42 2024 Evidence of Coverage for WA PEBB Kaiser Permanente Senior Advantage Chapter 3: Using our plan for your medical services Prior authorization For the services and items listed below and in the Medical Benefits Chart found at the front of this EOC, your network provider will need to get approval in advance from our plan or Medical Group (this is called getting "prior authorization"). Decisions regarding requests for authorization will be made only by licensed physicians or other appropriately licensed medical professionals. If you ever disagree with authorization decisions, you can file an appeal as described in Chapter 7. • Services and items identified in the Medical Benefits Chart found at the front of this EOC with a footnote (†). • If your network provider decides that you require covered services not available from network providers, they will recommend to Medical Group that you be referred to an out-of- network provider inside or outside our service area. The appropriate Medical Group designee will authorize the services if they determine that the covered services are medically necessary and are not available from a network provider. Referrals to out-of-network providers will be for a specific treatment plan, which may include a standing referral if ongoing care is prescribed. It specifies the duration of the referral without having to get additional approval from us. Please ask your network provider what services have been authorized if you are not certain. If the out-of-network specialist wants you to come back for more care, be sure to check if the referral covers the additional care. If it doesn't, please contact your network provider. • After we are notified that you need post-stabilization care from an out-of-network provider following emergency care, we will discuss your condition with the out-of-network provider. If we decide that you require post-stabilization care and that this care would be covered if you received it from a network provider, we will authorize your care from the out-of-network provider only if we cannot arrange to have a network provider (or other designated provider) provide the care. Please see Section 3.1 in this chapter for more information. • Medically necessary transgender surgery and associated procedures. • Medically necessary bariatric surgery. • Care from a religious nonmedical health care institution described in Section 6 of this chapter. • If your network provider makes a written or electronic referral for a transplant, Medical Group's regional transplant advisory committee or board (if one exists) will authorize the services if it determines that they are medically necessary or covered in accord with Medicare guidelines. In cases where no transplant committee or board exists, Medical Group will refer you to physician(s) at a transplant center, and Medical Group will authorize the services if the transplant center's physician(s) determine that they are medically necessary or covered in accord with Medicare guidelines. kp.org