--- title: Kaiser Permanente Hawaii ABA coverage (QUEST Integration). url: "https://carelu.com/payers/kaiser-permanente-hawaii" markdown_url: "https://carelu.com/payers/kaiser-permanente-hawaii.md" state: HI (Hawaii) payer: Kaiser Permanente Hawaii (QUEST Integration) kind: Medicaid managed care plan (MCO) parent_program: Hawaii Medicaid (Med-QUEST / QUEST Integration) description: "How Kaiser Permanente Hawaii delivers the Med-QUEST ABA benefit as a QUEST Integration plan — its integrated, mostly in-house model, authorization of outside providers through ARM, and the ABA details Kaiser does not publish." last_reviewed: October 2026 --- # Kaiser Permanente Hawaii ABA coverage (QUEST Integration). _Payer Guide · Kaiser Permanente · Hawaii · Last updated October 2026 · 12 primary sources_ > Kaiser Permanente QUEST Integration plan. Integrated model — most care in-house; outside ABA providers need an ARM authorization. ABA rules undocumented publicly. Kaiser Permanente is one of Hawaii’s QUEST Integration plans. It is built differently from the others: its QUEST manual says Kaiser "provides most services through its own hospital and clinics" and through Hawaii Permanente Medical Group, with contracted outside providers accounting for "only 2% of all services." For a Kaiser QUEST child, ABA is the Med-QUEST EPSDT benefit — the manual names intensive behavioral therapy "including applied behavioral analysis (ABA)" for children with ASD — but an outside ABA agency needs a Kaiser authorization through Authorization and Referral Management (ARM). Kaiser publishes no ABA-specific policy, code list or hour rules that we could find, so most plan-level fields are marked unverified. Kaiser’s commercial HMO plans in Hawaii are also under Luke’s Law through HRS § 432D-23 (under 14, $25,000 a year for ABA). This guide covers the QUEST line. This plan administers the **Hawaii Medicaid (Med-QUEST / QUEST Integration)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Hawaii Medicaid (Med-QUEST / QUEST Integration) guide](https://carelu.com/payers/hawaii-medicaid). ## Prior authorization and diagnosis at a glance - **Prior auth for the assessment:** Not published / unverified. Verify via: Kaiser Permanente QUEST office (808) 432-5330 / 1-800-651-2237, or Authorization and Referral Management. [3][5] - **Prior auth for treatment**: Required for outside providers — "When services or items from an outside provider are needed, an authorization request is submitted and processed through" ARM; referrals are authorized "for specific services, including frequency and duration" [3] - **Autism diagnosis required?**: Yes — the QUEST manual describes EPSDT intensive behavioral therapy "including applied behavioral analysis (ABA) for the treatment of children with an ASD diagnosis"; the diagnosing rules come from Med-QUEST memo QI-2431 [3][6] ## At a glance - **Plan type:** QUEST Integration plan (integrated Kaiser Permanente model) - **Benefit source:** Med-QUEST memo QI-2431 / FFS 24-13 (IBT / ABA), EPSDT under 21 - **Outside providers:** Authorized through Kaiser’s Authorization and Referral Management (ARM) - **Retro authorizations:** Not processed, except narrow exceptions (e.g., members transferring from another QUEST plan) - **ABA specifics:** No published ABA policy or code list — confirm with the QUEST office ## An integrated plan: authorization runs through ARM Kaiser’s QUEST manual: when services from an outside provider are needed, "an authorization request is submitted and processed through Kaiser Permanente’s Authorization and Referral Management Department (ARM)," and the Kaiser Physician-in-Charge makes the final review of out-of-plan requests, "including Behavioral Health." Referrals are authorized "for specific services, including frequency and duration of treatment," and anything beyond needs a new authorization. PA "must be obtained before service is rendered," and "No retroactive requests will be processed," except for newborns, state retroactive enrollments, certain discharges, and "when members transition to Kaiser from another QUEST health plan" — which matters for ʻOhana families moving on January 1, 2027. [3][6][4] The benefit follows Med-QUEST’s memo: under 21, the memo’s diagnosing providers, a treatment plan with standardized goal measurement, 26-week periods, supervision at 1–2 hours per 10 RBT hours, Medicaid secondary to other coverage. The memo lists Kaiser’s Health Coordination line as (808) 432-5330. [3][6][4] ## Claims: when to submit Kaiser’s QUEST provider manual: "Claims for services provided to Members should be submitted for payment within ninety (90) days of such service," but all claims and encounter