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Kaiser Permanente is a unique entity as both an insurer and a healthcare provider system. Kaiser covers addiction treatment services for its members, often within its own network of hospitals and clinics. Medical necessity determinations for SUD care at Kaiser are guided by evidence-based clinical guidelines, including the ASAM Criteria. In fact, Kaiser Permanente’s Mental Health and Addiction Medicine services have adopted the ASAM Criteria to define medical necessity for substance use treatment and level of care determination (Substance Use Disorder Treatment | Clinical Review Criteria) (Substance Use Disorder Treatment | Clinical Review Criteria). Kaiser must also comply with state regulations (e.g., in California and Washington, Kaiser follows state laws requiring ASAM criteria usage ([PDF] Changes to Medical Necessity Review Criteria for Substance Use ...) (Substance Use Disorder Treatment | Clinical Review Criteria)). Here’s how Kaiser handles detox, rehab, outpatient programs, and MAT, plus what the prior authorization process looks like in the Kaiser system, and relevant billing codes (for when external billing is needed):
Kaiser’s Integrated Approach and ASAM Criteria
Kaiser Permanente often provides addiction treatment “in-house.” That means members may receive detox at a Kaiser hospital, attend an intensive outpatient program at a Kaiser clinic, etc. Utilization management at Kaiser is typically internal – Kaiser's own physicians and care coordinators will review medical necessity. Kaiser explicitly states it uses ASAM Criteria for reviewing residential, inpatient, and detox services (Substance Use Disorder Treatment | Clinical Review Criteria). They note that ASAM criteria help match patients to the right level of care and that Kaiser has adopted these criteria across their system.
For providers outside the Kaiser system, getting Kaiser to authorize out-of-network treatment can be challenging unless the service is not available in-network. Kaiser generally tries to keep treatment within their network. But if, say, a Kaiser member needs a specialized residential program Kaiser doesn’t offer, Kaiser might contract it out – in such cases, they will use the same ASAM-based criteria to approve that external service.
Detoxification (Withdrawal Management) – Kaiser Permanente Criteria
Within Kaiser, withdrawal management is often done in Kaiser hospitals or clinics. Kaiser uses ASAM to determine if a member needs:
Inpatient hospital detox (ASAM Level 4) – e.g., for severe alcohol or benzo withdrawal risk, or if the patient has medical comorbidities that require hospital-level care. Kaiser's criteria would align with needing 24/7 medically managed detox.
Non-hospital residential detox (ASAM 3.2 or 3.7-WM) – Kaiser might have some designated beds or could refer out if they don’t. Criteria: significant withdrawal risk that can be managed in a non-hospital setting with medical monitoring.
Outpatient/ambulatory detox – Kaiser runs outpatient detox clinics for opioids (using buprenorphine inductions) and sometimes for alcohol (daily check-ins for a librium taper). They’ll allow ambulatory detox if the withdrawal severity is mild to moderate and the patient is deemed reliable to come for daily monitoring, consistent with ASAM criteria.
A Kaiser Permanente guideline excerpt from Washington states: "The following services may be considered medically necessary when criteria are met using ASAM Criteria: Outpatient Services, IOP, Partial Hospitalization, Inpatient Detox, Residential, Sub-Acute Detox." (Substance Use Disorder Treatment | Clinical Review Criteria). It also explicitly says "No prior authorization required for contracted providers for opioid use disorder methadone (H0020)" (Substance Use Disorder Treatment | Clinical Review Criteria), implying Kaiser WA at least doesn’t require extra auth for methadone maintenance detox/stabilization in network.
Kaiser’s internal process: Typically, a Kaiser primary care or ER doc will initiate the detox referral. The Addiction Medicine physician at Kaiser evaluates and applies ASAM. If criteria met, they admit the patient to Kaiser service. If not, they might do outpatient management.
