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 within three calendar days after we receive the request. If the request was received orally or in writing and is denied, we will send a letter to you within five calendar days after we receive the request. The decision letter will explain the reason for the determination along with instructions for filing an appeal. You may request a copy of the complete Utilization Review criteria used to make the determination by calling Member Services. Your PCP or Participating Provider will request authorization when necessary. The following are examples of Services that require prior, concurrent, or post-service authorization:  Acupuncture Services (physician referred). The initial evaluation and management visit and up to six treatment visits in a New Episode of Care do not require authorization.  Bariatric surgery Services.  Breast reduction surgery.  Drug Formulary exceptions.  Durable Medical Equipment.  External Prosthetic and Orthotic devices.  Gender Affirming Treatment.  General anesthesia and associated hospital or ambulatory surgical facility Services provided in conjunction with non-covered dental Services.  Habilitative Services.  Hospice and home health Services.  Inpatient hospital Services, including birthing centers. EWCLGDED1983ACT0124 32 WAPEBB-CL-ACT