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Background
High-cost Clinically Administered Medications (CAMS) require Prior Authorization from KPCO Utilization Management department before administration.
As of 11/17/2021 some CAMS also require approval from KPCO Pharmacy Authorization Services (PAS) Team if the medication will be administered at a KPCO clinic.
Xolair can be administered in KPCO Primary Care Departments at Briargate MOB (Co Springs), Pueblo North MOB (Pueblo,) and Loveland MOB (Loveland.)
The prescribing provider who is directing the patient to get this medication is responsible for seeking Prior Authorization in the way you submit authorization requests now.
Instructions
- Prior Authorization Forms can be found on the KPCO Community Provider Portal website.
- Once completed, the Form will need to be sent by fax to KPCO Utilization Management Department at 866-529-0934.
- Once Authorization review has been completed, the prescribing provider and member will receive an Approval or Denial Letter from KPCO Utilization Management department.
- Members will be able to locate the Authorization Letter online in their kp.org account, or they will be sent the Authorization Letter by mail if they do not have kp.org (Kaiser patient portal account.)
Important Notes:
- Review of Routine Prior Authorization requests can take up to two weeks to process as KPCO Utilization Management and Pharmacy Authorization Services Teams need time to review.
- This means that members will not be able to have the CAM administered the same day in a KPCO facility!
- If there is a need for the patient to have the medication administered urgently, please submit an Urgent request. Urgent requests are processed in 72 hours.
Acute Rehab /LTACH reviews - Kaiser Permanente Colorado conducts medical necessity reviews for Acute Inpatient Rehabilitation and Long-Term Acute Care Hospitalizations utilizing MCG guidelines. When cases are approved the authorization will be valid for 48 hrs. If the member does not admit within 48 hrs., the request for desired level of care will need to be re-submitted with updated clinicals for review. Once the member has admitted to the chosen AR/LTACH the initial authorization period for Commercial Members will be for 7 days. The initial authorization period for Medicare Members will be 14 days for AR and 25 days for LTACH. Concurrent/Continuation of Care reviews will be conducted biweekly, with authorizations updated by 4:00pm to facilities via Affiliate Link Portal.
Medicare Payment Denial - Kaiser Permanente Colorado implemented a new Standard Operating Procedure Effective 06/25/2020. All inpatient Medicare cases will be concurrently reviewed when the length of stay is greater than 10 days. If the case is no longer meeting medical necessity based on MCG criteria, the facility will be notified and given the opportunity to conduct a peer to peer with our Utilization Medical Director. If after the peer to peer the UMMD determines it is still not meeting inpatient medical criteria, a payment denial will be issued to the provider. This process was created to ensure KP members are utilizing inpatient hospital setting appropriately, and that they are transitioned to the correct lower level of care timely.