Follow-up care with a specialist
The specialist's office must contact our Review Services Department to obtain prior authorization for the situations listed below. After the initial authorized duration or visits have been exhausted, the primary care provider or personal physician must request prior authorization for any subsequent visits or treatment.
If a specialist provides consultation for a member in an emergency room (in person), regardless of the provider's contract status, the specialist may be able to see that member for appropriate follow-up care with prior authorization.
Request for authorization of follow-up care will be reviewed on an individual basis to determine medical necessity.
An emergency room specialist may refer a patient directly to an ophthalmologist or optometrist for care, regardless of the specialist's contract status. The scope and length of that authorization will be determined by a clinical review of the request.
Contracted specialty physicians in a member's network who have consulted on a patient during an inpatient stay are allowed appropriate follow-up care with the patient in accordance with our authorization guidelines, provided that care begins within 30 days of the hospital discharge.
Non-contracted or non-network physicians who have consulted with a patient during an inpatient stay can see the patient for consultative follow-up care — for the purpose of transitioning care to a network provider — provided that care begins within 30 days of the hospital discharge.
The patient's primary care provider must submit a request to authorize any additional visits to both contracted and non-contracted specialists.
The following consultants can refer patients for specific specialties without interaction with the patient's primary care provider. The Review Services Department can approve authorizations in these circumstances. Medical necessity review may apply.
For office visits, any contracted provider who has a current office visit authorization with a scope of office visits, minor lab, and X-ray office procedures can use OneHealthPort to request prior authorization for office visits to any other contracted provider.
Contact your Provider Services consultant if you have questions or requests for more information regarding our authorization and clinical review criteria.
|Specialty Type||Authorization Limits|
|Audiology||Contracted MD or osteopath with current authorization from the patient's personal care physician may provide secondary referrals to an in-network audiologist.|
|Complimentary Alternative Medicine||Acupuncturists, naturopaths, and massage therapists can request authorization updates or extensions.|
|Diabetic Education||Endocrinologist with current authorization may refer patient to a network diabetic educator.|
|Epidural Steroid Injections||Contracted neurologist, neurosurgeon, orthopedist, or physiatrist with current authorization may refer to network physician who treats pain with ESI.|
|Hospitalists||Contracted hospitalist may refer patient for specialty care following inpatient stay. Standard prior authorization management guidelines apply. Extensions or updates must come from patient's primary care provider.|
|Nephrology||Contracted nephrologist with current authorization can refer to a network general or vascular surgeon for stent or port line placement, and to network dialysis facilities.|
|Oncology & Radiation Oncology||Contracted oncologist with current authorization can refer to in-network radiation oncologists. Contracted oncologist, radiation oncologist, or contracted radiation facility can refer to a network general surgeon for stent or port line placement.|
|Ophthalmology & Optometry||Contracted ophthalmologists and optometrists can refer patients to network ophthalmologists.|
|Physical & Occupational Therapy||Contracted MD, osteopath, or podiatrist with a current authorization can refer to a network physical or occupational therapy provider. No authorization from Kaiser Permanente is required. The member is covered up to their benefit limit.|
|Women's Health Care||Women's health care provider can refer to any network consultant for women's health care services or other services diagnosed within routine women's health care exam.|
Content on this page is from the provider manual | Disclaimer