Pre-certification Form and Instructions
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.
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.
Turn-Around-Time (TAT) 2024
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. |
Hospital (Inpatient) Emergency Admissions
Emergency Related Admission
Point-of-Service (POS) Plans
- 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
Pregnancy Related
- 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
Pre-Certification Guidelines and Services
To find a list of services that require pre-certification, click the link below designated to the member’s region:
Mid-Atlantic
Georgia
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
Colorado
Small Group – PPO
Small Group – 3 Tier- POS
Large Group – 3 Tier-POS
Large Group – PPO
FOR COLORADO DESIGNATED MEMBERS ONLY
Providers and members designated to the Colorado region ONLY, 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
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.
Medical Necessity Appeals
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, 2nd Floor, Room 20R22
San Diego, CA 92108
Fax: 866-338-0266 or
Email: PermAdvantageTeam-KPPA@kp.org