Clinical review criteria
Kaiser Permanente clinical review criteria are developed to assist in administering plan benefits. Please visit our Utilization review page for more details, including our Clinical guidelines and Clinical review criteria.
Staff available to discuss utilization management decisions or process
Utilization Management staff can answer questions and provide assistance over the phone including:
- Review requests for coverage based on need, and
- Discuss utilization and clinical review coverage determinations
Staff are available at 1-800-289-1363 on weekdays from 8 a.m. to 5 p.m. PST. After business hours, please leave a voice message with your contact information. Messages received after normal business hours are returned on the next business day and messages received after midnight on Monday - Friday are responded to on the same business day.
Kaiser Permanente physician incentives
The National Committee for Quality Assurance (NCQA), one of the organizations that accredits Kaiser Permanente, requires us to distribute a statement about incentives for care. We are committed to providing appropriate, comprehensive, and coordinated care in partnership with our members. Our goal is to provide high-quality care in the appropriate setting, at the right time, and by the most appropriate practitioner.
Kaiser Permanente affirms that:
- Care management decision making is based only on the appropriateness of care, service, and the existence of coverage.
- We do not specifically reward, hire, promote, or terminate doctors or other individuals for issuing coverage denials for needed care or service.
- Financial incentives for care management decision makers do not encourage decisions that result in underuse of services.
If you have questions about the NCQA requirements, contact Janet Lucchesi, Director of Accreditation at 1-303-513-3473.
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