AUTHORIZATION
In an effort to reduce paper waste and preserve our environment, Key Medical Group requires that all authorization requests must be submitted using our online portal, Cerecons. The request must include ICD-10 and CPT codes. All in-patient admissions and most out patient services require prior authorization. Most initial consultation with an in-panel provider will be an automatic approval, however you must still submit a request for the referral. This allows Key Medical Group to verify patient eligibility, provider contract and monitor utilization. As a result, this will eliminate any potential problems with the referral. If you need further assistance using our online portal or have any questions please contact our office at (559) 734-1321.
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All requests must have complete information attached for review, such as physician's progress notes, physician's signature, laboratory and radiology results, etc. Routine requests for authorization will be reviewed and processed within 5 business days. Retrospective requests will be reviewed and processed within 30 business days. If additional information is received, it will be reviewed and a decision will be made based on the health plan policies and guidelines and will be returned to the referring physician as well as a letter to the member. You have the right to obtain the criteria used for authorization decision making. Please contact Key Medical Group at (559) 734-1321 and ask that a specific criteria be sent to you.
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Requests for second opinions for appropriate care will be provided within the local panel of providers. Out of area second opinions must be requested and will be managed by your health plan and not by Key Medical Group. Once the member is seen for an out of area second opinion, any additional services out of panel will be requested to Key Medical Group by the out of area provider. Any services requested out of area that can be provided within panel, must be done in our local provider network.
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Under the HMO's, women have direct access to contracted OB/GYN's within the Key Medical Group panel. Direct access means the member can see the OB/GYN without a referral for evaluation and management services. A Key Medical Group, OB/GYN provider can perform or request up to $500.00 worth of services. Services over $500.00 need to have prior authorization.
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Retrospective authorizations are only given when 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 and submit appropriate documentation.
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Authorization does not guarantee payment. All payments are subject to Health Plan provisions.