For outside providers: If a Kaiser member shows up at a non-Kaiser ER in severe withdrawal, that hospital should contact Kaiser for authorization to admit. Kaiser will likely approve if it’s an emergency (they have to under emergency care rules). For planned transfers to detox outside, Kaiser might require their physician to review and approve it.
Billing codes for detox (Kaiser):
If you are a non-Kaiser facility providing detox to a Kaiser member (with authorization), you’d bill Kaiser using standard codes: likely H0010/H0011 for inpatient detox. Kaiser will pay per diem or under a case agreement.
Kaiser itself, when billing internally (for internal accounting), might use similar codes, but generally, Kaiser doesn’t bill itself. For external, treat Kaiser like an insurer: claims go to Kaiser insurance.
Kaiser often has a separate TPA for non-Kaiser claims (e.g., Kaiser in Northern California uses Data Interchange, etc.). Use the codes authorized.
Residential Rehabilitation – Kaiser Permanente Criteria
Kaiser provides some residential SUD treatment through affiliated programs (like Kaiser has contracts with community residential facilities or runs a day-treatment but for overnight might partner with local rehab centers). Not every Kaiser region has Kaiser-owned rehab centers, so they often refer to contracted facilities for residential care.
Kaiser’s medical necessity for residential rehab relies on ASAM:
The patient must have functional impairments and relapse risks warranting 24-hour care and cannot be effectively treated at lower levels. Kaiser’s internal reviewers will check: Did the patient try outpatient? Is the home environment unsupportive? Are psychiatric conditions stable enough for rehab (if unstable, maybe they need a psych hospital first)? ASAM dimensions 5 and 6 weigh heavily.
Kaiser is also mindful of cost/utilization – they won’t approve 30 days residential just because; they will approve what’s necessary, often starting with 14 days then reviewing. But under parity, they can’t arbitrarily limit days if medically justified.
Within Kaiser’s system, if a provider thinks a member needs residential, they might convene a multidisciplinary team to present the case (Addiction doc, therapist, utilization manager). If consensus is yes (ASAM criteria met), Kaiser arranges placement, usually at a contracted facility, and covers it.
If you are a provider at a contracted rehab receiving Kaiser referrals, know that Kaiser will expect:
Frequent updates (often Kaiser clinicians will call weekly to discuss patient progress).
That you begin discharge planning early (Kaiser is integrated, they will slot the patient into Kaiser IOP or outpatient after discharge).
Billing codes for residential (Kaiser):
Contracted facilities usually have an agreement with Kaiser on rates (per diem). They may bill using codes H0018/H0019 with revenue code 1002, or simply an all-inclusive per diem code.
Kaiser might prefer billing through invoices if under a case rate agreement rather than standard claims – depends on contract.
If you’re billing Kaiser insurance for a non-contracted scenario (rare, maybe if Kaiser had to send patient out-of-network by necessity), use H0018 and include the auth number.
Partial Hospitalization & IOP – Kaiser Permanente Criteria
Kaiser has robust outpatient programs. Many Kaiser regions run their own Intensive Outpatient Programs (IOP) for SUD, often combined with mental health if co-occurring. Kaiser also sometimes runs Partial Hospitalization Programs (PHP) specifically for mental health; for SUD, they more commonly use IOP level (which is typically ~9 hours/week).
Kaiser’s adoption of ASAM means:
PHP (ASAM 2.5) is approved if needed (but Kaiser might rarely use SUD PHP unless extremely necessary; they might instead supplement IOP with extra services).
IOP (ASAM 2.1) is a standard offering Kaiser uses for many members after detox or instead of residential. Criteria: patient needs more structure than weekly therapy, can commit to ~3 times a week sessions, has stable housing or can be in sober living (Kaiser often coordinates with sober living homes).
Kaiser Washington explicitly lists IOP and PHP as services considered medically necessary if ASAM criteria met (Substance Use Disorder Treatment | Clinical Review Criteria).
Kaiser tends to not require “authorization” in the traditional sense for IOP/PHP if done in-network (because Kaiser itself is providing it). The care team decides and enrolls the member. The utilization management is done via internal case reviews rather than formal auth numbers.
