Last updated March 2019

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Laureen Clark
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1 Last updated March 2019 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 authorization with some exceptions listed below. Grid Legend: "Yes" or "Yes" with additional text, indicates service requires pre- "No" indicates no pre-authorization is necessary. Acute Rehab (inpatient) Yes Allergy Serum No No No No Allergy Treatment & Injections and Doctor Services No No No Ambulance Services Anesthesia (Non-Pain management) Yes, for non KP Providers No No Yes, for non-network Providers Autism (Behavioral ) Yes, for non KP Providers Autism Treatment Yes Bariatric Surgery Yes, for non KP Providers Biofeedback Yes Blood Services No No No No Biopsies - Breast, Liver & Thyroid No No No No, for contracted OR Vail All other biopsies need preauthorization Cardiac Rehab No No No No, for contracted OR Vail Cardio - Coronary Cath No No No Valley View Hospital Cardio - ECG No No No No, for contracted OR Vail Cardio - Echo No No No No, for contracted OR Vail Cardio - Function No No No No, for contracted OR Vail Cardio - ICD device No No No No, for contracted Cardio - ICM device No No No No, for contracted Cardiology - Programming Device No No No No, for contracted Cardiology - Stress Test No No No No, for contracted OR Vail Cardiology Consultation Yes, for non KP Providers No No Yes, for non KP or non KPCO authorization guide Page 1 of 5

2 Cardiology EP Yes, for non KP Providers No No Yes, for non KP or non Cardiovascular Surgery - Peds Yes CHCO/RMHC only providers Chemical Dependency Yes, for non KP Providers Yes Child Advocacy Team at CHCO Yes Child Development Unit at CHCO Yes Chiropractic Services No No No No Complementary Medicine Services N/A N/A N/A N/A All covered benefits can be accessed by self referral 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 Yes, for non KP Providers No No Yes, for non KP or non Dermatology Light Therapy Yes, for non KP Providers No No Yes, for non KP or non This does not apply a DME item Diabetes for Children Yes No No Yes Home would require an authorization Dialysis No No No Yes, for non-contracted. DME and Orthotics Yes EMG Services No No No Yes, for non KP or non EXCEPT Vail Summit Orthopedics Endocrinology Yes No No Yes, for non KP or non ENG/EEG Services. EXCEPT Vail for EEG Only Enteral / Parenteral Therapy Yes Enuresis Encopresis Clinic Yes Extracorporeal Shock Wave Yes Gait Clinic - Peds Yes Gamma and Cyber Knife Gastroenterology Eosinophilic Esophagitis Clinic EEC Yes Genetics counseling or testing or Informed DNA KPCO authorization guide Page 2 of 5

3 GI Scopes or Skyridge No No No, for contracted OR Vail with contracted provider Gynecological Services Yes, for non KP Providers No No Yes, for non KP or non Education Services No No No No Hearing Aid Exams and Equipment Yes, for non KP Providers No No Yes, for non KP or non Hemophilia Center Yes Holter & Event Monitors No No No No, for contracted Home Services Complete Home Care, Denver Hospice, Interim, Tru Community Care, VNA Complete Home Care, Interim, VNA Banner Home Care, Banner Home MedSolutions, Interim, VNA Home Care & Hospice of the Valley Hormonal Treatment of prostate cancer Yes, for non KP Providers No No No Hospice No No No Home Care & Hospice of the Valley Hyperbaric Oxygen Therapy Yes Implantable devices 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 Excludes Ambulatory BP Monitoring In Office Procedures: ENT, Plastic Surgery, Vascular Yes, for non KP In Office Procedures: Any other specialty (For example: MOHs, No No No No Opthalmology, OB/GYN, Oral Surgery, Podiatry) Infertility Services Influenza Vaccine No No No No Infusion Services, Complete Home Care, Denver Hospice, Interim, Tru Community Care, VNA Complete Home Care, Interim, VNA Banner Home Care, Banner Home MedSolutions, Interim Yes, except for Chemotherapy This does not apply to chemotherapy Inpatient Hospital Services and Inpatient Rehabilitation Hospital Yes Services J Codes Yes, See J Code Tab Yes, See J Code Tab Yes, See J Code Tab Yes, See J Code Tab KPCO authorization guide Page 3 of 5

