-payment review (aka line item deduction) and medical necessity review for inpatient and outpatient claims (PDF)
Effective February 1, 2021, facility claims with billed charges of $20,000 and greater will be subject to prepayment review for billing appropriateness.

Changes to medical necessity review criteria for bone anchored hearing system (BAHA) (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for bone anchored hearing systems (BAHA) for non-Medicare members.

Changes to medical necessity review criteria for chromoendoscopy and narrow band imaging for colonoscopy (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse for chromoendoscopy and narrow band imaging during colonoscopy. Although Kaiser Permanente has not covered these services historically, this letter serves as formal notification of this new non-coverage policy.

Changes to medical necessity review criteria for hyperbaric oxygen therapy (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for hyperbaric oxygen therapy for non-Medicare members.

Changes to medical necessity review criteria for next generation sequencing (NGS) for advanced cancer (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) has selected CellNetix Pathology & Laboratories as the preferred provider for next generation sequencing (NGS) in advanced cancer.

Multiple payment policy changes effective 1/1/2021 (PDF)
Drug Waste Policy
Women's Health Policy
Surgical Codes - Anatomical Modifiers

Multiple payment policy changes effective 1/1/2021 (PDF)
High Level Evaluation and Management Services with a Diagnosis of "No Abnormal Findings"
Change of Policy Name and Addition of Medicare Specific Language

Multiple payment policy changes effective 1/1/2021 (PDF)
Diagnosis Related Group (DRG) Payment and Review

Medicare Part B drugs requiring step therapy (PDF)
Effective January 1, 2021, step therapy review will be required for the non-preferred Part B drugs.

Changes to medical necessity review criteria for reduction mammoplasty surgery (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for reduction mammoplasty surgery.

Changes to medical necessity review criteria for cardiac ambulatory monitoring for extended duration (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for cardiac ambulatory monitoring for extended duration.

Changes to medical necessity review criteria for brachytherapy (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Brachytherapy.

Changes to medical necessity review criteria for genetic panels using Next Generation Sequencing (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Genetic Panels using Next Generation Sequencing (NGS) when ordered for non-Medicare members.

Multiple Procedure Payment Reduction (MPPR) on Outpatient Hospital Claims (PDF)
Effective December 1, 2020, Kaiser Permanente facility outpatient claims billed with a professional revenue code will be treated like they have a 26 modifier and all other facility revenue codes will be treated as though they have a Technical Component (TC) modifier.

Innovator/Biosimilar pricing changes (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will make changes to the KFHPWA Addendum B Fee Schedule.

Neurostimulator electrode array (PDF)
Effective November 1, 2020, Kaiser Permanente will align with the Centers for Medicare and Medicaid Services (CMS) for reimbursement for neurostimulator electrode array.

Genetic testing preferred provider is Invitae Corporation (PDF)
Effective October 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are directing genetic testing to Invitae Corporation (Invitae) for in-network coverage for non-Medicare members when the requested test(s) are available at Invitae.

Changes to medical necessity review criteria for phonophoresis (PDF)
Effective October 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for phonophoresis.

Changes to medical necessity review criteria for sports hernia surgery (PDF)
Effective October 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for sports hernia surgery.

Changes to medical necessity review criteria for Transcatheter Aortic Valve Replacement (TAVR) (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are changing the Transcatheter Aortic Valve Replacement (TAVR) clinical review criteria to allow coverage for all patients with documented severe, symptomatic aortic valve stenosis, regardless of operative risk.

Changes to medical necessity review criteria for Monitored Anesthesia Care during gastrointestinal endoscopic procedures (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.(Kaiser Permanente) will enforce existing prior authorization requirements for Monitored Anesthesia Care (MAC) and a change has been made to the medical necessity criteria for MAC during gastrointestinal procedures to require an American Society of Anesthesiologists (ASA) risk-stratification of class IV.

Changes to medical necessity review criteria for Micronutrient Panel Testing (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc., (Kaiser Permanente) will implement medical necessity criteria for Micronutrient Panel Testing.

Changes to medical necessity review criteria for Neonatal Intensive Care Unit (NICU) admissions (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for NICU admissions.

Changes to medical necessity review criteria for lumbar spine magnetic resonance imaging (MRI) (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for MRI of the lumbar spine for non-Medicare patients.

Alglucosidase (Lumizyme) & Natalizumab (Tysabri) in the home infusion setting restricted to administration by Kaisr Permanente Home Infusion (PDF)
Effective September 1, 2020, the criteria for the specialty home infusion products listed above will change.

Changes to medical necessity review criteria for microinvasive glaucoma surgery (PDF)
Effective August 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are changing the medical necessity criteria, by establishing clinical indications for all microinvasive glaucoma surgeries, including but not limited to iStent, Hydrus, and Xen Gel implants.

Changes to medical necessity review criteria for driving skills assessments (PDF)
Effective August 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. will discontinue coverage of driving skills assessments.

