CurrentKaiser PermanentePolicy N/A

2025 PPO preauthorization and notification requirements

Lists services that require notification or preauthorization for Kaiser Permanente Washington PPO members and explains where members and providers can verify requirements; affects members, providers, and billing/authorization staff in Washington.

Policy Summary

PayerKaiser Permanente

Policy2025 PPO preauthorization and notification requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain required notification or preauthorization before providing listed services or risk denial of payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MultipleService categories listed

Notification: AllInpatient admissions

Home oxygen, wheelchairsDME/prosthetics examples

Extensive listSurgery

kp.org/walproviderProvider tools online

Coverage stance and where to find criteria

High-level coverage stance

Coverage and prior authorization criteria are maintained on the provider portal; specific services listed require prior authorization or notification and may be denied if authorization is not obtained.

Providers and members must check kp.org/walprovider or contact Member Services to verify current prior authorization and notification requirements; services that require preauthorization will be denied if not obtained.

Services requiring notification: All inpatient admissions (including emergency, planned, mental health, and withdrawal management), home health care (including home infusion and dialysis), hospice, long-term acute care, skilled nursing facility, and substance abuse disorder residential admissions require notification.

Durable medical equipment, prosthetics, and supplies requiring preauthorization

Examples requiring preauthorization include bone growth stimulators, home oxygen, mobility devices, negative pressure wound therapy, prosthetic limbs, and speech generating devices.

Policy Summary

PayerKaiser Permanente

Policy2025 PPO preauthorization and notification requirements

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain required notification or preauthorization before providing listed services or risk denial of payment.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Surgical procedures requiring preauthorization

Autologous chondrocyte implantation and other cell-based cartilage treatments; bariatric surgery (gastric reflux and obesity surgery when benefit is available); blepharoplasty and brow ptosis repair; bone lengthening; cardiac defibrillators; chemical peels/dermabrasion/microdermabrasion/laser skin treatment; cochlear implant; cryosurgical ablation of breast tumors; deep brain stimulation; extracranial carotid angioplasty/stenting; facet neurotomy; gastric electrical stimulation; hip procedures for femoroacetabular impingement; image-guided minimally invasive lumbar decompression; implantable bone conduction/hearing aids; keratoprosthesis; meniscal allografts and collagen meniscus implants; occipital nerve stimulation; orthognathic surgery; pacemakers; panniculectomy; percutaneous neuromodulation therapy (PNT); peroral endoscopic myotomy (POEM); plugs for fistula repair; posterior tibial nerve stimulation; radiation therapy for palmar fibromatosis; radiofrequency ablation of tumors (RFA); reconstructive breast surgery/mastopexy/autologous fat grafting and implant management; reduction mammoplasty; renal sympathetic nerve ablation; restorative and cosmetic procedures; rhinoplasty; sacral nerve modulation/stimulation; sinus surgeries; sling procedures for urinary incontinence; spinal cord stimulation; spinal decompression devices; cervical and lumbar fusion; minimally invasive lumbar decompression; minimally invasive sacroiliac joint fusion.

Notification, preauthorization, and provider obligations

Prior Authorization

Prior Authorization Required

The following services require notification or preauthorization. Services that require preauthorization will be denied if preauthorization is not obtained. This list does not include services that may be reviewed post-service for medical necessity upon receipt of the claim; claims reviewed for medical necessity may result in a denial. Kaiser Permanente Washington members and providers can check prior authorization requirements and current lists by signing in to kp.org or contacting Member Services.

Preauthorization required services will be denied if preauthorization is not obtained.
Some services may be reviewed after the claim is submitted for medical necessity and can be denied.
Check kp.org or contact Member Services for plan-specific requirements and current authorization lists.

Note

Notification Required

Notification is required for the following admissions and services. Providers must notify the health plan per the plan's notification procedures for all inpatient and specified settings.

All inpatient admissions, including emergency admissions, planned admissions, mental health, and withdrawal management.
Home health care, including home infusion and home dialysis.
Hospice.
Long-term acute care admission.
Skilled nursing facility admissions.
Substance use disorder residential admissions.

Prior Authorization

DME, Prosthetics, and Supplies — Prior Authorization Required

Durable medical equipment (DME), prosthetics, and certain supplies require prior authorization. Obtain authorization before providing these items to avoid denial. Concurrent care review may be required and visit limits may vary by plan.

Bone growth stimulators (electrical and ultrasonic).
Electrical stimulation devices.
Home oxygen.
Mobility assist devices, including wheelchairs and other high-end mobility equipment.
Negative pressure wound therapy pumps.
Oscillatory chest compression devices.
Prosthetic limbs.
Speech generating devices.
Tumor treating fields therapy.
Concurrent care review required; visit limits may be higher depending on plan.

Prior Authorization

Other Services — Prior Authorization Required

A range of other services require prior authorization. Providers should verify authorization requirements for specific services and plan benefits; some items (e.g., genetic testing, clinical trials, fertility services, experimental services) may have additional documentation or coverage criteria.

