Last updated December 2015 All inpatient stays require authorization All provided by non-contracted providers require pre-authorization SoCO/NoCO (POS 11) - For contracted providers in office specialty do not require an authorization regardless of who the referred by provider is. Grid Legend: "Yes" or "Yes" with additional text, indicates service requires pre-authorization. "No" indicates no pre-authorization is necessary. Services Denver/Boulder Southern Colorado Northern Colorado Mountain Colorado Comments Acute Rehab (inpatient) Yes Allergy Serum No No Yes, for non-kp Allergy Treatment & Injections and Doctor No No Yes, for non-kp Services Ambulance Services Anesthesia (Non-Pain management) No No Yes, for non-network Autism (Behavioral Health) Autism Treatment Yes Bariatric Surgery Biofeedback Yes Blood Services locations No No Yes Breast Biopsies No No No No, for contracted Cardiac Rehab No No No No, for contracted Cardio - Coronary Cath No No No No, for contracted Cardio - ECG No No No No, for contracted Cardio - Echo No No No No, for contracted KPCO authorization guide Page 1 of 7
Cardio - Function No No No No, for contracted Cardio - ICD device No No No No, for contracted Cardio - ICM device No No No No, for contracted Cardio - Stress Test No No No No, for contracted Cardiology - Programming Device No No No No, for contracted Cardiology - Stress Test No No No No, for contracted Cardiology Consultation No No or non Cardiology EP No No or non Cardiovascular Surgery - Peds Yes CHCO/RMHC only providers Chemical Dependency Yes Child Advocacy Team at CHCO Yes Child Development Unit at CHCO Yes NoCO auths obtained through KP "BHAC" (Behaviroal Health Access Center) Chiropractic Services Yes, for Medicare Members Yes, for Medicare Members Yes, for Medicare Members Yes, for Medicare Members Complementary Medicine Services N/A N/A N/A N/A All covered benefits can be accessed by self referral except medicare chiropractic Concussion Clinic at CHCO Yes Continuous Glucose Monitoring System Yes Dental - Cleft Palate Yes No No Yes Dental Services -Oral and TMJ No No Yes Dermatology Dermatology Light Therapy No No or non No No or non This does not apply as a DME item KPCO authorization guide Page 2 of 7
Diabetes for Children Yes No No Yes Home Health would require an authorization Dialysis Yes, unless perfomed at St. Joseph, Good or Davita No No Yes, for non-contracted. DME and Orthotics Yes EMG Services No No No No, for contracted Endocrinology Yes No No or non ENG/EEG Services Enteral / Parenteral Therapy Yes Enuresis Encopresis Clinic Yes Extracorporeal Shock Wave Yes Gait Clinic - Peds Yes Gamma and Cyber Knife Yes Yes or non Gastroenterology Eosinophilic Esophagitis Clinic EEC Genetics counseling or testing Yes GI Scopes at St. Joseph, Good or Skyridge No No or non Gynecological Services Health Education Services Hearing Aid Exams and Equipment No No or non No No N/A No No or non KPCO authorization guide Page 3 of 7
Hemophilia Center Yes Holter & Event Monitors No No No No, for contracted Home Health Services at at at at Complete Home Complete Home Health Banner Home Care, Banner Home Care & Hospice of Health Care, Denver Care, Interim, VNA Home MedSolutions, the Valley Hospice, Interim, Tru Interim Community Care, VNA Hormonal Treatment of prostate cancer No No No Hospice No No No at Home Care & Hospice of the Valley Hyperbaric Oxygen Therapy Yes Implantable devices Excludes Ambulatory BP Monitoring In Office Medication and Injectables: Growth Hormone, Asthma Management, e.g. Xolair, CHF Management, e.g. Flolan, Tracleer, Immunization for RSV, e.g. Synagis, Immunosuppressive Management e.g. Humira, Remicade, Enbrel, Tysabri, Orencia, Actemra, Osteoporosis Treatment, e.g. Reclast, Prolia, Boniva, Xgeva, Zometa, Immune Globulin In Office Procedures: ENT, Plastic Surgery, Vascular In Office Procedures: Any other specialty (For example: MOHs, Opthalmology, OB/GYN, Oral Surgery, Podiatry) Yes No No No No Infertility Services KPCO authorization guide Page 4 of 7
Influenza Vaccine No No No No Infusion Services Inpatient Hospital Services and Inpatient Rehabilitation Hospital Services at St. Joseph, Good, Complete Home Health Care, Denver Hospice, Interim, Tru Community Care, VNA at Complete Home Health Care, Interim, VNA at Banner Home Care, Banner Home MedSolutions, Interim Yes, except for Chemotherapy Yes This does not apply to chemotherapy J Codes Yes, See J Code Tab Yes, See J Code Tab Yes, See J Code Tab Yes, See J Code Tab Laboratory Services No No No, for contracted /providers Lap Band Adjustments No No or non LTAC (Long Term Acute Care) Yes Medicare Annual Wellness visit Mental Health Treatment No No No Yes Metabolic Clinic Yes Nephrology No No or non Neurology No No or non Neurosurgery No No or non Neuropsychological evaluation and testing Yes See Genetics Testing NoCO auths obtained through KP "BHAC" (Behaviroal Health Access Center) Observation Bed Yes Office Circumcision Procedure Yes Office Vasectomy Ophthalmology No No or non No No or non KPCO authorization guide Page 5 of 7
Optical Services for Lenses, Frames, and No No No No Contacts Oral Maxillofacial Yes No No Yes Orthopedics Office Visits Otolaryngology Outpatient /Ambulatory Surgery Services Outpatient Rehabilitation Hospital Services Outpatient physical, occupational, speech therapy No No or non No No or non Pacemaker Checks No No No or non Pain Management including epidural steroid injections Yes Yes or non Photopheresis Yes Podiatry No No or non Procedures performed outside of office setting require authorization Prenatal Maternity Service by an OB/GYN specialty including ultrasound No No or non Preventive Services - Adult No No or non Prostate/ Colorectal cancer screening 18+ No No or non Prosthetics Yes Pulmonary Function Test No No No No, for contracted Pulmonary Rehabilitation No No No No, for contracted KPCO authorization guide Page 6 of 7
Radiation/Oncology Therapy at St. Joseph, Good or Skyridge No No or non Radiology Services not including MRI, CT, PET, and Nuclear Medicine Radiology: MRI (including open and standing), MRA, CT, PET and Nuclear Med Studies No No No No Plain Films, Ultrasound, Bone Density, Fluoroscopy, Mammograms at St. Joseph or Good, or by Radiology Imaging Associates or Diversified Radiology Yes, through CareCore Yes, through CareCore No, for MtCO Facilities Sleep Study Yes Yes or non SNF (Skilled Nursing Facility) Yes Surgical Sterilizations Yes Therapeutic Abortions Yes Transgender Service (Surgical) Yes Transplants (organ and tissue) Yes Travel Immunizations No No or non Treadmill Testing No No No No, for contracted Urology No No or non Well Child Routine Services No No or non KPCO authorization guide Page 7 of 7