Authorization FAQs

Required Forms

Key Medical Group requires that all authorization requests be faxed on the Key Medical Group form to the medical group.  Telephone authorizations are not given for non-emergent services.  The forms must be complete and include ICD-9 and CPT codes.  A physician signature on the form is a requirement of all health plans and must be on the form in order for the medical group to process. Request forms can be obtained from our provider resource page.

Back to Top

Required Information

In addition to the information on the authorization request form, any notes from the physician, or test results documenting the condition would be appreciated.  At times, the Medical Director of Key Medical Group will request further information from the requesting physician.  This will be requested either via fax or telephone.  No action will be taken on the request until the information is received.

Back to Top

Time Frame

Once the request is received by Key Medical Group it will be processed and reviewed within 2 working days of receipt for routine authorizations, 1 working day for urgent and 30 days for retrospective requests.  If further information is requested by the Medical Director, the request will be pended until the information is received.  Routine requests that do not have all the necessary information needed to make a medical necessity decision when received by the UM Department will be placed in pending.  Additional information will be requested upon review.  If the information is not received within 24 hours, a second request will be sent within 48 hours of the initial request. A letter will also be sent to the member notifying them of the delay in determination and the reason for the delay.  The case will then be pended for up to 45 days. If no information is received within 45 days, the case will be closed and written notification will be sent to the member and the requesting provider of the “lack of information”. The letter to the patient will include the information needed, the Physician reviewers name and contact number and grievance and appeal information.  If the needed information is received, the authorization request will be reviewed within 24 hours and a decision will be made and communicated to the requesting provider within 24 hours of the decision. A letter will also be sent to the member notifying them of the authorization within 2 working days.   Authorizations to the Physician for approved services will specify the service approved, the facility the service is approved at and CPT/HCPCS codes approved.

All patient management determinations are communicated by fax within 24 hours of making the decision.  All denials are communicated to the requesting provider by fax and by mail to the patient within 24 hours of the determination.  All denial letters state the reason for the denial, any unmet criteria guidelines, and an alternative treatment plan.  The denial letter also includes the appeals process, including expedited appeals.   

If the physician’s office has not heard back from Key Medical Group after 48 hours from submitting the request, they may contact the medical group at 559-735-3892 to request the status of the authorization.  Fax machines are not perfect, and sometimes things get lost!  Please do not re-fax the request as this can actually slow down the processing of the request.

Back to Top

What Requires Prior Authorization?

All elective in-patient admissions, outpatient surgeries, Imaging studies over $500 (such as MRI and CT, nuclear medicine studies, X-rays over the $500. limit), follow up specialist visits, DME, office procedures over $500, home health care and initial consultations with specialists outside of the local provider panel require prior authorization.

Initial consultation with a local, in panel provider do not require prior authorization, however, an authorization request form is required to be faxed to Key Medical Group notifying the medical group of the referral.  This allows Key Medical Group to verify patient eligibility, provider contract and monitor utilization.  That way, we can notify you if there are any potential problems with the referral.  If specialists request an authorization number you may ask them to contact Key Medical Group at 559-735-3892, the UM staff will remind the provider of the automatic authorizations.

Member requests for a second opinion about appropriate care will be provided within the local panel of providers.  If a qualified local provider cannot be obtained, Key Medical Group will work with the health plan in locating a provider within the health plan network.  The authorization will be given by the health plan, not the medical group.  If a second opinion request is denied, notification will be made within 24 hours of the determination.

Direct Access for women to OB/GYN’s.  Under the HMO’s, women have direct access to contracted OB/GYN’s within the KMG panel.  Direct access means the member can see the OB/GYN without a referral for evaluation and management services. A KMG provider can perform or request up to $500.00 worth of services. Services over $500.00 need to have prior authorization.

Back to Top

Retrospective Authorizations

Retrospective authorizations are only given when the services performed were of an urgent or emergent nature.  Routine office visits require prior authorization, except when the patient is seeing the primary care physician or ob/gyn. If a service was performed on an urgent/emergent basis, please indicate this on the authorization request form and submit appropriate documentation.

Back to Top