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Referral information
Specialty-to-Specialty Referrals
Specialty-to-specialty referrals will only be allowed in limited circumstances. Primary care physicians (PCPs) should generate all referrals for specialty care in KP Online-Affiliate, and specialists should coordinate with the member’s PCP to have the member referred and all relevant clinical information forwarded.
In certain limited circumstances, specialty-to-specialty referrals may be allowed. They include the following, along with those listed in the specialty referral grid
Ob-gyn may refer to any specialty for all pregnancy related illnesses
Any specialty can refer to hematology/oncology
Any specialty can refer to self-referral specialties (dermatology, ob-gyn, ophthalmology, optometry, office-based behavioral health)
Pediatric specialties follow the same specialty to specialty referral pattern as adult specialties
If you have questions, please contact Provider Contracting and Network Management at 877-465-0029.
Authorization policies
View and submit referrals
You can view and submit referrals by signing on to our provider tools
A referral is defined as sending a member for office-based professional services. Referrals are required for all specialties other than dermatology, ob-gyn, ophthalmology, optometry, and outpatient behavioral health. Other services (including routine radiology, lab, etc.) do not require a referral. See Section 4.5 of the Provider Manual for further clarification.
Primary care physicians should generate referrals via KP Online-Affiliate when referring members to specialists or the claims will deny. Specialists need to verify referrals are in KP Online-Affiliate. If there is no referral in the system, contact the primary care office.
We will no longer be providing paper referral grids. You will get that information from KP Online-Affiliate. Kaiser Permanente expects referring physicians to supply all pertinent diagnosis and clinical information to the specialist via the online request for the referral.
Please call the Kaiser Permanente QRM Intake Services department at 404-364-7320 or 800-221-2412 (toll-free) for assistance when referring a Kaiser Permanente member for specialty care.Back to top
Referred specialty care
Referred specialty care services are coordinated by the member's personal physician, which includes care that members receive in the hospital or from specialists.
Patients look to their personal physician for guidance when they need to see a specialist. Often, the personal physician has an established relationship with a specific group of specialty care providers, improving coordination of care. When patients need specialty care, we encourage physicians to talk to them about the numerous benefits of seeing a Kaiser Permanente specialist. We have provided the TSPMG Specialty Care Guide for you to share with members.
Primary care physicians should generate referrals via KP Online-Affiliate. The member's personal physician will advise if the referral requires authorization from authorization.
Targeted review list
Targeted Review List Procedure Codes
Kaiser Permanente reserves the right to add or remove from the Targeted Review List* any procedures or services deemed appropriate by the Kaiser Permanente Quality Forum Committee, Quality Resource Management (QRM), or management. QRM will strive to provide sufficient notification prior to any anticipated change. Please contact them with any questions.
All procedures or services found on the targeted review list require authorization or medical necessity review by QRM. Please submit complete supporting clinical information with all requests.
Initiate routine requests via KP Online-Affiliate by calling 404-364-7320 or 800-221-2414 (toll-free), or by faxing to 404-364-7187. STAT requests must be entered with the priority of “Urgent” in KP Online-Affiliate. All requests must include pertinent, supporting clinical indications for the requested study.
An authorization is valid when the following conditions are met:
An approval notification has been received via KP Online-Affiliate In-Basket message, fax, or phone call from Kaiser Permanente, including the authorization number
Services are rendered between the assigned start date and expiration date of the authorization to the specialist or facility, as noted on the authorization
Member has the appropriate benefit and is eligible on the date of service
Procedure or treatment is medically necessary for the member’s diagnosis
Procedure or treatment is performed in a practitioner’s office, outpatient hospital, or ambulatory surgery center
Kaiser Permanente reserves the right to close an authorization prior to its expiration date.