Infliximab products in the home infusion setting restricted to administration by Kaiser Permanete Home Infusion (PDF)
Effective August 1, 2020, the criteria for the specialty home infusion products Remicade & Inflectra will change. For home infusion, these specialty home infusion products and administration of these products is limited to Kaiser Permanente Home Infusion for non-Medicare Health Maintenance Organization (HMO) members.

Revised notification: Referrals & authorization provider site upgrade (PDF)
This upgrade was scheduled to become effective on March 20, 2020, but implementation was delayed. The revised effective date for the referrals & authorization provider site upgrade is August 15, 2020.

Referrals & authorization provider site upgrade (PDF)
We are excited to inform you that we will be rolling out an upgraded referrals and authorization provider experience on our Kaiser Permanente provider site on March 20, 2020.

Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. and Magellan Healthcare, Inc. form a partnership (PDF)
Effective July 1, 2020, Magellan will begin managing outpatient behavioral health and substance use service providers credentialing, information about your practice and member referrals.

Changes to medical necessity review criteria for elective total hip replacement in an inpatient hospital setting (PDF)
Effective April 1, 2020, Kaiser Permanente will implement medical necessity criteria for elective total hip replacements performed in an inpatient hospital setting for all members.

Claims processing practices for emergency department services (PDF)
Effective April 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will begin using the Optum® Emergency Department Claim (EDC) Analyzer tool.

Changes to wound care treatment clinical review criteria: Biological and synthetic skin substitutes (PDF)
Effective April 1, 2020, Kaiser Permanente is changing the Wound Care Treatments clinical review criteria to only cover the following biological and synthetic skin substitutes.

Rituximab (Rituxan®) updated prior authorization criteria (PDF)
Effective April 1, 2020, the prior authorization criteria for rituximab (Rituxan) will be revised.

Site of Care prior authorization requirement
Effective March 1, 2020, Site of Care prior authorization criteria will apply to the following medications.
Crysvita (PDF)
Exondys 51 (PDF)
Herceptin (PDF)
Ilaris (PDF)
Lemtrada (PDF)
Onpattro (PDF)
Radicava (PDF)
Truxima (PDF)
Tysabri (PDF)

Trauma activation, inpatient admissions, and pre-payment billing reimbursement changes (PDF)
Effective March 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are making changes regarding reimbursement of services for trauma activation, inpatient admissions, and pre-payment billing review criteria.

Trastuzumab (Herceptin®) will require prior authorization approval (PDF)
Effective February 1, 2020, prior authorization approval will be required for trastuzumab (Herceptin®) before administration of this medication in a physician's office.

EPRO (Emergency Patient Resources & Options) post - stabilization policy (PDF)
Starting January 1, 2020, Kaiser Permanente of Washington will require notification at the time of stabilization and prior to hospital admission. This is in accordance to Washington State Legislature RCW 48.43.093.

Changes to prior authorization process for genetic lab tests (PDF)
Effective January 1, 2020, Kaiser Permanente is changing the utilization management requirement for all genetic lab tests. Prior authorization will be required for these tests in advance of submitting a claim for payment.

Changes to prior authorization process for mental health and wellness (PDF)
Changes to prior authorization process for mental health and wellness 90834 Q&A (PDF)
Effective January 1, 2020, Kaiser Permanente will implement changes to authorizations regarding outpatient psychotherapy. Outpatient psychotherapy will be authorized as CPT Code 90834, which will no longer be limited to 20 visits and reauthorization is only required annually via an abbreviated reauthorization form.

Ambulance Services payment policy (PDF)
Starting January 1, 2020, Kaiser Permanente Washington (KPWA) will enforce the existing Ambulance Services Payment Policy.

Bevacizumab (Avastin®) will require prior authorization (PDF)
Effective December 1, 2019, prior authorization review will be required for bevacizumab (Avastin®). This letter is a notification of the upcoming change in prior authorization approval required before administering this medication in a physician's office.

Clarification notification to Intraoperative Neurophysiological Monitoring (PDF)
This letter provides additional clarification to the previous letter regarding Intraoperative Neurophysiological Monitoring. The new notification does not change the effective date of September 1, 2019. This letter clarifies Medicare Advantage review for Intraoperative Neurophysiological Monitoring.

Intraoperative Neurophysiological Monitoring (PDF)
Effective September 1, 2019, Kaiser Permanente is changing the medical necessity review criteria and requiring pre-authorization for coverage on some plans. Kaiser Permanente has adopted Kaiser Permanente National criteria for Intraoperative Neurophysiological Monitoring for the Washington region.

IV Immune Globulin (IVIG) in the home infusion setting will be restricted to Kaiser Washington home infusion (PDF)
Effective August 1, 2019, the criteria for the products listed will be updated. These products will be restricted to Kaiser Washington Home Infusion when administered in the home infusion setting for non-Medicare patients.

Alpha-1 Proteinase Inhibitors in the home infusion setting will be restricted to Kaiser Washington home infusion (PDF)
Effective June 1, 2019, the criteria for the products listed will be updated. These products will be restricted to Kaiser Washington Home Infusion when administered in the home infusion setting for non-Medicare patients.

