Prior authorization when KHS is secondary payer
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States Kern Family Health Care's rules for prior authorization when KHS is the secondary insurer; explains when prior authorization is not required and lists exceptions that still require prior authorization. Affects providers submitting claims for members with other primary insurance (including Medicare).
No material clinical or coverage changes in this revision.
Secondary Payer Coverage Rules
Secondary payer prior authorization criteria
Coverage stance when KHS is secondary payer.
Coding / Code List
Provider Requirements and Actions
Prior authorization rules when KHS is secondary payer
KHS does not require prior authorization for covered services when a member has Medicare or other health insurance as their primary insurer. If a provider has received a denial from the member's primary coverage prior to the services being rendered, providers can submit an authorization request to KHS with the denial determination from the primary coverage. Exceptions that continue to require prior authorization with KHS as secondary payer include Home Health, Medications, and Services not covered under the primary health plan. All other requests remain subject to review and KHS prior authorization requirements.
- No prior authorization required when another insurer (including Medicare) is primary.
- If primary payer denied coverage prior to services, submit authorization request to KHS with the primary denial determination.
- Exceptions still requiring KHS prior authorization: Home Health; Medications; Services not covered under primary plan.
- All other requests are subject to review and prior authorization requirements.
Denial risk when service not medically necessary
KHS may deny payment if it determines the services were not a medically necessary covered benefit. Providers should be aware that even when KHS is secondary, payment is contingent on the service meeting KHS medical necessity and covered benefit criteria.
- Denial of payment can occur when KHS determines services were not medically necessary covered benefits.
Documentation to submit after primary denial
When a provider receives a denial from the member's primary coverage prior to services being rendered, the provider may submit a prior authorization request to KHS together with the primary payer's denial determination.
- Submit the primary payer's denial determination along with the authorization request to KHS.
- This applies only when the primary denial was received prior to the services being rendered.
Exceptions and Definitions
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