4 Labor and Delivery (NICU LEVEL AMISSION ONLY) Yes, for No No No Laboratory Services Yes, for non KP Providers No No No, for contracted See Genetics Testing /providers OR Vail Lap Band Adjustments Yes, for non KP Providers No No Yes, for non KP or non LTAC (Long Term Acute Care) Yes Medicare Annual Wellness visit Yes, for non KP Providers No No N/A Mental Treatment Yes, for non KP Providers Yes Metabolic Clinic Yes Nephrology Yes, for non KP Providers No No Yes, for non KP or non Neurology Yes, for non KP Providers No No Yes, for non KP or non Neuromonitoring Neurosurgery Yes, for non KP Providers No No Yes, for non KP or non Neuropsychological evaluation and testing Yes Observation Bed Yes Office Circumcision Procedure Yes Office Vasectomy Yes, for non KP Providers No No Yes, for non KP or non Ophthalmology Yes, for non KP Providers No No Yes, for non KP or non Optical Services for Lenses, Frames, and Contacts No No No No Oral Maxillofacial Yes No No Yes Orthopedics Yes, for non KP Providers No No Yes, for non KP or non Otolaryngology Yes, for non KP Providers No No Yes, for non KP or non Outpatient /Ambulatory Surgery Services Yes, for non KP Providers Outpatient Rehabilitation - Aquatic Therapy Yes Outpatient Rehabilitation Hospital Services Yes No No No Outpatient physical, occupational, speech therapy Pacemaker Checks No No No Yes, for non KP or non Pain Management Office Visits Yes, for non KP Providers No No No Pain Management procedures including epidural steroid injections Yes, for non KP Providers Photopheresis Yes KPCO authorization guide Page 4 of 5

5 Podiatry Yes, for non KP Providers No No Yes, for non KP or non Procedures performed outside of office setting require authorization Prenatal Maternity Service by an OB/GYN specialty including ultrasound Yes, for non KP Providers No No Yes, for non KP or non Preventive Services - Adult Yes, for non KP Providers No No Yes, for non KP or non Prostate/ Colorectal cancer screening 18+ Yes, for non KP Providers No No Yes, for non KP or non Prosthetics Yes Pulmonary Function Test No No No Yes, for non KP or non Pulmonary Rehabilitation No No No Yes, for non KP or non Radiation/Oncology Therapy No No Yes, for non KP or non or Skyridge Radiology Services not including MRI, CT, PET, and Nuclear Medicine Radiology: MRI (including open and standing), MRA, CT, PET and Nuclear Med Studies MtCO - OK at Vail if done by contracted provider MtCO - OK at Vail if ordered MtCO - OK at Vail if ordered MtCO - OK at Vail if ordered No No No No Plain Films, Ultrasound, Bone Density, Fluoroscopy, Mammograms St. Joseph or Good, or by Radiology Imaging Associates or Diversified Radiology Yes, through EviCore Yes, through EviCore No, for MtCO Facilities Excludes Low Dose Lung Cancer Screening Sleep Study Yes, for non KP Providers SNF (Skilled Nursing Facility) Yes Surgical Sterilizations Yes Therapeutic Abortions Yes Transgender Service (Surgical) Yes Transplants (organ and tissue) Yes Travel Immunizations Yes, for non KP Providers No No Yes, for non KP or non Treadmill Testing No No No No, for contracted /providers Urology Yes, for non KP Providers No No Yes, for non KP or non Well Child Routine Services Yes, for non KP Providers No No Yes, for non KP or non Wound Care No No No No MtCO - OK at Vail if ordered KPCO authorization guide Page 5 of 5

Last updated May 2018

Last updated May 2018 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