Kaiser Permanente determines coverage based on each member's Evidence of Coverage (EOC) document and Kaiser's internal clinical guidelines. Coverage decisions for non-emergency services are made during the prior authorization process. For disputed coverage, members and providers can request a formal coverage determination.
Step 1: Check member's EOC for covered benefits. Step 2: Submit prior auth if required. Step 3: If coverage denied, request formal determination in writing. Step 4: Kaiser responds within 30 days (standard) or 72 hours (urgent). Step 5: If denied, appeal within 180 days.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-50 | Non-covered service | Service excluded from EOC | Verify EOC coverage before scheduling |
| CO-11 | Medical necessity | Clinical guidelines not met | Include guidelines-based documentation |
| CO-167 | Diagnosis not covered | ICD-10 code not covered under plan | Verify diagnosis coverage in EOC |
If the coverage determination is unfavorable, file an appeal within 180 days. Kaiser's appeal process has two internal levels. After exhausting both, request an external Independent Medical Review through your state's regulatory body.
The Evidence of Coverage (EOC) document is available on the Kaiser member portal. Providers can also call Kaiser Provider Services to verify specific service coverage for a member.
Yes. Providers can request a formal coverage determination in writing on behalf of their patient. Include the member ID, service requested, ICD-10 and CPT codes, and clinical justification.
Standard determinations: 30 calendar days. Urgent or expedited determinations: 72 hours. If Kaiser fails to respond within these timeframes, the determination may be deemed approved under state regulations.
Altair verifies Kaiser coverage requirements and flags potential denials before you submit.