Choice PPO plan
Pre-Certification
To ensure that the medical service ordered is medically necessary and cost effective, prior approval may be required. This is known as pre-certification for services ordered by an In-Network Provider or Out-of-Network Provider.
To see data regarding approvals and denials of pre-certification requests click here for medical and click here for pharmacy.
What requires pre-certification?
In-Network Providers
Kaiser Permanente Providers
- For care with Kaiser Permanente Providers and the Colorado statewide network of contracted providers, your provider will arrange for pre-certification, if required, for certain services.
First Health® and the Cigna HealthcareSM PPO Network
- Some services may require pre-certification to be covered, such as inpatient care (for example: hospital surgical procedures) and some outpatient procedures.
- If using the First Health Network (in Kaiser Permanente states except Colorado) and Cigna Healthcare PPO Network (in non-Kaiser Permanente states) for care, the First Health Network providers and Cigna Healthcare PPO providers are responsible for obtaining pre-certification on your behalf when pre-certification is required. You won’t be financially responsible if First Health Network and Cigna Healthcare PPO providers fail to obtain pre-certification for covered services.
How do I receive pre-certification?
- Your In-Network Provider will obtain pre-certification for you.
- To learn more, review the pre-certification section in your Certificate of Insurance (COI) for details.
Out-of-Network Providers
- For Out-of-Network Providers, some services require pre-certification to be covered, such as inpatient care (for example: hospital surgical procedures) and some outpatient procedures.
How do I receive pre-certification?
- Your Out-of-Network Provider may obtain pre-certification for you or your authorized representative by calling 1-855-364-3184 (TTY 711). Representatives are available Monday through Friday, 8 a.m.–6 p.m., Mountain time. You may, however, request pre-certification 24 hours a day, seven days a week, especially for urgent requests.
- If you don’t obtain pre-certification for services obtained from Out-of-Network Providers, you may have to pay the entire expense which reduces your benefit. The penalty does not apply toward your deductible or out-of-pocket maximum. So, it’s really important to get pre-certification.
- To learn more, review the pre-certification section in your Certificate of Insurance (COI) for details.
Need pre-certification?
Call 1-855-364-3184 (TTY 711)
Download the medical:
Prior Authorization Form for Services within CO Permanente Advantage Pre-Certification FormDownload the Pharmacy Prior Authorization Request Form (KPIC MRF).