Pre-certification requests

Automated capability for a quicker and easier way to determine if a service/code requires pre-certification.

Please note: This tool is used only for Preferred Provider Organization (PPO) & Point of Service (POS) products. Results for members with KP HMO, Medicare (Senior Advantage), Cigna, or Self-funded products/plans are not included.

---------------------------------

Permanente Advantage provides pre-certification for medical services ONLY for Kaiser Permanente Insurance Company (KPIC) Point-of-Service (POS) and Preferred Provider PPO plan members. Permanente Advantage provides determination using evidence-based, nationally established criteria. As a URAC certified organization in Health Utilization Management (HUM), this exemplifies our commitment to high performance by embedding quality management principles into our daily operations. The certification process verifies and confirms our operational soundness, developed policies and procedures, set priorities, and identified organizational improvements.

Verification of pre-certification is required in advance prior to services being rendered, excluding emergency services. Pre-certification requests should be submitted by a healthcare provider. Any provider wishing to provide services listed under the individual member’s Certificate of Insurance (COI) is required to call, verify, and submit in advance a pre-certification request along with clinical information. You may submit your completed request form with supporting clinical documentation by fax or email to the following:

Fax #: 866-338-0266

Email: PermAdvantageTeam-KPPA@kp.org

Link to Permanente Advantage Pre-Certification Request Form.

If you would like a copy of the pre-certification requirements or have any questions about the pre-certification request form, the pre-certification process, or verification of services that require pre-certification, please email us at PermAdvantageTeam-KPPA@kp.org or call us at the appropriate phone number below.

California Members: 1-888-251-7052
Colorado Members: 1-888-525-1553
Hawaii Members: 1-888-529-1553
Mid-Atlantic Members: 1-888-567-6847
Georgia Members: 1-855-265-0311

Failure to follow the pre-certification instructions may result in delay of processing your request or a denial of the request and possible non-payment for services, if rendered.

Providers and members can use the following links below to review the clinical criteria used in a denial determination or to access clinical criteria for potential future services.

MCG Health Transparency Link: MCG Transparency Portal - Login

---------------------------------

List of Services by Region that require Pre-Certification

To find a list of services that require pre-certification, click the link below designated to the member’s region:

Mid-Atlantic

MD Small Group – POS
MD Large Group – OOA PPO
MD Large Group – POS
VA Large Group – OOA PPO
VA Large Group – POS
DC Large Group – OOA PPO
DC Large Group – POS

Georgia

Dual Choice PPO – Small Group

Dual Choice PPO – Large Group

California

Small Group - PPO (STD)
Large Group - POS (NGF)
Large Group - PPO (GF)
Large Group - OOA PPO (GF+)
Large Group - POS (GF+)
Large Group - PPO with HSA
Large Group - OOA PPO (NGF)

Hawaii

Point-of-Service (POS)

Colorado

Small Group – PPO
Small Group – 3 Tier- POS
Large Group – 3 Tier-POS
Large Group – PPO

FOR COLORADO DESIGNATED MEMBERS ONLY

Additional Step Therapy Criteria: Step Therapy CAMS

If you have any questions about the pre-certification request form, the pre-certification process, or verification of services that require pre-certification, please call us at the appropriate phone number below.

California Members: 1-888-251-7052
Colorado Members: 1-888-525-1553
Hawaii Members: 1-888-529-1553
Mid-Atlantic Members: 1-888-567-6847
Georgia Members: 1-855-265-0311

Fax: 1-866-338-0266

Link to Permanente Advantage Pre-Certification Request Form.

