Download Prior Authorization Guide | Providers | KPS Health Plans

Services that require prior authorization
A guide for providers
Services that Require Prior Authorization
The following services require preauthorization for KPS Health Plan’s members. Services that require preauthorization will be denied if
preauthorization is not obtained. The following list does include services that will be reviewed post service for medical necessity upon
receipt of the claim.
For services to be paid, the Member must be eligible on the date of service and the service must be a covered benefit.
KPS offers a variety of forms to use to obtain authorization prior to rendering services. You will find a Prior Authorization Request form
online at kpshealthplans.com. Please fax requests to Attn: KPS Medical Management at fax number: 360-405-9180.
Providers also have the option to submit prior authorization requests online through MyKPS. These requests are routed directed
to KPS via secured email.
Here are some tips for getting to the fastest response to your request:
• Print out forms and reply in legible handwriting prior to faxing. Unreadable forms result in mistakes and delays.
• Fill form out completely. Unanswered questions result in delays.
• Access forms online when you need one, rather than pre-printing and storing them. We revise forms periodically, and
outdated forms may delay your request.
Procedures/Services that Require Prior Authorization
The following procedures/services require prior authorization from KPS. To verify Member benefits and eligibility please call Customer
Service at 360-377-5576 or toll-free at 800-552-7114.
This information may not be an all-inclusive list and is subject to change at any time. Some member’s health plans may have specific
requirements for prior authorization that may not be listed below. Please contact Customer Service.
Inpatient Hospital Admissions
All services
Skilled Nursing Facility Admissions
Inpatient Care only
Mental Health Care and Substance Use
Disorder Treatment
Inpatient Care only
Home Health, Home IV Infusion
and Hospice Care
All Services
Outpatient or Inpatient Procedures
Anesthesia for dental procedures
Bariatric Surgeries: All inpatient/outpatient obesity related surgeries
Biofeedback for urinary stress incontinence (non-covered for any other diagnosis)
Blepharoplasty (upper/lower lids and brow lift)
Bone anchored hearing aid system (BAHA)
Breast MRI
Breast surgeries: All inpatient/outpatient surgeries including Breast reduction/Mammoplasty
Circumcisions (except Newborns 0-28 days)
Cochlear implants
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Services that require prior authorization
A guide for providers
Outpatient or Inpatient Procedures, cont.
Collagen injections for urinary stress incontinence
Deep brain stimulation
Elective convulsive shock therapy “ECT”
Gamma knife surgery (stereotactic radiosurgery)
Gene Expression Profiling testing, Pharmacogenomic/Pharmacological testing and Risk Prognosticator Testing
Genetic testing
High end radiology – PET scans, MRAs (check plan benefits for non-emergent MRIs)
Hyperbaric oxygen
Hyperhydrosis
Hysterectomy (inpatient requests only)
Implantable pumps
Inpatient rehabilitation
Partial hospitalization, including mental health and chemical dependency
Potentially cosmetic procedures
Proton beam therapy
Pulse dye laser
Photochemotherapy: PUVA, Broadband UVB & Narrow band UVB Light Therapy
Radiofrequency ablation (any diagnosis)
Removal of scars
Residential treatment for mental health and chemical dependency
Rhinoplasty
Septoplasty
Sleep surgeries (any surgeries for snoring, obesity, OSA (obstructive sleep apnea)
• Adenoidectomy
• Glossectomy (tongue reduction)
• LAUP (Laser Assisted Uvulopalatoplasty)
• Septoplasty
• Tonsillectomy
• Turbinate reduction
• UARS (upper airway resistance syndrome):
• Uvulectomy
• UPP (Uvulopalatoplasty) and UPPP (Uvulopalatopharyngoplasty)
Spinal Surgeries: All inpatient and outpatient surgeries
Turbinate reduction
Transgender services
Transplants (except corneal), artificial hearts and ventricular assist devices
Varicose vein treatment (any)
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Services that require prior authorization
A guide for providers
Office/Outpatient Administered Drugs
These are non self-administered drugs covered under the medical benefit which are provided by an outpatient facility, specialty pharmacy, at
home, or by a physician in a physician’s office. See the 2015 Specialty Drug List of non self-administered drugs that require prior authorization.
Pharmacy Specialty Drugs
These drugs are provided by MedImpact or Diplomat. MedImpact and Diplomat will handle these prior authorization reviews.
See the Pharmacy Specialty Drug List.
Durable Medical Equipment
Bone growth stimulators (all types)
Continuous glucose monitor device
CPM machines
Enteral therapy
Home Prothrombin Time (INR) Monitoring Device
Insulin pumps
Light box therapy for Seasonal affective disorder (SAD)
Microprocessor- controlled upper limb and lower limb prosthesis
Neuromuscular stimulators (inpatient, outpatient, trial, permanent insertion,
revision, or removal)
Oxygen
Seat/Chair lift mechanism
Synchromed pump
Therapeutic devices for the feet
Wound vacuums
Wheelchairs (including scooters and power operated vehicles) with purchase price greater than $5,000
Any other DME with a purchase price greater than $2,500
Please contact Customer Service regarding the need for prior authorization of any other services that appear to be primarily for cosmetic reasons or
considered an experimental treatment, including Category III or other new technology or procedures which do not yet have CPT codes assigned.
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