Retroactive authorizations, extenuating circumstances, and provider reconsideration requests

Kaiser Permanente requires that providers request authorization for services prior to or within fourteen calendar days of services rendered. Exceptions to this policy are made only under standard extenuating circumstances as defined by the WorkSMART Institute's best practice recommendations (PDF), and under Washington State Administrative Code 284-43-2060.

Retroactive authorizations

Kaiser Permanente will accept a request for retroactive authorization if the request meets either of the following guidelines:

• The request precedes a bill for services (no claim received by Kaiser Permanente) and is within fourteen days of the service OR
• The request precedes a bill for services (no claim received by Kaiser Permanente) and one of the extenuating circumstances applies

Extenuating circumstances

If your request for retroactive authorization qualifies under the guidelines above, you may submit your request to Review Services via One Health Port, or telephone. If your request is more than fourteen days after the date of service, please indicate which of the extenuating circumstances apply.

Extenuating circumstances fall into three categories:

• Unable to Know Situation-The provider and/or facility is unable to identify from which health plan to request an authorization. The patient is not able to tell the provider about their insurance coverage, or the provider verified different insurance coverage prior to rendering services.
• Not Enough Time Situations-The patient requires immediate medical services and the provider is unable to anticipate the need for a preauthorization immediately before or while performing a service.
• An enrollee is discharged from a facility and insufficient time exists for institutional or home health care services to receive approval prior to the delivery of the service.

Requirements for retroactive preauthorization consideration:

In each case, the provider is unable to request prior authorization for services as required by the provider's contract and the member's coverage agreement. Kaiser Permanente will accept the request for authorization more than fourteen calendar days after services are delivered as long as the provider made the request prior to submitting the claim for payment. The provider must provide proof of the extenuating circumstance in the retroactive request for authorization. If this documentation is not provided, Kaiser Permanente will deny the request and will not reconsider the decision. Please refer to the Washington Administration Simplification Guidelines for more information on extenuating circumstances and preauthorization rules.

Providers are encouraged to request the authorization as soon as they are able.

Reconsiderations of a denial

• If your claim or request for retroactive authorization is denied, and you are required to write off the charges, you have the option to request a reconsideration of the denial.
• Note: If there is any member financial responsibility for the denial, a request for reconsideration or appeal MUST go through the member appeals process.
• Subject to the provisions of your contract with Kaiser Permanente, including obtaining a member's prior written agreement to be financially responsible for the specific non-covered service, providers may bill a member for non-covered services.

Submitting a reconsideration

• When submitting reconsideration requests and medical records, please fax these requests and records to our team at 844-660-0747 or use the online reconsideration request form, within 24 months of the claim denial. These are sent directly to our team via Outlook and are stored with the reconsideration case. We will review your case within 60 days.
• We do not have a way to process, download, save or store CDs. When hard copies or CDs are sent to the post office box in Seattle, our Provider Reconsideration team does not have a way to monitor or ensure those documents are received.

Alternatively, you may mail the request to:

Kaiser Foundation Health Plan of Washington
Attn: Provider Reconsideration ACN-2
PO Box 30766
Salt Lake City, UT 84130-0766

For reconsiderations that did not deny for medical necessity see, Post service: Claims payment review & reconsideration process.