How to Access Covered Care
Choose your doctor and change anytime.
Getting in-depth information on how your plan works and getting connected with a provider who suits your individual needs is the first priority. Choose from a wide range of great providers or stay with your current provider. And, remember—you can change at any time. Your plan provides you with that flexibility.
Below is an overview of getting care with the PPO Plan. In the PPO plan, there are two tiers to choose from: Participating Provider Tier or Non-Participating Provider Tier.
For members who have a POS, Out-of-Area PPO, or PPO plan – For Information about Kaiser Permanente Insurance Company’s (KPIC’s) Network Adequacy Policy, please review our Frequently Asked Questions Document
Participating Providers
Many ways to access care through Participating Providers.
- To find a Participating Provider or confirm if your current provider is part of the Participating Provider Tier, you can search for Providers by Location:
In Kaiser Permanente States: The PHCS Network for KPIC provides access to care in the Kaiser Permanente states of CA, CO, GA, HI, MD, OR, VA, WA, and DC.
In Non-Kaiser Permanente States: The CignaPPONetwork* only provides access to care in non-Kaiser Permanente states
*Disclaimer: The Cigna PPO Network refers to providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration.
- After your initial search by type and location, you can then filter the search with several options including those who offer Telemedicine Services (another term for Telehealth) for appointments via methods such as telephone, video, or email.
- No referral is needed to see a specialist. However, you will need precertification for some services and procedures if using the PHCS Network in California or other Kaiser Permanente states. You are responsible for obtaining precertification. You must call 1-888-251-7052 (TTY 711) Monday through Friday, 6 a.m. to 6 p.m. Pacific Time for precertification. If using the Cigna PPO Network for care in non-Kaiser Permanente states, the Cigna PPO providers are responsible for obtaining precertification on your behalf when precertification is required. You won’t be financially responsible if a Cigna PPO provider fails to obtain precertification for covered services.
- Kaiser Permanente Providers and Hospitals are not contracted under the PPO plan and would be considered and processed under the non-participating provider tier.
Can I nominate a physician to become a Participating Provider?
- Yes. If you were seeing a doctor who is not a member of either the PHCS Network for KPIC within California or other Kaiser Permanente States (CO, GA, HI, MD, OR, VA, WA and DC) or the Cigna PPO Network outside of the Kaiser Permanente States before you became a PPO member, you can nominate that doctor to join our network. Please keep in mind your provider may choose not to be contracted
- To nominate a PHCS provider in CA or other Kaiser Permanente states, visit multiplan.com/kaiser. To nominate a Cigna PPO Network provider outside of Kaiser Permanente states, call Customer Service at 1-800-788-0710 (TTY 711), Monday through Friday 7a.m. to 7p.m., Pacific time.
- Review can take up to six months. Whether a physician or practitioner is accepted depends on several considerations including the provider’s interest in joining, so a nomination doesn’t guarantee acceptance.
Helpful Tips
- When making an appointment. Make sure the provider is a Participating Provider based on their location. To confirm if your current provider is part of the Participating Provider Tier, you can search for Providers by Location:
In Kaiser Permanente States: The PHCS Network for KPIC provides access to care in the Kaiser Permanente states of CA, CO, GA, HI, MD, OR, VA, WA, and DC.
In Non-Kaiser Permanente States: The CignaPPONetwork* only provides access to care in non-Kaiser Permanente states
*Disclaimer: The Cigna PPO Network refers to providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration.
- Preparing for your Appointment
- When checking in for your visit. Bring your gold ID card with you. If your provider has any questions, have them call the customer service phone number on the back of your ID card. Make sure the provider only refers you to laboratory, radiology, and other service providers and facilities that are also participating providers.
- Provide the Preparing for your Appointment document to your provider. This helps identify you as a Kaiser Permanente PPO Plan member with access to care through the PHCS Network for KPIC. It also gives the provider’s office important information about filing claims on your behalf.
- After your visit. Your Participating Provider office will take care of claim submissions for you.
Non-Participating Providers
Call any licensed provider’s office directly.
- Your Non-Participating Provider Tier benefits cover care you receive from any licensed provider (outside the Participating Provider Tier).
- You can call the provider’s office directly to make an appointment.
- No referral is needed when you see a specialist. However, you will need precertification for some services and procedures. You must call 1-888-251-7052 (TTY 711), Monday through Friday, 6 a.m. to 6 p.m., Pacific time, for precertification.
- Your doctor may require you to pay the full cost of the visit. You may need to submit a Medical Claim Form and itemized bills for reimbursement.
- You’ll have to pay coinsurance and meet a deductible. You’ll also be responsible for any difference between what your provider charges for service and the payment Kaiser Permanente Insurance Company provides.
Helpful Tips
- When making an appointment. Make sure the provider understand that your plan allows you to see any licensed provider.
- Preparing for your Appointment
- When checking in for your visit. Bring your gold ID card with you. If your provider has any questions, have them call the customer service phone number on the back of your ID card.
- Provide the Preparing for your Appointment document to your provider. This helps identify you as a Kaiser Permanente PPO Plan member with access to care to any licensed provider. It also gives the provider’s office important information about filing claims on your behalf.
You’ll generally pay the highest out-of-pocket costs when you receive services from a Non-Participating Provider or facility.
It’s important to keep in mind:
- Your cost-shares will vary in each provider tier.
- The amount you pay for a particular service will depend on the provider tier you choose and—in some cases—where you choose to receive care.
To find out more:
- See your PPO Member Handbook for details about accessing covered care using the different tiers.
- Refer to your Certificate of Insurance (COI).
- Contact the human resources/benefits officer where you work if your employer provides your coverage.
- Call Customer Service at 1-800-788-0710 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Pacific time, or refer to your ID cards.
Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc., underwrites the Participating Provider Tier and the Non-Participating Provider Tier.
KPIC has contracted with PHCS, a subsidiary of MultiPlan. Some services require precertification. KPIC has also contracted with the Cigna PPO Network outside of Kaiser Permanente states for health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO for Shared Administration.
Cigna is an independent company and not affiliated with Kaiser Foundation Health Plan, Inc., and its subsidiary health plans. Access to the Cigna PPO Network is available through Cigna’s contractual relationship with the Kaiser Permanente health plans. The Cigna PPO Network is provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
For more information, see your Certificate of Insurance (COI).