Clinical review

Coverage provided by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente).

Kaiser Permanente Clinical Review Criteria are developed to assist in administering plan benefits. These criteria neither offer medical advice nor guarantee coverage. For information concerning whether a specific service or benefit is covered, please refer to the patient's medical coverage agreement, the Provider Manual, your Provider contract, or call the Kaiser Permanente Provider Assistance Unit at 1-888-767-4670. Kaiser Permanente reserves the exclusive right to modify, revoke, suspend or change any or all of these review criteria, at Kaiser Permanente’s sole discretion, at any time.

By viewing these criteria, you acknowledge that you understand and accept the following:

• These Kaiser Permanente Clinical Review Criteria are technical and written to assist medical personnel in making coverage determinations. They are not medical advice, nor are they intended to influence the practitioner or alter his/her duty in any way to exercise his/her independent professional judgment in the care of members.
• The Kaiser Permanente Clinical Review Criteria are developed to identify eligibility for coverage when the patient's coverage contract includes the service/device.
• It should not be assumed that a patient meeting the criteria has coverage for the service/device. Please check the patient's coverage contract for specific exclusions or limitations.
• The criteria developed for use by Kaiser Permanente are based on the best available clinical evidence and regionally or nationally accepted standards.
• All Kaiser Permanente Clinical Review Criteria are reviewed annually. However, they are regularly updated and subject to change without notice. Service requests for a member are reviewed using the most current criteria.
• Kaiser Permanente has included the results of reviews conducted by the Medical Technology Assessment Committee and the Pharmacy & Therapeutics Committee. These committees, using evidence-based standards, review new technologies and treatments for medical efficacy. By including these reviews on this site, you will find that not all services listed in the directory are covered, and therefore some do not have approved criteria. Please carefully check the coverage and criteria sections under each of the topics.
• Members and practitioners have the right to appeal coverage decisions. If the Kaiser Permanente medical director or his/her designee determines that a service is not covered, a notice will be issued to both the member and the practitioner. In addition to outlining the rationale for the denial, the notice will contain instructions for appealing the decision.
  
  

Kaiser Permanente also utilizes externally developed clinical criteria. Those documents can be reviewed on the KPWA MCG Guidelines page.

If you have questions, call the Kaiser Permanente Provider Assistance Unit at 1-888-767-4670. For more information about how Kaiser Permanente applies the criteria, see Utilization Review.