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Pre-certification requests

Doctor with patient

Pre-Certification Code Check Tool 

Automated capability for a quicker and easier way to determine if a service/code requires pre-certification.

Note: The Pre-Certification Code Check Tool provides pre-certification requirements for medical services covered by Point-of-Service (POS) and Preferred Provider (PPO) plans underwritten by Kaiser Permanente Insurance Company (KPIC) and reviewed by Permanente Advantage ONLY. The Pre-Certification Code Check Tool does not provide results for products underwritten by Kaiser Foundation Health Plan or Medicare Products. Services that require pre-certification by Cigna providers are also not included.

The Pre-Certification Tool reflects services requiring Pre-Certification for outpatient services only. Inpatient results are not included, and ALL INPATIENT SERVICES REQUIRE Pre-Certification.

Refer to the Pre-Certification Code Check Frequently Asked Questions.

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.

If you need to request pre-certification (also called “prior authorization”) for a medical service, please remember that this must be done before the service is provided, except in emergencies. Your healthcare provider should send the pre-certification request, including any required clinical information, before you receive care. If you are seeking reauthorization of a previously approved service, your provider must also follow this process. To submit a completed request form and supporting clinical documents, your provider can send them by fax or email using the contact information below.

Fax #: 866-338-0266

Email: PermAdvantageTeam-KPPA@kp.org

Link to Permanente Advantage Pre-Certification Request Form.

Link to Maryland Uniform Treatment Plan Form (Exclusively for Maryland Members ONLY for Mental Health/Substance Use Disorder Requests).

If you would like a copy of the pre-certification requirements or have any questions about the pre-certification request form, the pre-certification process, or verification of services that require pre-certification, please email us at PermAdvantageTeam-KPPA@kp.org or 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

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.

Providers and members can use the following links below to review the clinical guidelines / criteria for potential future services or the guideline / criteria used in a denial determination.

To find a list of services that require pre-certification, click the link below designated to the member’s region:

N/A

To see data regarding approvals and denials of pre-certification requests for the Colorado Plans please view the following:

Additional state-specific criteria/guidelines

FOR COLORADO DESIGNATED MEMBERS ONLY

To see data regarding approvals and denials of pre-certification requests for the Georgia Plans please view the following:

To see data regarding approvals and denials of pre-certification requests for the Hawaii Plans please view the following:

District of Columbia

To see data regarding approvals and denials of pre-certification requests for the District of Columbia Plans please view the following:

Maryland

Additional state-specific criteria/guidelines
FOR MARYLAND DESIGNATED MEMBERS ONLY

Virginia

To see data regarding approvals and denials of pre-certification requests for the Virginia Plans please view the following:

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.

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.

 

For ALL Inpatient hospital admits – it is important to provide immediate notification of the covered person’s admission status. Please review the following pre-certification guidelines for Hospital admission:
 

Emergency Related Admission

Point-of-Service (POS) Plans

Emergency admissions is covered under ALL plans –under the HMO benefit (Tier 1). –HMO Utilization Management department must be notified first of the covered person’s ER to inpatient admission. Emergent care up until the point when the patient is stable for transfer is covered under HMO (Tier 1) benefit and is managed by each region’s local HMO UM department. Please contact the local department below, designated to the member’s region:

Preferred Provider Organization (PPO) Plans

ALL Direct or ER to Inpatient admissions will be reviewed by Permanente Advantage, as the member does not have an HMO benefit tier. Immediate notification of admission is required. Submission of pre-certification must be requested and marked as “Urgent” with attached supporting clinicals for review.
 
Emergency services do not require pre-certification.
 

Pregnancy Related

When a Covered Person is admitted to a hospital for delivery of a child, the Covered Person is automatically authorized based on the hospital Mandated Length of Stay for a minimum of:
  • 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

Permanente Advantage will review ALL planned hospital confinement procedures. As soon as reasonably possible after the Covered Person, Authorized Representative, or provider learns of the need for hospital confinement or any treatment or services requiring hospital confinement pre-certification but at least three days prior to admission or performance of treatment or service, they must notify and request for pre-certification.
 
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.

Effective 01/01/22 – Kaiser Permanente Insurance Company has moved to ONLY a Level One Appeal process, except for CO Region, which still has a voluntary 2nd level appeal.

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, Room 10R10
San Diego, CA 92108
Fax: 866-338-0266 or
Email: PermAdvantageTeam-KPPA@kp.org