PPO plan
Prior Approval
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 a Participating Provider or Non-Participating Provider.
To see data regarding approvals and denials of pre-certification requests view the Medical Preauthorization Rates Report and the Pharmacy Preauthorization Rates Report.
What requires pre-certification?
Participating Provider Tier
First Health® and the Cigna 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 Cigna PPO Network for care in non-Kaiser Permanente states, the Cigna PPO providers are responsible for obtaining pre-certification on your behalf when pre-certification is required. You won’t be financially responsible if a Cigna PPO provider fails to obtain pre-certification for covered services.
How do I receive pre-certification?
- Your Participating Provider will obtain pre-certification for you.
- To learn more, view the Permanente Advantage Flier, or review the pre-certification section in your Evidence of Coverage (EOC)/Certificate of Insurance (COI) for details.
- To see criteria used to determine medical necessity for your current or future pre-certification request:
- Send an email to Permanente-Advantage@kp.org to request a secure sign-on. Be sure to state in the email what health care service you are interested in viewing.
- You may also fax your request to: 1-866-338-0266.
- Once you have received your secure sign-on, click here http://kpic.access.mcg.com, or enter this web address into your browser to access the criteria.
- To see data regarding approvals and denials of pre-certification requests view the Medical Preauthorization Rates Report and the Pharmacy Preauthorization Rates Report.
Non-Participating Provider Tier
- For Non-Participating 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 Non-Participating Provider may obtain pre-certification for you or your authorized representative by calling 1-888-525-1553 (TTY 711). Representatives are available Monday through Friday, 6 a.m. to 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 in the Non-Participating Provider Tier, 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, view the Permanente Advantage Flier, or review the pre-certification section in your Evidence of Coverage (EOC)/Certificate of Insurance (COI) for details.
- To see criteria used to determine medical necessity for your current or future pre-certification request:
- Send an email to Permanente-Advantage@kp.org to request a secure sign-on. Be sure to state in the email what health care service you are interested in viewing.
- You may also fax your request to: 1-866-338-0266.
- Once you have received your secure sign-on, click here http://kpic.access.mcg.com, or enter this web address into your browser to access the criteria.
- To see data regarding approvals and denials of pre-certification requests view the Medical Preauthorization Rates Report and the Pharmacy Preauthorization Rates Report.
Need pre-certification?
Call 1-888-525-1553 (TTY 711)
Download the medical Permanente Advantage Pre-Certification Form.
Donwload the Pharmacy Prior Authorization Request Form (KPIC MRF).