Kaiser Permanente (KP) operates as an integrated healthcare system, providing both health coverage and medical care through its own network of hospitals and physicians. Because of this structure, members generally receive all services within the KP network, which can make seeking outside medical care a complex process. This guide provides clear direction on the specific conditions, formal steps, and financial implications of obtaining authorization to see providers outside of the KP system.
Criteria for Seeking External Care
Obtaining an external referral requires demonstrating that the requested service meets specific criteria that cannot be fulfilled internally. The primary justification for an external referral is that the necessary medical service is not available within the Kaiser Permanente provider network. This means the specific procedure, treatment, or technology is simply not offered by a KP physician or facility.
An external referral may also be approved if the required specialist possesses a unique level of professional training or expertise that is not represented among the plan providers. The expertise needed must be highly specialized and not reasonably substituted by an internal KP physician. The Utilization Management team reviews these requests based on nationally recognized clinical guidelines to determine medical necessity.
A third justification involves issues of access, specifically if KP cannot provide the medically necessary service without unreasonable delay or travel. This focuses on the availability of a specialist or facility within a reasonable geographic area and timeframe. If a member requires a time-sensitive procedure and the KP specialist has a significant waitlist, an external referral may be authorized to prevent unreasonable delay.
The Formal Authorization Process
The first step in seeking a referral outside of Kaiser Permanente is to initiate a discussion with your Primary Care Physician (PCP). The PCP serves as the gateway to the referral process and must agree that external care is medically appropriate before any formal request can proceed. If your PCP supports the request, they will submit a formal referral request to the Utilization Review or Referral Department.
This formal submission must include detailed clinical documentation and a clear rationale explaining why the service cannot be provided internally. The Utilization Management team, which includes physicians and nurses, reviews the request against established clinical criteria. For non-urgent requests, the decision is typically made within two working days after the department receives all the necessary information.
If the review is for an urgent situation, defined as one where the passage of time could seriously jeopardize the patient’s health or ability to regain function, the decision timeline accelerates significantly. Urgent requests are generally decided and communicated to the requesting provider within 24 hours of the request. It is paramount that you receive a written authorization document from Kaiser Permanente before scheduling or receiving any external services to ensure coverage.
Recourse for Denied Requests
If your formal request for external care is denied, Kaiser Permanente will send a denial letter detailing the specific reasons for the refusal. This letter also outlines the process and timelines for filing an internal appeal. Members typically have 180 calendar days from the date they receive the denial letter to submit a written appeal.
The internal appeal process involves a comprehensive review of the original request and any additional medical evidence you provide. For standard, non-urgent appeals, Kaiser Permanente issues a decision within 30 working days for services that have not yet been provided. If the appeal is for a service already rendered, the decision timeline may extend up to 45 working days.
In medically urgent situations, an expedited appeal is available, with a decision rendered within 24 to 72 hours. If the internal appeals process upholds the denial, the member may request an external review. This involves an independent review organization, often overseen by a state regulatory body, which provides an unbiased assessment of the medical necessity of the denied service.
Understanding Financial Liability
Financial liability for external care depends entirely on whether the service was sought with or without prior authorization from Kaiser Permanente. If the external referral is formally approved, the member is typically responsible only for the same cost-sharing amounts they would have incurred for an in-network service. This means you will pay the standard copayment, deductible, or co-insurance as defined by your specific plan.
Seeking care from an out-of-network provider without a formal, written authorization carries substantial financial risk. In such unauthorized cases, Kaiser Permanente may deny the claim entirely, leaving the member responsible for 100% of the billed charges. These services are often subject to a claims review that can result in zero reimbursement for the member.
Federal protections, such as the No Surprises Act, provide a safeguard against unexpected balance billing for emergency services or care received at an in-network facility from an unexpectedly out-of-network provider. Outside of these protected scenarios, obtaining a written authorization is the only way to ensure that your out-of-network financial responsibility is limited to your usual in-network cost-sharing.