Prior authorization rules for Medicare Part B office/outpatient services
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Governance of prior authorization for Kern Family Health Care (KHS) members who have Medicare as their primary insurance, limited to office and outpatient services and affecting providers submitting those claims.
No material clinical or coverage changes in this revision.
Medicare Primary Coverage Rules
Medicare primary coverage criteria
Covered when ALL of the following are met:
ALL of the following
Exceptions that still require prior authorization
- Home Health requires prior authorization.
- Durable Medical Equipment requires prior authorization.
- Medications require prior authorization.
Coding and Authorization Applicability
| No codes listed |
Provider Notification, Authorization, and Denial Risks
Prior authorization and notification requirements for Medicare-primary members
KHS does not require prior authorization for Medicare Part B-covered office or outpatient services when Medicare is the member's primary insurance. Exceptions that still require prior authorization are Home Health, Durable Medical Equipment, and Medications. KHS must be notified of all inpatient admissions (Acute Inpatient Hospitals, Long Term Care & Skilled Nursing Facilities, and Inpatient Rehabilitation Facilities) so KHS can coordinate benefits for claims payment.
- No prior authorization required for Medicare Part B office/outpatient services when Medicare is primary
- Prior authorization still required for: Home Health; Durable Medical Equipment; Medications
- Notify KHS of all inpatient admissions for benefit coordination
Risk of payment denial for non‑medically necessary services
KHS may deny payment if it determines the services were not a medically necessary covered benefit for members with Medicare as primary.
- Denial can occur when services are not medically necessary covered benefits
Contact and documentation/notification
For questions or to notify KHS as required, contact the KHS Provider Relations Department at (661) 664-5146.
- Contact: KHS Provider Relations Department
- Phone: (661) 664-5146
Service Definitions and Exceptions
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