Clarification notification to changes to medical cecessity review criteria for Total Knee Replacement (PDF)
This letter provides additional clarification to the previous letter regarding total knee replacement. This new notification does not change the effective date of June 1, 2019. This letter clarifies Medicare Advantage review for total knee replacements in an inpatient setting.

Changes to medical necessity review criteria for Total Knee Replacement (PDF)
Effective June 1, 2019, Kaiser Permanente will implement medical necessity criteria for Total Knee replacements performed in an inpatient setting.

Tivity/WholeHealth Network notice re: Group Summary and Fee Schedule update for Chiropractors (PDF)
The Group Summary and Fee Schedule has been updated. Reimbursement for services provided on or after 01/01/2019 will be based on the updated fee schedule for chiropractic claims.

Change to prior authorization requirement for non-invasive prenatal fetal testing(PDF)
Effective March 1, 2019, Kaiser Permanente is changing the utilization management requirement for non-invasive prenatal fetal testing.

Changes to medical necessity review criteria for total knee replacement (PDF)
Effective March 1, 2019, Kaiser Permanente will implement medical necessity criteria for Total Knee replacements performed in an inpatient setting.

Buprenorphine (Probuphine®) will require prior authorization(PDF)
Effective February 1, 2019, prior authorization review will be required for buprenorphine (Probuphine®).

Paclitaxel protein-bound particles (Abraxane®) will require prior authorization (PDF)
Effective February 1, 2019, prior authorization review will be required for Paclitaxel protein-bound particles (Abraxane®).

Secukinumab (Cosentyx®) will not be covered under the medical benefit (PDF)
Effective February 1, 2019, Secukinumab (Cosentyx®) will NOT be covered under the medical benefit.

Tocilizumab (Actemra®) will not be covered under the medical benefit (PDF)
Effective February 1, 2019, Tocilizumab (Actemra®) will NOT be covered under the medical benefit.

Multiple procedure payment reduction (PDF)
Effective November 8, 2018, Kaiser Permanente will begin to apply our multiple imaging reduction payment policy. When benefits allow, Kaiser Permanente will apply the Multiple Procedure Payment Reduction on Diagnostic Imaging, implemented by CMS in 2012.

Darbepoetin alfa (Aranesp®) for ESRD will require prior authorization (PDF)
Darbepoetin alfa (Aranesp®) for use in patients with end-stage renal disease (ESRD) will be added to the list of non-Medicare medical benefit drugs requiring prior authorization.

Claims PO Box updated (PDF)
This is a notification that our Claim’s PO Box is UPDATED. Please send all future paper claims submissions to: PO Box 30766 Salt Lake City, UT 84130-0766.

Services incidental to inpatient admissions (PDF)
** Critical access hospitals are excluded from this policy**
Effective September 1, 2018
Kaiser Permanente will begin to apply our services incidental to inpatient hospital stay payment policy. When benefits allow, Kaiser Permanente will reimburse incidental services to the inpatient admission on the inpatient claim. Incidental services are considered included in the inpatient reimbursement rate. Kaiser Permanente will NOT reimburse services rendered prior to the related inpatient admission separately.

Changes to medical necessity review criteria for Kaiser Permanente: Implantable loop recorders (PDF)
Effective July 1, 2018, Kaiser Permanente is changing the medical necessity review criteria for implantable loop recorders.

Infliximab (Remicade®) updated prior authorization approval (PDF)
Effective June 1, 2018, the criteria for infliximab (Remicade®) will be updated. This letter is a notification of the upcoming change in prior authorization approval required before administering this medication in a physician's office.

Important changes in pre-authorization requirements for Kaiser Permanente Washington’s Access PPO, Elect PPO or Omni PPO Plans (PDF)
Effective May 1, 2018, Kaiser Permanente Washington is changing our pre-authorization requirements for our Access PPO, Elect PPO or Omni PPO plans.

Site of service prior authorization requirement for additional medications (PDF)
Effective April 1, 2018, site of service prior authorization criteria will apply to additional drugs. This letter is a notification of the upcoming change in prior authorization approval requirements before administering these medications under the medical benefit. This only applies to Kaiser Foundation Health Plan of Washington commercial PPO and HMO plans and will not affect Medicare members.

All blood factor products to be dispensed through BloodWorks NW (PDF)
Effective April 1, 2018, all blood factor products listed will be restricted to BloodWorks NW for non-Medicare patients. This letter is a notification of the upcoming change that the list of blood factors will NOT be covered outside of BloodWorks NW.

Ferric carboxymaltose (Injectafer®) and ferumoxytol (Feraheme) will require prior authorization (PDF)
Effective April 1, 2018, prior authorization review will be required for ferric carboxymaltose (Injectafer®) and ferumoxytol (Feraheme). This letter is a notification of the upcoming change in prior authorization approval required before administering this medication under the medical benefit.

Immune globulin (Hizentra®) will not be covered under the medical benefit (PDF)
Effective April 1, 2018, Immune globulin (Hizentra®) will NOT be covered under the medical benefit. This letter is a notification of the upcoming change in coverage for this medication under the medical benefit.