Utilization Management
An appropriate peer reviewer (Medical Director, Pharmacist, or Associate Clinical Director) is available to discuss any Utilization Management denial decision by calling Customer Service at 1-800-440-1561. Policy is available upon request.
Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services to ensure medical necessity and appropriateness of care are met prior to services being rendered.
- Use this Prior Authorization Form to request:
- OP/IP procedures
- DME items
- Non-covered services and benefits
- Specialist office visits, when PCP is not ordering
- Therapy services, beyond initial
- All services listed on the Prior Authorization list.
Use this Referral Form to request office visits for a non-participating provider when a PCP is ordering.
Use the Notification of Inpatient Hospitalization form to notify Community Health Plan that a member has been admitted to the hospital for planned and non-planned services.
- Other Forms and Tools
- Names and Numbers
- Pre-existing condition overview for clinic staff
- Routine Care and Screening Guidelines
- Authorization for Release of PHI
- 2012 Prior Authorization List
- 2011 Prior Authorization List
Most current fax numbers:
- Prior Authorizations and Referrals: 206-613-8873
- Inpatient: 206-652-7078
- Clinical Review: 206-652-7082