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To request a referral, please contact your Provider.
If your Provider decides that you need covered services from a Specialist, your Provider will request a referral for you. If you did not receive a referral during your visit and you would like to request one, please call Member Services at (800) 777-7902 to start the process. You will receive a decision on your requested referral whether the referral is approved or denied.
The types of referrals are listed below with additional information on how the process will work.
Referrals to specialists
If your Provider decides that you need medically necessary and appropriate covered services from a specialist, then we will refer you to a Kaiser Permanente plan physician or another plan provider for that service. All referrals must be approved before you receive services. Referrals are reviewed and approved by the Utilization Management team, which includes referral nurses, physical therapists, physicians, and support staff who use nationally recognized guidelines to approve or deny your referral.
Referrals to non-plan providers
Your Provider or attending specialist may refer you to a non-plan provider. We will approve services from non-plan providers only if we do not have a plan provider with the professional training and expertise to treat or provide health care services for your condition or disease or if we cannot provide reasonable access to a plan provider with the professional training and expertise to treat or provide health care services for your condition or disease without unreasonable delay or travel. You must have an approved referral to the non-plan provider for us to cover the services and/or supplies. If we approve the referral to the non-plan provider, you pay only what you would have paid if a plan provider provided the services/supplies.
Standing Referrals for pregnant members
If you are pregnant, you will receive a standing referral to an obstetrician. The obstetrician will be responsible for the management of your pregnancy, including the issuance of referrals, through the postpartum period. A written treatment plan may not be required when a standing referral is to an obstetrician.
Standing referrals to specialists
If you suffer from a life-threatening, degenerative, chronic, or disabling disease or condition that requires specialized medical care, your Provider may decide with you and a specialist, that you need continuing care from that specialist and issue a standing referral to the specialist. The standing referral will be based on a written treatment plan consisting of covered services.
Additional services not covered
Any additional services not specifically listed in your specialist’s treatment plan and/or that are provided by a professional not named in the referral is not approved and will not be covered.
If a non-plan provider for whom you have received an approved referral recommends additional services that were not included in the approved referral, contact your plan provider. Your plan provider will work with Health Plan to determine whether those services can be provided by a plan provider.
Referral decision timeframes
Referral decisions will be made within the following timeframes:
- Urgent requests: Decisions will be made and communicated to the requesting provider within 24 hours of the request. If the referral is not approved a letter will be sent to you within 24 hours of the decision.
- Non-urgent requests: Decisions will be made within two (2) working days after we receive all the needed information. The decision will be communicated to the requesting provider within one (1) working day.
If your referral is approved
If your referral is approved, we will give you instructions to make your appointment(s).
If your referral request is not approved
If your referral is not approved, we will send you a denial letter with instructions for filing an urgent or non-urgent appeal.
How to file a non-urgent appeal
How to file a non-urgent (pre-service or post-service) appeal:
You or your authorized representative may file an appeal by sending a written request, including all supporting documentation that relates to the appeal to:
Kaiser Permanente
Attention: Appeals Department
Nine Piedmont Center
3495 Piedmont Road, NE
Atlanta, GA 30305-1736
Fax: 404-949-5001
1. In your request, please include
2. your name, medical record number, claim number
3. your medical condition or symptom
4. the specific treatment, service or supply that you are requesting and
5. the specific reason(s) for your request that we review our initial decision
Your appeal must be filed in writing within 180 calendar days of your receipt of our denial letter. If your appeal is filed after 180 calendar days, we will send a letter denying your appeal because it was not filed timely.
How to file an urgent appeal
Urgent appeals are available for medically urgent situations. In these cases, call Member Services at 800-777-7902 (TTY 711) (toll free).
Monday through Friday, 7:30 a.m. to 9 p.m.
After working hours, call an advice nurse:
- Within the Washington, DC metro area, 703-359-7878 (TTY 711)
- Outside the Washington, DC, metro area, toll free at 800-777-7904 (TTY 711)
Within 24 hours of our receipt of your appeal, we will contact you if we need additional information to make a decision. If we request additional information, you will have only 48 hours to submit the requested information.
Urgent appeal decision timeframes
We will decide within twenty-four (24) hours of:
- Our receipt of the information from you; or
- the end of the period we specified for submitting the requested information.
Decisions on urgent appeals will be communicated to you or your authorized representative by telephone within twenty-four (24) hours. An authorized representative is an individual authorized by you to act on your behalf or who may, under or under State or other applicable law, act on your behalf. We will also send you a letter within one (1) calendar day of our decision.
Non-urgent appeal acknowledgment
We will acknowledge receipt of your appeal within five (5) working days of our receipt of your written appeal.
Pre-service appeal decision timeframe
If your appeal is for a health care service that has not been provided, we will send you and your authorized representative a letter within 30 working days of the date that you filed your appeal to let you know if your appeal is approved or denied.
Post-service appeal decision timeframes
If your appeal is asking for payment for health care services already provided, we will send you and your authorized representative a letter within the earliest of 45 working days or 60 calendar days of the date that you filed your appeal to let you know if your request is approved or denied.
For both pre-service and post-service appeals, if we need more time to decide, we will send you and your authorized representative a letter seeking your written approval for an extension of no more than thirty (30) working days. If you or your authorized representative do not agree to the extension, then we will make the appeals decision within the original timeframe. Any agreement to extend the period for a grievance decision will be documented in writing.
For questions, please call Member Services at (800) 777-7902 (TTY 711) (toll free).
To request a referral, please contact your Provider.
If your Provider decides that you need covered services from a Specialist, your Provider will request a referral for you. In certain instances, your Provider or attending specialist may refer you to a non-plan provider. We will approve services from non-plan providers only if we do not have a plan provider with the professional training and expertise to treat or provide health care services for your condition or disease or if we cannot provide reasonable access to a plan provider with the professional training and expertise to treat or provide health care services for your condition or disease without unreasonable delay or travel. You must have an approved referral to the non-plan provider for us to cover the services and/or supplies. If we approve the referral to the non-plan provider, you pay only what you would have paid if a plan provider provided the services/supplies.
If you did not receive a referral during your visit and you would like to request one, please call Member Services at (800) 777-7902 or submit a written request to Member Services via the kp.org website to start the process. You will receive a decision letter letting you know whether your requested referral is approved or denied. Your decision letter will provide instructions on how to proceed if your referral is approved or how to appeal if your referral is denied.
You can find additional information related to referral requests and/or what to do if your referral request is denied in your contract.