data must arrive no later than 365 days after the date of service (or a longer period your agreement or the law sets). Payment disputes go to Kaiser’s Claims Administration Department with the signed waiver of liability, the original claim and the denial remittance. [1][2][3] Federal Medicaid rules set the payment floor for every managed care plan: a state’s contract with an MCO "must provide that the organization will meet the requirements of § 447.45(d)(2) and (d)(3)" (42 CFR 447.46) — pay 90 percent of clean claims from practitioners within 30 days of receipt and 99 percent within 90 days — unless the plan and the provider agree in writing to an alternative schedule stipulated in the contract. A "clean claim" is one that "can be processed without obtaining additional information from the provider of the service or from a third party" (42 CFR 447.45(b)). [1][2][3] ## Intake gates The questions that decide whether a family can start with Kaiser Permanente Hawaii (QUEST Integration), and what they have to bring. - **Age limit**: Under 21 — EPSDT; Kaiser’s manual describes the ABA benefit for children with ASD, and the MQD memo sets the under-21 limit. [3][6] - **Referral required?**: Yes for outside providers: external referrals are "generated in Kaiser’s electronic medical record" for ARM to review, and the authorization names the services, frequency and duration. [3] - **Prior-auth decision time**: The federal managed-care limit applies: 7 calendar days standard (rating periods from January 1, 2026; extendable by 14) and 72 hours expedited. Kaiser’s manual says each authorization step is tracked against "the allowable timeframes as described in the QUEST contract." No retro authorizations except narrow exceptions. [8][3] - **Other insurance (who pays first)** _(plan-dependent)_: Medicaid is secondary to all other insurance (MQD memo). Kaiser’s manual does not set out ABA-specific COB. TRICARE pays after other coverage except Medicaid; CHAMPVA pays last. [6][9][13][14] - Ask the plan: Kaiser Permanente QUEST office (808) 432-5330. - **Diagnosis recency** _(ask the plan)_: No recency window in the MQD memo; no Kaiser rule found. [6] - Ask the plan: Kaiser Permanente QUEST office (808) 432-5330. - **Who may diagnose** _(ask the plan)_: MQD memo list: developmental-behavioral or developmental pediatrician, neurologist, pediatrician, psychiatrist, psychologist, or other licensed practitioner with ASD expertise. No Kaiser variation published. LCSW: no Kaiser-specific answer; under the MQD memo an LCSW fits only the "other licensed practitioner with specialized expertise in ASD" category. Hawaii scope rule: the practice of social work includes "(8) Clinical diagnosis or psychotherapy, or both, provided by a licensed clinical social worker" (HRS § 467E-1), and Luke's Law covers autism treatment "prescribed or ordered" by a licensed physician, psychiatrist, psychologist, licensed clinical social worker or registered nurse practitioner (HRS § 431:10A-133). [6][12][10] - Ask the plan: Kaiser Permanente QUEST office (808) 432-5330. - **Diagnostic tools required** _(ask the plan)_: MQD memo: "evidence-based assessments," no instrument named. No Kaiser requirement published. [6] - Ask the plan: Kaiser Permanente QUEST office (808) 432-5330. - **Telehealth** _(ask the plan)_: MQD memo QI-2527 applies (audio-video, modifier 95/GT/GQ); it lists Kaiser’s community-provider portal as the contact for plan rules. No Kaiser ABA telehealth rule found. [7] - Ask the plan: Kaiser customer service / MCSA department 800-966-5955. ## Delivery and billing rules Coverage decides whether Kaiser Permanente Hawaii (QUEST Integration) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under. - **Supervision** _(ask the plan)_: No Kaiser-specific rule published; the MQD memo sets it: 1–2 hours of case supervision per 10 RBT hours, at least one direct, direct supervision at least 5% of BCaBA and RBT hours. [6] - Ask the plan: Kaiser Permanente QUEST office (808) 432-5330, or the Kaiser contracted-provider agreement. - **Concurrent billing (97153 + 97155)** _(ask the plan)_: The MQD memo allows 97153 and 97155 concurrently when both codes’ criteria are met and they carry different modifiers. No Kaiser billing rule published. [6] - Ask the plan: Kaiser claims / Community Medical Services (808) 432-7529. - **Daily limits / MUEs** _(ask the plan)_: Kaiser authorizes specific services with frequency and duration; no published ABA unit cap. The MQD memo sets no cap. [3][6] - Ask the plan: The ARM authorization itself. - **Session-note signature** _(ask the plan)_: Not published by Kaiser or the MQD memo. [3] - Ask the plan: Kaiser contracted-provider