PRIOR AUTHORIZATION METRICS FOR MEDICAL ITEMS AND SERVICES (EXCLUDING DRUGS)

To comply with the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization final rule, Kaiser Permanente is required to report certain prior authorization information on our website every year for specific plans. This includes a list of all medical items and services (not including drugs) that need prior authorization, as well as related data from the last calendar year. Sharing this information helps make the process clearer and easier to understand. It helps patients learn how prior authorization works, and it helps providers review how payers are performing. These metrics can help people compare plans, programs, and payers.

If you have questions about the information below, email External-Care-Management-Team@kp.org.

Reporting Period:  2025

Medical Items and Services Requiring Prior Authorization

These are the medical items and services for which we require prior authorization (not including drugs), visit Prior Authorization List and choose a region.

Prior Authorization Decision Timeframes

Before January 1, 2026

Impacted payers were required to send prior authorization decisions within these timeframes:

Medicare Advantage plans and applicable integrated plans:

  • Expedited urgent requests: within 72 hours
  • Standard non-urgent requests: within 14 days

Medicaid managed care plans and CHIP managed care entities:

  • Expedited urgent requests: within 72 hours
  • Standard non-urgent requests: within 14 days

Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs):

  • Expedited urgent requests: within 72 hours
  • Standard non-urgent requests: within 15 days

Starting January 1, 2026

The CMS Interoperability and Prior Authorization final rule now requires payers to send prior authorization decisions within these timeframes:

Medicare Advantage plans and applicable integrated plans:

  • Expedited urgent requests: within 72 hours
  • Standard non-urgent requests: within 7 days

Medicaid-managed and CHIP-managed plans:

  • Expedited urgent requests: within 72 hours
  • Standard non-urgent requests: within 7 days

Qualified Health Plan (QHP) issuers on the Federally Facilitated Exchanges (FFEs):

  • Expedited urgent requests: within 72 hours
  • Standard non-urgent requests: within 15 days

CMS Prior Authorization Metrics Reporting 

Region

PDF

Machine Readable File

Southern California

Prior Authorization Metrics Report - Southern California.pdf

Prior Authorization Metrics Report - Southern California.xml

Northern California

Prior Authorization Metrics Report - Northern California.pdf

Prior Authorization Metrics Report - Northern California.xml

Colorado

Prior Authorization Metrics Report - Colorado.pdf

Prior Authorization Metrics Report - Colorado.xml
Georgia Prior Authorization Metrics Report - Georgia.pdf

Prior Authorization Metrics Report - Georgia.xml

Hawaii

Prior Authorization Metrics Report - Hawaii.pdf

Prior Authorization Metrics Report - Hawaii.xml

Northwest- Oregon / South West Washington

Prior Authorization Metrics Report - Oregon and Southwest Washington.pdf

Prior Authorization Metrics Report - Oregon and Southwest Washington.xml

Washington

Prior Authorization Metrics Report - Washington.pdf

Prior Authorization Metrics Report - Washington.xml

Mid-Atlantic States- Maryland/Virginia/Washington, D.C.

Prior Authorization Metrics Report - Mid-Atlantic.pdf

Prior Authorization Metrics Report - Mid-Atlantic.xml

Maryland Medicaid

Prior Authorization Metrics Report - Maryland.pdf

Prior Authorization Metrics Report - Maryland.xml