To ensure that the medical service ordered is medically necessary, prior authorization approval may be required. This is known as prior authorization for services ordered by a PPO provider, or non-participating provider.
What requires prior authorization?
For participating providers and non-participating providers, some services, such as inpatient care (for example, hospital surgical procedures) and some outpatient procedures, require prior authorization to be covered.
For care with Kaiser Permanente providers, your provider will arrange for prior authorization, if required, for certain services.
How do I receive prior authorization?
To obtain prior authorization or for questions about medical necessity requirements, please call Kaiser Permanente’s Resource Stewardship Department at 1-855-281-1840 (TTY 711).
Your non-participating provider may obtain prior authorization for you or your authorized representative by calling 1-855-281-1840 (TTY 711).
If you don’t obtain prior authorization for services in the non-participating provider tier, you may have to pay the entire expense. The penalty does not apply toward your deductible or out-of-pocket maximum, so it is important to get prior authorization before receiving these services.
To learn more, review the prior authorization section in your Evidence of Coverage (EOC) for details.
The following require prior authorization:
Inpatient admissions and services.
Inpatient rehabilitation therapy admissions, services, and programs.
Subacute admissions and services.
Inpatient skilled nursing facility and long-term care admissions and services.
Inpatient mental health and chemical dependency admissions and services.
Non-hospital residential services, partial hopsitalizaiton and day treatment for mental health and chemical dependency OP.
Bariatric surgery/gastric bypass, stapling, or bandng.
Home health (all services, including home uterine monitoring).
Home infusion (including tocolytics).
Varicose vein treatments/sclerotherapy.
Upper airway procedures.
Hyperbaric oxygen treatment.
Enhanced external counterpulsation (EECP).
Plasmapheresis for multiple sclerosis.
Vagal nerve stimulation for epilsepsy.
Imaging services – MRI, MRA, CTA, PET, EBCT.
Infertility referral and related services.
Durable medical equipment.
Need prior authorization or have questions about it?
Call 1-855-281-1840 (TTY 711).
All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR 97232.