Precertification & Claims

Who needs to submit claims within each option of Flexible Choice?

Option 1: There are virtually no claims forms within Option 1.

Option 2: Providers in the PHCS and MultiPlan networks.

• PHCS providers should submit claims on the member’s behalf.
• Members should never have to file a claim.

Option 3: Licensed providers out of network.

• Providers usually require the member to pay at time of service.
• The member submits claims for repayment.
• The member is responsible for any balance billing.

Troubleshooting claims

For more information on the claims process (for Options 2 and 3) call: 1-800-392-8649.

What is the precertification process?

For Option 2 (PPO) and Option 3 (Out of network) services, the member or the provider must obtain precertification for inpatient stays and certain outpatient treatments.

Option 1: Physicians obtain preauthorizations for members.

Option 2 and Option 3 providers:

• Members and providers should work together to make sure that precertification is authorized in plenty of time for services.
• Physicians, hospitals and authorized representatives may obtain precertification on the member’s behalf.
• Only the providers can submit the authorization request form. Supporting documentation should also be included.
• For a precertification form for a member, download this form.
• Find out which services require precertification.

Troubleshooting Precertification

If the precertification is denied and the case doesn’t meet medical necessity, Permanente Advantage will:

• have the physician reviewer call the provider.
• notify the providers by phone and fax.
• You may file an appeal or contact Customer Service.

The best way to troubleshoot precertification is to understand the process. You can find information about guidelines, urgent requests, hospital admissions, and more at our provider portal under precertification requests.