Acupuncture (after 8 visits*).
Advanced care at home.
Advanced imaging.
Applied behavioral analysis (ABA) therapy.
Capsule endoscopy.
Cardiac telemetry.
Charged particle radiation therapy.
Clinical trials.
Craniofacial dental procedures.
Elective air transport.
Electroconvulsive therapy.
Experimental and investigational services, including new technologies.
Fertility services.
Genetic testing and panels (e.g., cell-free fetal DNA testing, BRCA, Lynch).
Hyperbaric oxygen therapy.
Inpatient rehabilitation.
Level of Care reviews/policies.

Prior Authorization

Surgery — Prior Authorization and Site-of-Care Guidance

Surgical procedures require prior authorization. Providers must consult the current surgical authorization rules and site-of-care guidance posted on kp.org. Follow the Ambulatory Surgery Center (ASC) Site of Care Policy and the Clinical Review Criteria available on the provider site for up-to-date lists and any site-of-care restrictions.

See kp.org/walprovider → Authorization & Clinical Review → Clinical Review Criteria → A → Ambulatory Surgery Center (ASC) Site of Care Policy for the current surgery authorization list and site-of-care guidance.
Examples of surgeries that require prior authorization include (but are not limited to): autologous chondrocyte implantation and other cell-based cartilage treatments; bariatric surgery (reflux and obesity surgery when benefit available); blepharoplasty and brow ptosis repair; bone lengthening; cardiac defibrillators; cochlear implants; deep brain stimulation; facet neurotomy; gastric electrical stimulation; hip procedures for femoroacetabular impingement criteria; implantable hearing aids; keratoprosthesis; meniscal allografts; orthognathic surgery; pacemakers; panniculectomy; peroral endoscopic myotomy (POEM); plugs for fistula repair; reconstructive breast surgery and related breast implant management; reduction mammoplasty; rhinoplasty; sacral nerve modulation; sling procedures for urinary incontinence; spinal surgeries (cervical fusion, lumbar fusion, minimally invasive procedures); vertebroplasty and vertebral augmentation; stereotactic radiosurgery and stereotactic body radiation therapy; transcatheter valve procedures (TAVR/Mitra-clip); transplants; vagus nerve stimulation; varicose vein treatment.
Follow site-of-care directions (e.g., ASC vs hospital-based) as specified in the ASC Site of Care Policy to ensure appropriate authorization and avoid denials.

Prior Authorization

Office-Administered Injectable Drugs — Prior Authorization Required

Office-administered injectable drugs require prior authorization per the maintained pharmacy list. Providers must check the current injectable drug prior-authorization list on the provider website before administration.

See kp.org/walprovider → Pharmacy → Pharmacy Overview → Injectable Drugs Requiring Prior Authorization for the current list.
Obtain prior authorization before administering office-administered injectable drugs to avoid claim denial.

Key terms

inv-09: Definition — Preauthorization

TermPreauthorization

DefinitionA requirement that authorization be obtained from Kaiser Permanente Washington before the service is provided; services that require preauthorization will be denied if preauthorization is not obtained.

Where to verifyProviders and members should check current prior authorization requirements by signing in to kp.org or contacting Member Services.

Claims and medical necessitySome services may be reviewed post-service for medical necessity upon receipt of the claim and may be denied even if not on the preauthorization list.

inv-10: Definition — Notification (required for admissions and certain post-acute services)

TermNotification (required for admissions and certain post-acute services)

DefinitionA requirement to notify Kaiser Permanente Washington for specified admissions and post-acute services (notification, not prior authorization).

Services requiring notificationAll inpatient admissions (including emergency and planned admissions, mental health, and withdrawal management), home health care (including home infusion and home dialysis), hospice, long-term acute care admissions, skilled nursing facility admissions, and substance use disorder residential admissions.

Where to verifyProviders and members should sign in to kp.org or contact Member Services to verify notification requirements and related coverage rules.

Where to verify requirements and tools

This policy directs providers and members to the Kaiser Permanente Washington provider portal for the authoritative, up‑to‑date lists of services that require notification or preauthorization. The portal includes maintained clinical review criteria, current surgical authorization lists, and pharmacy pages that identify office‑administered injectable drugs requiring prior authorization. Providers and members may also contact Member Services to verify coverage or preauthorization requirements.

Per the policy, services that require preauthorization will be denied if preauthorization is not obtained; other services on the lists may be reviewed after claim submission for medical necessity and may be denied. For specific procedures and categories (including the extensive surgery list and other services such as advanced imaging, clinical trials, fertility services, and DME/prosthetics), follow the portal instructions: go to kp.org/walprovider and use the "Authorization & Clinical Review" and relevant Pharmacy or Clinical Review Criteria pages or the online Preauthorization Code Check Tool.

OpenPayer

2025 PPO preauthorization and notification requirements

Coverage stance and where to find criteria

Authorization tools and coding references

Notification, preauthorization, and provider obligations

Key terms

Where to verify requirements and tools