Kaiser Permanente handles most care in-network through its integrated system. Out-of-network claim denials follow a standard appeals process with a 180-day filing deadline. Appeals are reviewed by a physician not involved in the original denial decision.
Day 1: Receive denial notice. Days 1-14: Gather clinical documentation and prepare appeal. Day 15: Submit appeal in writing. Days 16-45: Kaiser physician review. Day 46: Written decision. If denied: request external independent review within 4 months.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-11 | Medical necessity | Kaiser does not deem service medically necessary | Include clinical notes and peer-reviewed guidelines |
| CO-50 | Non-covered service | Service outside Kaiser benefit plan | Verify coverage with Kaiser before service |
| CO-197 | Precertification absent | Auth not obtained from Kaiser | Always obtain Kaiser referral/auth before out-of-network care |
First-level appeal: submit within 180 days. Kaiser responds within 30 days. If denied, request second-level review within 60 days. After exhausting internal appeals, request an Independent Medical Review (IMR) through your state's Department of Managed Health Care (California) or Department of Insurance (other states).
Yes. If Kaiser denied coverage for out-of-network care, submit an appeal within 180 days with documentation showing why the care was necessary and not available within the Kaiser network.
After exhausting Kaiser's internal appeals (two levels), contact your state's insurance department or Department of Managed Health Care. In California, file with the DMHC at dmhc.ca.gov. External review decisions are binding on Kaiser.
Yes. If the standard 30-day timeline could jeopardize the patient's health, request an expedited appeal. Kaiser must respond within 72 hours.
Altair tracks denial patterns and appeal deadlines across all payers including Kaiser Permanente.