In most cases, Members need a referral to see a Specialist the first time. Please call Member Services for information about specialty Services that require a referral or discuss your concerns with your primary care Participating Provider. Any PCP can make a referral to a Specialist when needed. Once a Member has been referred to a Specialist, they will not need a referral for return visits for the same condition. In some cases, a standing referral may be allowed to a Specialist for a time period that is in accord with your individual medical needs, as determined by the PCP and Kaiser. Some outpatient specialty Services are available in Participating Medical Offices without a referral. You do not need a referral for outpatient Services provided in the following departments at Participating Medical Offices owned and operated by Kaiser Permanente. Please call Member Services to schedule routine appointments in these departments:  Audiology (routine hearing exams).  Cancer Counseling.  Mental health Services.  Obstetrics/Gynecology.  Occupational Health.  Optometry (routine eye exams).  Social Services.  Substance Use Disorder Services. Referrals to Non-Participating Providers and Non-Participating Facilities If your PCP decides that you require Services not available from Participating Providers or Participating Facilities, they will recommend to Medical Group and Kaiser that you be referred to a Non-Participating Provider or Non-Participating Facility. If the Medical Group’s assigned Participating Provider determines that the Services are Medically Necessary and are not available from a Participating Provider or Participating Facility and determines that the Services are covered Services, Kaiser will authorize your referral to a Non- Participating Provider or Non-Participating Facility for the covered Services. You pay the same Cost Share for authorized referral Services that you would pay if you received the Services from a Participating Provider or at a Participating Facility. You will need written authorization in advance in order for the Services to be covered. If Kaiser authorizes the Services, you will receive a written “Authorization for Outside Medical Care” approved referral to the Non-Participating Provider or Non-Participating Facility, and only the Services and number of visits that are listed on the written referral will be covered, subject to any benefit limitations and exclusions applicable to these Services. Prior and Concurrent Authorization and Utilization Review When you need Services, you should talk with your Participating Provider about your medical needs or your request for Services. Your Participating Provider provides covered Services that are Medically Necessary. Participating Providers will use their judgment to determine if Services are Medically Necessary. Some Services are subject to approval through Utilization Review, based on Utilization Review criteria developed by Medical Group or another organization utilized by the Medical Group and approved by Kaiser. If you seek a specific Service, you should talk with your Participating Provider. Your Participating Provider will discuss your needs and recommend an appropriate course of treatment. If you request Services that must be approved through Utilization Review and the Participating Provider believes they are Medically Necessary, the Participating Provider may submit the request for Utilization Review on your behalf. If the request was received electronically and is denied, we will send a letter to you EWCLGHDHP1983ACT0124 32 WAPEBB-CD-ACT