
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)
Please keep in mind of the following when submitting for pre-certification:
Non-Urgent/Routine Request - Turn-Around-Time (TAT):
2-business day turnaround for VA / MD members.
5-calendar day turnaround for CA members.
5-business day turnaround for CO / HI members.
7-calendar day turnaround for GA members.
14-business day turnaround for DC members.
Urgent Request - Turn-Around-Time (TAT):
24-hour turnaround for DC / MD members.
72-hour turnaround for CA / CO / HI / GA / VA members.
Urgent requests: must be mark “Urgent” and will be reviewed based on the definition under Kaiser Permanente Insurance Company Certificate of Insurance, NOT by the Scheduled Service Date. If qualified as medically urgent, request will be processed within 24-72 hours as defined by state regulations. We DO NOT review STAT or EMERGENT requests.
Supporting clinical documentation is required and MUST BE submitted with completed pre-certification form. 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.
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
Notification of Decision on ALL Submitted Requests
- Notify the provider verbally and follow-up with written or electronic notification once the decision is available; and
- Notify the Covered Person and/or their Authorized Representative with written or electronic notification.
- Notify the provider, Covered Person and/or their Authorized Representative verbally once the denial, alternate treatment, or service recommendation determination is completed; and
- Notify the provider, Covered Person and/or Authorized Representative with written or electronic notification.
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 link below to review the clinical criteria used in a denial determination. Request for access to clinical criteria for potential future service, is also available. To request a criteria code and password for access to MCG Health Transparency Portal, please submit your request to Permanente Advantage by:
Fax: 866-338-0266 or
Email: Permanente-Advantage@kp.org
MCG Health Transparency Link: MCG Transparency Portal - Login
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, Ste 406
San Diego, CA 92108
Fax: 866-338-0266 or
Email: PermAdvantageTeam-KPPA@kp.org