Please keep in mind of the following when submitting for pre-certification:

Kaiser Region	Routine Turnaround Time	Urgent Turnaround Time	Concurrent Turnaround Time	Retrospective Turnaround Time
Maryland (MD)	Within 2- working days	Within 24 hours (including weekend/holidays) of receipt of the request.	1 business day	30 calendar days
Virginia (VA)	Within 2- business days	Within two (2) business days, not to exceed 72 hours (including weekend/holidays) of receipt of the request.	24 hours
District of Columbia (DC)	Within 5- calendar days	Within 24 hours after receipt of the information necessary to make the request.
California (CA)	Within 5- calendar days	Within 72 hours (including weekend/holidays) of receipt of the request.
Colorado (CO)	Within 5- business days	Within 72 hours (including weekend/holidays) of receipt of the request.
Georgia (GA)	Within 7- calendar days	No later than seventy-two (72 hours) after receipt of the information necessary to make the
Hawaii (HI)	Within 15- calendar days	Within 72 hours (including weekend/holidays) of receipt of the request.

For ALL Inpatient hospital admits – it is important to provide immediate notification of the covered person’s admission status. Please review the following pre-certification guidelines for Hospital admission:

Emergency Related Admission

Point-of-Service (POS) Plans

Emergency admissions is covered under ALL plans –under the HMO benefit (Tier 1). –HMO Utilization Management department must be notified first of the covered person’s ER to inpatient admission. Emergent care up until the point when the patient is stable for transfer is covered under HMO (Tier 1) benefit and is managed by each region’s local HMO UM department. Please contact the local department below, designated to the member’s region:

Hawaii 1-800-227-0482 out of state or 1-808-342-7252 in state
California 1-800-225-8883
Mid-Atlantic States 1-800-810-4766
Colorado 1-303-318-1111
Georgia 1-855-265-0311

Preferred Provider Organization (PPO) Plans

ALL Direct or ER to Inpatient admissions will be reviewed by Permanente Advantage, as the member does not have an HMO benefit tier. Immediate notification of admission is required. Submission of pre-certification must be requested and marked as “Urgent” with attached supporting clinicals for review.

Emergency services do not require pre-certification.

Pregnancy Related

When a Covered Person is admitted to a hospital for delivery of a child, the Covered Person is automatically authorized based on the hospital Mandated Length of Stay for a minimum of:

Forty-eight (48) hours for a normal vaginal delivery; and
Ninety-six (96) hours for a Cesarean section deliver

Automatic authorization begins the day of delivery of the child. Any extended confinement or admit prior to delivery will require pre-certification review based on medical necessity.

Planned Inpatient Admission

Permanente Advantage will review ALL planned hospital confinement procedures. As soon as reasonably possible after the Covered Person, Authorized Representative, or provider learns of the need for hospital confinement or any treatment or services requiring hospital confinement pre-certification but at least three days prior to admission or performance of treatment or service, they must notify and request for pre-certification.

Failure to submit supporting clinicals may result in the delay of processing your request, denial for lack of clinicals, and/or pre-certification penalty. Clinical information cannot be received verbally, all information must be faxed or emailed.

Effective 01/01/22 – Kaiser Permanente Insurance Company has moved to ONLY a Level One Appeal process, except for CO Region, which still has a voluntary 2nd level appeal.

If your initial request for pre-certification or subsequent concurrent review was denied by Permanente Advantage, the patient has the right to appeal the decision. Please refer to the denial letter for complete Appeal Rights information.

As outlined in the Appeal Rights, please include in your request: (1) your name and your Medical Record Number: (2) your medical condition or symptom; (3) the specific treatment, service, or supply that you are requesting; and (4) the specific reason(s) for your request that we review our initial decision. Please also include any additional information you want considered in the appeal review process.

If a provider wishes to appeal on behalf of the member, a Statement of Authorized Representative (SAR) form must also be submitted. The SAR must be completed and signed by the patient (or patient’s parent/guardian if the patient is under 18 years of age). An appeal request from a provider will not be processed without a completed Statement of Authorized Representative Form (SAR).

Download Statement of Authorized Representative (SAR).

Appeals Level-One

For California, Colorado, Georgia, Hawaii, or Mid-Atlantic members, please submit appeal requests to:

Permanente Advantage, LLC
Appeals Department
8954 Rio San Diego Drive, Room 10R10
San Diego, CA 92108
Fax: 866-338-0266 or
Email: PermAdvantageTeam-KPPA@kp.org