Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services according to established criteria or guidelines. We use prior authorization, concurrent review, and post-review to ensure appropriateness, medical need, and efficiency of health care services, procedures, and facilities provided. This is known as utilization management. It ensures that medical necessity and appropriateness of care prior to services being rendered.
Please refer to the National Coverage Guidelines and/or Local Coverage Guidelines. Failure to obtain the required prior authorization may result in a denied claim. Services are subject to benefit coverage, limitations, and exclusions as described in plan coverage guidelines.
Providers should submit prior authorization requests through our Care Management Portal, JIVA. In the portal, you can check eligibility and authorization status, print approval letters, and submit requests online 24/7. For registration issues or technical assistance, contact Portal Support at [email protected] .
Review our current utilization guidelines for each area requiring prior authorization. These lists provide information on notification requirements for inpatient hospitalization, outpatient programs, and general authorization requirements and deadline. The Prior Authorization lists are not all-inclusive. Services are subject to benefit coverage, limitations and exclusions. Please contact Customer Service to verify member benefits and coverage. You can also verify coverage in the Care Management Portal. For Medicare coverage limitations, please refer to the National Coverage Guidelines and/or Local Coverage Guidelines.
Behavioral Health Prior Authorization
Treatment for mental health including outpatient programs, substance use disorder treatment, and residential treatment may require prior authorization or notification. If you are not sure if a service is covered, refer to the utilization guidelines for behavioral health services.
Pharmacy Prior Authorization
Some medications, including professional administered drugs, require prior authorization. Find information about step therapy, medication management, or quantity limit override. Access a current list of in-network pharmacies and find out which drugs are covered on the formulary.
Physical Health Prior Authorization
Certain services, procedures, or treatments may require prior authorization. Most inpatient services are covered, but not all. Patients will need to meet certain requirements for prior authorizations to be granted. Medical supplies, durable medical equipment, and prosthetics may also require prior authorization. Provider service representatives can help verify benefits and coverage.
If you prefer to fax your prior authorization requests, fill out the appropriate form and fax it to the number listed on the form. If you do not see the appropriate form on the list, please check the Provider Resources page.
We use several resources to determine whether a specific intervention is medically necessary. Each case is assessed using appropriate criteria, also taking into account individual case information.
We rely on the nationally recognized MCG Guidelines as the primary source for evidence-based recommendations for clinical coverage. In addition, we have created Clinical Coverage Criteria (CCCs) for situations not addressed by MCG Guidelines. For behavioral health medical necessity decisions we use Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) criteria, MCG criteria, and American Society of Addiction Medicine (ASAM) criteria for substance use disorders. You can refer to LOCUS/CALOCUS documents provided below.
CHPW utilizes the Centers for Medicare and Medicare Services (CMS) national coverage determinations (NCDs) and local coverage determinations (LCDs), if available. NCDs and LCDs are available through Noridian, Washington’s Medicare Fee-for-Service Contractor, or they are accessible on the CMS website. If CMS criteria are not available, then MCG Guidelines and/or CHPW’s CCCs are used.
Our medical directors will take into consideration the enrollee’s age, social situation, co-morbidities, and availability of services within the community when making utilization review determinations. These guidelines are available for reference below.
You can also access criteria online through the Care Management Portal.
Services for a specific program may not be a covered benefit. Please verify online through HealthMAPS, contact Customer Service, or consult the Member Benefit Grids.
Documentation required to support decision-making
Please provide documentation with the request to support medical necessity. Examples of appropriate documents include:
CHPW requires notification of all inpatient admissions, planned and urgent, within 24 hours or the next business day.
All planned admissions require prior authorization.
Community Health Plan of Washington and its providers use care guidelines written by experts in the field of medicine and behavioral health. These guidelines help providers know when to use certain treatments and what problems to look out for. To request a copy of the criteria used in making a decision, please contact customer service 7 days a week at 1-800-942-0247 from 8 a.m. to 8 p.m.
These resources can include MCG Guidelines®, Medicare coverage determinations, national standards, the expertise of board-certified practitioners in applicable specialties, and Community Health Plan of Washington clinical coverage criteria documents. An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any authorization or denial.
Community Health Plan of Washington Utilization Management (UM) staff are available to discuss this process. An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any authorization, denial, or UM issue at 1-800-942-0247 (TTY: Dial 711). If requested, language assistance will be provided free of charge. You can also consult our FAQ page for prior authorization questions.
Required Training
Providers are required to complete a Fraud, Waste, and Abuse training within 90 days of contracting with CHPW and annually thereafter. All clinic staff – including CEOs, senior leaders, managers, clerical/admin staff, physicians, and other clinical staff – are required to receive this training. Training courses are available on the CMS Medicare Learning Network website.
More information can be found in our Provider Manual.
Community Health Plan of Washington is an HMO plan with a Medicare contract and a contract with the Washington State Medicaid program. Enrollment in Community Health Plan of Washington depends on contract renewal. Community Health Plan of Washington complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. If you need an accommodation, or require documents in another format or language, please call 1-800-942-0247 (711) 8 a.m. to 8 p.m., 7 days a week. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-942-0247 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-942-0247 (711).
Based on a Model of Care review, Community Health Plan of Washington has been approved by the National Committee for Quality Assurance (NCQA) to operate a Special Needs Plan (D-SNP) through 2024.
Limitations, copayments, and restrictions may apply.
You must continue to pay your Medicare Part B premium.
Language assistance services, including interpreters and translation of printed materials, are available free of charge.
You will need Adobe reader to open PDFs on the site. Download the free version on Adobe Reader.
Copyright ©2024 Community Health Plan of Washington
