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How to Access Covered Care

Choose your doctor and change anytime.

Getting in-depth information on how your plan works and getting connected with a provider who suits your individual needs is the first priority. Choose from a wide range of great providers or stay with your current provider. And, remember—you can change at any time. Your plan provides you with that flexibility. However, the benefits provided under the HMO In-Network Provider Tier, Participating Provider Tier, and Non-Participating Provider Tier are not the same. Some services are covered only at the HMO In-Network Provider Tier.

Here’s an overview of getting care with Choice Products. In the 3 Tier Point-of-Service (POS) plan, there are three Tiers to choose from: HMO In-Network Provider Tier, Participating Provider Tier, and Non-Participating Provider Tier.

For members who have a POS, Out-of-Area PPO, or PPO plan – For Information about Kaiser Permanente Insurance Company’s (KPIC’s) Network Adequacy Policy, please review our Frequently Asked Questions Document

HMO In-Network Provider Tier

Kaiser Permanente Providers

Many ways to access care through Kaiser Permanente.

Your care in the Kaiser Permanente network starts with your own personal doctor—your primary care physician—who will coordinate your care. You choose your own doctor and you can change your doctor at any time.
You can also see most specialists without a referral.
You can manage your care at kp.org. Visit anytime from anywhere to make an appointment, refill most prescriptions, see most lab results, and much more.
You could also have a video or telephone visit with a doctor at no extra cost.

With Kaiser Permanente Providers, you’ll usually pay the lowest out-of-pocket costs with no or a lower deductible.

Participating Provider Tier

Provider Directory Options by Location:

In Colorado: Find Network providers and locations

In Kaiser Permanente States: The 3T POS, PPO, and OOA’s First Health Network provides access to care in the Kaiser Permanente states of CA, CO, GA, HI, MD, OR, VA, WA, and DC.

Non-Kaiser Permanente States: The Cigna Healthcare^SMPPO Network* only provides access to care in non-Kaiser Permanente states.

*Disclaimer: The Cigna PPO Network refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration.

To find a Participating Provider or confirm if your current provider is part of the Participating Provider Tier, you can search for Providers by location (Kaiser Permanente and non-Kaiser Permanente states) or call Customer Service at 1-855-364-3184 (TTY 711), Monday through Friday 8 a.m.-6 p.m., Mountain time

Through the Participating Provider Tier, you have access to First Health providers and Cigna PPO Network providers based on service location.
No referral is needed for office visits to Participating Provider physicians or specialists. However, your Participating Provider will need to obtain pre-certification for some services and procedures. Your Participating Provider must call 1-888-525-1553 (TTY 711) for pre-certification.
It is always a good idea to call the provider’s office to confirm that they are a Participating Provider.

Can I nominate a physician to become a Participating Provider?

Yes. If you were seeing a doctor who is not contracted with the First Health Network in Colorado or other Kaiser Permanente states, or with the Cigna PPO Network outside of KP states, you can nominate the doctor to join the network. Please keep in mind your provider may choose not to be contracted.
To nominate a provider, call Customer Service at 1-855-364-3184 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m., Mountain time.
Nominations can take up to 60 – 120 days from receipt of the provider’s complete application. Whether a physician or practitioner is accepted depends on a number of considerations including the provider’s interest in joining, so a nomination doesn’t guarantee acceptance.

Helpful Tips

When making an appointment. Make sure the provider is a Participating Provider that is part of the First Health Network or Cigna PPO Network that is accepting new patients.
When checking in for your visit. Bring your ID card with you. If your provider has any questions, have them call the customer service phone number on the front of your ID card. Make sure the provider only refers you to laboratory, radiology, and other service providers and facilities that are also participating providers.
After your visit. Your participating provider office will take care of claim submissions for you.

Non-Participating Provider Tier

Call any licensed provider’s office directly.

Your Non-Participating Provider Tier benefits cover care you receive from any licensed provider (outside the HMO In-Network Provider Tier and the Participating Provider Tier).
You can call the provider’s office directly to make an appointment.
You don’t need a referral for Non-Participating Providers or specialists. However, you will need pre-certification for some services and procedures. You must call 1-888-525-1553 (TTY 711) for pre-certification.
Your doctor may require you to pay the full cost of the visit. And you will need to submit claim forms and itemized bills for reimbursement.
You’ll have to pay coinsurance and meet a deductible. You’ll also be responsible for any difference between what your provider charges for service and the payment Kaiser Permanente Insurance Company provides.

Helpful Tips

When making an appointment. Make sure the provider understands that your plan allows you to see any licensed provider.
When checking in for your visit. Bring your ID card with you. If your provider has any questions, have them call the customer service phone number on the front of your ID card.
After your visit. When you receive services from a Non-Participating Provider, you will need to submit a claim and you will be responsible for paying the difference.

You’ll generally pay the most out-of-pocket costs when you receive services from a Non-Participating Provider or facility.

It’s important to keep in mind:

Your cost-shares will vary in each provider Tier.
The amount you pay for a particular service will depend on the provider Tier you choose and—in some cases—where you choose to receive care.

To find out more:

See your Point-of-Service (POS) New Member Guidebook for details about accessing covered care using the different Tiers.
Refer to your Certificate of Insurance (COI).
Contact the human resources/benefits officer where you work, if your employer provides your coverage.
Call Customer Service at 1-855-364-3184 (TTY 711), Monday through Friday, 8 a.m. to 6 p.m., Mountain time, or refer to your ID card.

Kaiser Foundation Health Plan of Colorado, Inc.(KFHP), underwrites the HMO In-Network Tier and Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., underwrites the Participating Provider Tier and Non-Participating Provider Tier of the 3-Tiered POS Plan. Kaiser Permanente Insurance Company is contracted with First Health, First Health is a brand name of First Health Group Corp. The list of participating First Health providers is subject to change without notice. Some services require pre-certification.

KPIC has also contracted with the Cigna PPO Network outside of Kaiser Permanente states for health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration. Cigna is an independent company and not affiliated with Kaiser Foundation Health Plan, Inc., and its subsidiary health plans. Access to the Cigna PPO Network is available through Cigna’s contractual relationship with the Kaiser Permanente health plans. The Cigna PPO Network is provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. For more information, see your Certificate of Insurance (COI).