Prior authorization requirements and management guidelines

Prior authorization requirements vary by health plan. Kaiser Permanente must authorize all inpatient hospital care, regardless of plan type.

Members who have out-of-network benefits may use First Choice Health and First Health Network providers. Out-of-network provider office visits do not require prior authorization. Some treatments may require prior authorization.

Authorization management guidelines

We developed the following prior authorization management guidelines for our Core plans to emphasize the involvement of the primary care provider.

New requests

  • Number of visits and duration are limited by the scope of the authorization, unless the request is for services that are noted as exceptions below. See standard visits and exceptions tables.
  • The start date of the authorization is dependent on the request date and receipt date. Requests for authorization should be received prior to or within 14 calendar days of the requested start date. If the request is received more than 14 days after the requested start date, it will be considered a retroactive request and may be denied.

Procedure notifications

  • A specialist with an active authorization for "Evaluate and Treat" from the primary care provider can send a procedure notification directly to the Review Services Department.

Standard visits

When you are referring your patient for specialty care, you can choose the appropriate scope of care. By using one of these options you can ensure your patient is getting the right level of care.

SCOPE OF CARECPTMAXIMUM VISITS/DURATIONAPPROVED ACTIONS
Consult only 99202 3/6 months Office visits only
Second opinion only 99203 1/6 months Office visits only
Evaluate and treat; surgery if indicated 99201 3/6 months Office visits, routine diagnostics, in-office procedures. Evaluate and treat, and requests for surgeries can come directly from the consulting specialist on a separate authorization request.
Evaluate and treat; surgery if indicated 99214 6/6 months Office visits, routine diagnostics, in-office procedures. Evaluate and treat, and requests for surgeries can come directly from the consulting specialist on a separate authorization request.
Oncology and radiation therapy
Evaluate and treat; surgery if indicated 99214 999/6 months Office visits, routine diagnostics, in-office procedures. Requests for surgeries can come directly from the consulting specialist on a separate authorization request.

Exceptions to standard visits

The following table lists exception guidelines for authorizing services. Services are subject to the member's eligibility and benefit coverage. Some services are limited or not covered by the member's health plan. For more information on a specific member's benefits, contact the Provider Assistance Unit at 1-888-767-4670.

AUTHORIZATION TYPEAUTHORIZATION LIMITS
Mental health and wellness Mental health, including addiction and recovery authorizations are processed through that department. For details, see Mental health, including addiction and recovery.
Complimentary & alternative health services Acupuncture: Subject to limitations based on member's coverage. Member can self-refer to contracted acupuncturist for limited number of visits. After self-referred visits are exhausted, an authorization request from the treating acupuncturist, primary care physician, or specialist is required to authorize additional visits.

Chiropractic care: Most patients can self-refer to participating chiropractor for limited number of visits.

Massage therapy: Pre-authorization is not required for massage therapy for most members. Massage therapy must have a valid order or prescription from the member’s ordering provider. The number of visits is limited by the member’s coverage and benefits.

Naturopathy: Subject to limitations based on member's coverage. Member can self-refer to contracted naturopathic practitioner for limited number of visits. After self-referred visits are exhausted, an authorization request from the treating naturopath, primary care physician, or specialist is required to authorize additional visits.

For more information, see Complementary and alternative medicine.
Diabetic education 999/6 months
Diabetic retinopathy 999/6 months
Dialysis 999/6 months
Durable medical equipment DME, prosthetics, and orthotics are processed through Review Services. For more information, see Prior authorization for durable medical equipment.
Nutritional counseling 6/6 months
Occupational therapy When pre-authorization is required, up to 15 visits upon initial request. Subsequent visits in 15-visit increments up to the member's benefit limit.
Oncology (including chemotherapy and radiation therapy) 999/6 months
Phenylketonuria (PKU) 15 visits/6 months
Physical therapy When pre-authorization is required, up to 15 visits upon initial request. Subsequent visits in 15-visit increments up to the member's benefit limit.
Radiation therapy 999/6 months
Speech therapy When pre-authorization is required, up to 15 visits upon initial request. Subsequent visits in 15-visit increments up to the member's benefit limit.
Transplants/mechanical hearts 999/6 months for follow-up. Requires prior authorization.
Applied behavioral analysis therapy (ABA) Units approved are measured in hours and defined by Clinical Review over a six-month duration when preauthorized.

Extensions

  • Requests for more visits or more time require a new request for authorization which can be submitted using the Referral Request tool Padlock

Authorizations for Medicare coordination of benefits

  • We don't require and won't offer a prior authorization when we are secondary to Medicare (except for massage therapy). If Medicare covers a service, we will cover as secondary. If Medicare does not cover a service, we will process the claim applying the member commercial contract and medical necessity review, if required. Requesting a prior authorization when Kaiser Permanente is secondary to Medicare is discouraged.
  • For FEHB Core/Self-Funded Core plans that follow the maintenance of benefits rule, the amount paid by the primary insurance is used to reduce the amount that Kaiser Permanente would pay as the secondary. Members must follow network/authorization rules and members will be responsible for cost-shares determined by the plan.

Medicare coordination with a maintenance of benefits plan

When a Kaiser Permanente Medicare-eligible member is not eligible for our Medicare Advantage plans, we will coordinate benefits with traditional Medicare.

When Medicare is the primary payer, you must bill Medicare directly for services through the Medicare crossover process.

Note: Do not bill Kaiser Permanente for claims that will crossover electronically. This creates duplicate billing or payment. Remember to check your Medicare explanation of payment form, Reason Code MA18.


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