If a Kaiser member needs an external IOP/PHP (maybe traveling or no local Kaiser program), then Kaiser insurance would handle it like an out-of-network service requiring prior authorization. They would check that the patient indeed meets criteria and that Kaiser cannot provide it internally.
Billing codes for PHP/IOP (Kaiser):
Kaiser internal programs obviously don’t bill insurance in the same way (members might pay a copay per program or something).
External provider billing Kaiser: Use S0201 for PHP and H0015 for IOP, as usual. Ensure you have approval in writing (like an authorization letter) for those services. Kaiser might authorize a certain number of weeks and then require progress reports for extension.
Kaiser’s insurance side will pay according to the contract (often Medicare rates or negotiated).
Medication-Assisted Treatment (MAT) – Kaiser Permanente Criteria
Kaiser Permanente is generally very supportive of MAT. They employ physicians and addiction specialists who prescribe buprenorphine, administer naltrexone injections, and in some regions even operate methadone clinics (though Kaiser often partners with community OTPs for methadone).
Kaiser’s criteria for MAT:
Diagnosed opioid use disorder or alcohol use disorder with indication for MAT.
No contraindications (for example, they’ll check LFTs for naltrexone, etc., but these are clinical considerations).
Kaiser does not require patients to try abstinence-based treatment first. They follow modern guidelines that MAT is first-line for OUD.
In fact, Kaiser was ahead of many insurers in integrating buprenorphine treatment into primary care. They also have Kaiser pharmacies dispense Suboxone with usually just a copay, no prior auth needed (for preferred formulary versions).
Prior Authorization for MAT meds:
Buprenorphine: Typically on formulary with no PA for most dosages. Kaiser might require PA for high-dose or certain formulations (like brand-name Suboxone film if generic is available).
Methadone: If a Kaiser doc refers a member to an outside OTP, Kaiser covers it. Kaiser Northwest’s bulletin explicitly said methadone (H0020) doesn’t need prior auth for contracted providers (Substance Use Disorder Treatment | Clinical Review Criteria).
Naltrexone (Vivitrol): On formulary. Usually requires that it’s given in clinic (which Kaiser can do). They might require a treatment plan with it (like patient is in therapy or IOP, etc.), but generally if the physician orders it, Kaiser pharmacy dispenses it or the injection clinic administers it.
MAT in Kaiser programs: If a member is in Kaiser’s IOP, MAT (bupe or naltrexone) is offered concurrently. If in residential outside, Kaiser expects that facility to allow MAT (they prefer programs that don’t force patients off their meds).
Billing codes for MAT (Kaiser):
Kaiser internal providers use internal codes; from an insurance perspective:
H0020 – as mentioned, Kaiser covers methadone dosing at contracted OTPs without preauth in at least some regions (Substance Use Disorder Treatment | Clinical Review Criteria).
Office visits – Kaiser providers just log visits in EMR, but if you are an external provider treating a Kaiser member (rare, unless Kaiser authorized out-of-network specialist), use standard E/M or CPT codes. Must have authorization if out-of-network.
J2315 for Vivitrol – Kaiser typically stocks this in their pharmacies. If an external provider gives a Vivitrol shot, they need auth and then can bill Kaiser for the drug with J2315 and admin code. Kaiser might just handle it internally usually.
Kaiser Permanente’s Authorization Process and Provider Considerations
Unlike traditional insurers, Kaiser’s “authorization” process is mostly internal. If you are a Kaiser provider, you don’t go through a formal auth – you follow clinical guidelines and Kaiser’s internal UM will monitor. If you are a non-Kaiser provider or facility, you absolutely need to coordinate with Kaiser Utilization Management to get authorization for services.
For Kaiser members going outside Kaiser:
Contact Kaiser’s Utilization Management Department. Sometimes this is via the Member Services or a specific referral unit.