agreement or Community Medical Services (808) 432-7529. - **Place of service** _(ask the plan)_: Per the MQD memo: clinic, home or community named in the treatment plan; school ABA by DOE under the IEP; nothing outside Hawaii. No Kaiser-specific rule published. [6] - Ask the plan: Kaiser Permanente QUEST office (808) 432-5330. - **Bill as provider** _(ask the plan)_: Per the MQD memo: payment to the licensed practitioner or employing agency, with HO/HN/HM modifiers. Kaiser’s own contracted-provider billing rules were not found. [6] - Ask the plan: Kaiser claims / Community Medical Services (808) 432-7529. ## What intake should collect for Kaiser Permanente Hawaii (QUEST Integration) - **Kaiser QUEST member ID:** Confirm QUEST Integration enrollment with Kaiser. - **Kaiser referral / ARM authorization:** An outside ABA agency needs an authorization for specific services, frequency and duration before starting — no retro authorizations. - **ASD diagnosis and age:** Under 21, diagnosed by one of the Med-QUEST memo’s provider types (often inside Kaiser). - **Transferring from ʻOhana?:** Members moving from another QUEST plan are an exception to Kaiser’s no-retro rule; transition-of-care rules apply. Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf ## Common questions ### Does Kaiser Permanente Hawaii QUEST cover ABA? Yes — its QUEST manual describes EPSDT intensive behavioral therapy, including ABA, for children with an ASD diagnosis, under the Med-QUEST benefit for members under 21. ### Can an outside ABA agency treat a Kaiser QUEST child? Only with a Kaiser authorization through Authorization and Referral Management, naming the services, frequency and duration. Kaiser does not process retro authorizations except in narrow cases, including members transferring from another QUEST plan. ### What is Kaiser Permanente Hawaii’s timely filing limit for QUEST claims? Submit within 90 days of the service; the hard limit is 365 days after the date of service unless your agreement or the law allows longer (Kaiser QUEST provider manual). ## Primary sources 1. [42 CFR 447.46 — Timely claims payment by MCOs (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.46) 2. [42 CFR 447.45 — Timely claims payment (clean-claim definition; 90% in 30 days, 99% in 90 days) (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.45) 3. [Kaiser Permanente Hawaii — QUEST Provider Manual (KP25-013)](https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/community-providers/hi/ever/quest-integration-provider-manual-en.pdf) 4. [Kaiser Permanente Hawaii — Community Provider Portal: QUEST Integration](https://healthy.kaiserpermanente.org/hawaii/community-providers/quest-integration) 5. [Kaiser Permanente Hawaii — Community Provider Portal: Authorizations](https://healthy.kaiserpermanente.org/hawaii/community-providers/authorizations) 6. [Med-QUEST memo QI-2431 / FFS 24-13 (Dec 31, 2024) — Coverage of IBT for children under 21 with ASD: Guidelines for ABA (Attachments A–C)](https://medquest.hawaii.gov/content/dam/formsanddocuments/provider-memos/qi-memos/qi-memos-2024/QI-2431,%20FFS%2024-13%20Replaces%20QI-2301,%20FFS%2023-01%20Coverage%20of%20IBT%20for%20treatment%20of%20children%20under%2021%20years%20of%20age%20with%20ASD_Guidelines%20for%20ABA._FINAL%20(part%201)%20-%20signed.pdf) 7. [Med-QUEST memo QI-2527 / FFS 25-12 / CCS-2509 — Telehealth Implementation (Dec 8, 2025)](https://medquest.hawaii.gov/content/dam/formsanddocuments/provider-memos/qi-memos/qi-memos-2025/QI-2527%20FFS%2025-12%20CCS-2509%20%20Telehealth%20Implementation%20-%20signed.pdf) 8. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210) 9. [42 CFR 433.139 — Medicaid payment of claims involving third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139) 10. [HRS § 431:10A-133 — Autism benefits and coverage; notice; definitions (Luke’s Law; current text, archived 8/10/2026)](https://www.capitol.hawaii.gov/hrscurrent/Vol09_Ch0431-0435H/HRS0431/HRS_0431-0010A-0133.htm) 11. [S.B. 791 C.D. 1 (2015), enacted as Act 235 — Luke’s Law: §§ 3–6 add the insurer, mutual-benefit-society and HMO autism sections](https://www.capitol.hawaii.gov/session2015/bills/SB791_CD1_.htm) 12. [HRS § 467E-1 — Social workers: definitions (practice of social work incl. "(8) Clinical diagnosis or psychotherapy, or both, provided by a licensed clinical social worker")](https://www.capitol.hawaii.gov/hrscurrent/Vol10_Ch0436-0474/HRS0467E/HRS_0467E-0001.htm) 13. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm) 14. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270) Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member. Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.