Overview
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.
Key Requirements
- File appeals within 180 days of the denial notice.
- Submit in writing to the address on the denial letter or through the Kaiser provider portal.
- Include: original claim, EOB, clinical documentation, and a letter explaining why the denial should be overturned.
- Kaiser assigns a physician reviewer not involved in the original decision.
- Response time: 30 calendar days for standard appeals, 72 hours for urgent.
Timeline
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.
Common Denials
| 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 |
Appeals
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).
FAQ
Can I appeal a Kaiser denial for out-of-network care?
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.
How do I request an external review of a Kaiser denial?
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.
Does Kaiser have an expedited appeals process?
Yes. If the standard 30-day timeline could jeopardize the patient's health, request an expedited appeal. Kaiser must respond within 72 hours.
Prevent These Denials
Altair tracks denial patterns and appeal deadlines across all payers including Kaiser Permanente.