Provide clinical information justifying why the patient can’t get this service within Kaiser (e.g., Kaiser has no residential program, or patient needs a facility far from home, etc.).
Kaiser will give an authorization if approved, often with specific parameters (number of days, etc.). They might also have the facility sign a Letter of Agreement (LOA) for payment rates.
Kaiser internal UM:
Kaiser has committees that meet (often multidisciplinary rounds) to review cases in high levels of care. For example, if a member is in a non-Kaiser residential facility, a Kaiser addiction medicine physician might call in to discuss progress. This is part of their UM to decide on extensions or transition.
Decision-making is heavily criteria-driven: Kaiser clinicians use the ASAM criteria and any relevant state guidelines. For instance, in Maryland Kaiser must abide by the law requiring ASAM criteria usage and no arbitrary limits (similar to CareFirst law (CareFirst to use American Society of Addiction Medicine Guidelines)).
Because Kaiser is integrated, they emphasize discharge planning from day 1. They likely will only keep someone in a high level as long as needed and then step down to Kaiser’s own services (IOP, outpatient therapy, psych follow-up). That continuity is good for patients, but providers should be aware that Kaiser seldom authorizes extremely long stays in residential unless clear ongoing medical necessity.
Member Benefits:
Kaiser plans often have no dollar limit on SUD treatment (parity compliance), but some have day limits (older plans) – which they have to manage in parity context. Usually no nowadays.
Copays: Kaiser members might have a copay per day for inpatient or per program. Kaiser often waives copays for certain preventive services, and some SUD services might fall under that if intensive.
MAT meds are usually in the pharmacy benefit with small copays (Kaiser encourages MAT by making it affordable).
Provider Tips:
If you’re an external provider with a Kaiser patient, maintain contact with the Kaiser case manager. Provide timely updates, invite them to team meetings by phone, etc. This collaboration usually helps extend authorizations if needed because Kaiser sees you as a partner and gets real-time info.
Familiarize with Kaiser’s paperwork: Sometimes Kaiser requires filling out their own treatment request forms or continued stay forms aligned with ASAM dimensions. Use those if provided.
Kaiser is big on outcomes. They may ask for reports on discharge status, medications on discharge, etc. Provide thorough discharge summaries to Kaiser – it helps them coordinate aftercare and also justifies the care given.
Billing to Kaiser:
Submit claims to the Kaiser plan indicated (some Kaiser regions use different claim addresses for external services).
Kaiser is usually pretty efficient in paying authorized services, since they negotiate rates up front. Ensure the claim matches the authorization (dates, level).
If any denial occurs, contact the Kaiser UM rep – often it’s a clerical fix (like an extension auth wasn’t logged correctly).
In summary, Kaiser Permanente’s approach to addiction treatment is very much within an integrated care framework, using ASAM Criteria as the medical necessity benchmark for all levels of SUD care (Substance Use Disorder Treatment | Clinical Review Criteria) (Behavioral Health Substance Abuse Criteria for Utilization | Blue Cross and Blue Shield of Oklahoma). They strive to treat patients in the least intensive appropriate setting (but will authorize higher intensity when needed) and focus on continuity (stepping patients down to outpatient and MAT). For providers, working with Kaiser means understanding that you may be coordinating with Kaiser’s internal system quite a bit. The good news is Kaiser doesn’t arbitrarily deny needed care – if the patient meets the criteria, Kaiser will usually have a program or will pay for one.
One internal reference: Kaiser Permanente Washington’s provider update noted that effective 2020, Kaiser adopted ASAM criteria for all SUD treatment reviews, and will share copies of specific criteria upon request for individual cases (Substance Use Disorder Treatment | Clinical Review Criteria). This transparency means providers can ask, “What criteria are you using for this case?” and Kaiser will share the ASAM guideline piece they are looking at. This can help frame your discussions/appeals if needed.
By delivering organized, criteria-based information and collaborating closely, providers can ensure Kaiser members receive the full spectrum of addiction treatment – from detox to aftercare – with Kaiser’s coverage and support