 Inpatient and residential Substance Use Disorder Services.  Inpatient, residential, and Assertive Community Treatment (ACT) mental health Services.  Non-emergency medical transportation.  Open MRI.  Plastic surgery.  Referrals for any Non-Participating Facility Services or Non-Participating Provider Services.  Referrals to Specialists who are not employees of Medical Group.  Rehabilitative therapy Services. The initial evaluation and management visit and up to six treatment visits in a New Episode of Care for physical, massage, occupational and speech therapy do not require authorization.  Routine foot care.  Skilled nursing facility Services.  Spinal and Extremity Manipulation Therapy 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.  Organ transplant Services.  Transgender Surgical Services.  Travel and lodging expenses. If you ask for Services that the Participating Provider believes are not Medically Necessary and does not submit a request on your behalf, you may ask for a second opinion from another Participating Provider. You should contact the manager in the area where the Participating Provider is located. Member Services can connect you with the correct manager, who will listen to your issues and discuss your options. For more information about Utilization Review, a copy of the complete Utilization Review criteria developed by Medical Group and approved by Kaiser for a specific condition, or to talk to a Utilization Review staff person, please contact Member Services. Except in the case of misrepresentation, prior authorization review decisions will not be retrospectively denied. Prior authorization determinations shall expire no sooner than forty-five days from the date of approval. We may revoke or amend an authorization for Services you have not yet received if your membership terminates or your coverage changes or you lose your eligibility, or if we receive information that is materially different from that which was reasonably available at the time of the original determination. Individual Case Management When Medically Necessary and cost-effective, Kaiser may provide alternative care Services to a Member on a case-by-case basis. In order for Kaiser to provide alternative care Services, a written agreement that specifies Services, benefits, and limitations must be signed by the Member and the PCP or Participating Provider. Kaiser reserves the right to terminate these extended benefits when the Services are no longer Medically Necessary, cost-effective, feasible, or at any time by sending written notice to the Member. Home Health Care Alternative to Hospitalization When provided at equal or lesser cost, the benefits of this Plan will be available for home health care instead of hospitalization or other institutional care when furnished by a home health, hospice, or home care agency Participating Provider. Substitution of less expensive or less intensive Services will be made only with the consent of the Member, and when the Member’s PCP or Participating Provider advises that the Services will adequately meet the Member’s needs. Kaiser will base the decision to substitute less expensive or less intensive Services on the Member’s individual medical needs. Kaiser may require a written treatment plan EWCLGDED1983ACT0124 33 WAPEBB-CL-ACT