Provider Manual

The Community Health Plan Provider Manual provides an overview of Community Health Plan. It links to forms, procedures, and references to help you provide better service.

Download a printable PDF of the Provider Manual (May 2013 update).

For tools and information, see:

Welcome to Community Health Plan of Washington
Provider Relations
- Access to Care Standards and Responsibilities
- Credentialing and Recredentialing
- Provider Rights in Credentialing
- Access to Records and Enrollee Health Information
- Security of Health Information
- Medical Record Documentation Standards
- Reporting Changes in Provider Status
Provider Directory and Counties
- CHPW Provider Directory
- State Programs and Medicare Advantage Counties
- Healthy Options and the Children’s Health Insurance Program Counties
- Basic Health Counties
- Washington Health Program Counties
- Community HealthFirst™ Medicare Advantage Counties
- Medicare Advantage Providers in the Health Care Setting
CHPW Eligibility
- Eligibility Documents PCP Assignment Procedures Involuntary Disenrollment from Healthy Options, CHIP, Medical Care Services, Washington Health Program, and Basic Health
- Disenrollment Policy
- Disenrollment Procedure
- Involuntary Disenrollment Medicare Advantage Plan
- Change in residence
- Loss of entitlement to Washington State Medicaid
- Loss of entitlement to Medicare Part A or loss of enrollment in Part B
- Enrollee is deceased
- Disruptive behavior
- Failure to pay a Part-D Income Related Monthly Adjustment Amount (Part-D IRMAA)
- Fraud and abuse
- Contract termination
- Involuntary Disenrollment Documents
Enrollee ID Cards
- State Programs: Washington Health Program
- Medicaid: Healthy Options
- Medicaid: Children's Health Insurance Program (CHIP)
- Medicaid: Medical Care Services
- Medicaid: Medical Care Services--Yakima
- MA Community HealthFirst Plan 005: Special Needs
- MA Community HealthFirst Plan 006: HMO
- MA Community HealthFirst Plan 008: Pharmacy
- MA Community HealthFirst Plan 012: Enhanced Pharmacy & Dental
- MA Community HealthFirst Dental
Enrollee Benefits
- Benefit Information
- State Programs Enrollee Materials
- State Programs Enrollment Materials and Publications
- Children First rewards for children and pregnant women
Compliance Program and Program Integrity
- About the Compliance Program and Program Integrity
- Education and Training
- Privacy and Security
- Email Encryption
Fraud, Waste, and Abuse
- Preventing and Detecting Fraud, Waste, and Abuse
- What Are Fraud, Waste, and Abuse?
- Where Do Fraud, Waste, and Abuse Occur?
- Examples of Fraud, Waste, and Abuse
- Provider Fraud, Waste, and Abuse
- Provider Prescription Fraud, Waste, and Abuse
- Pharma Prescription Fraud, Waste, and Abuse
- Patient Fraud, Waste, and Abuse
- Consequences of Fraud, Waste, and Abuse
- Help Prevent Fraud, Waste, and Abuse
Exclusions, Disclosure Requirements, and Reporting
- Exclusions
- Disclosure Requirements
- Business Transaction Reporting
- Reporting Concerns
Compliance Policies and Procedures
- Policies and Procedures
- The Principles of Integrity
- Fraud, Waste, and Abuse Policy and Procedure (CO289)
- False Claims and Whistleblower Protections Policy (CO310)
- Identity Theft Prevention (Red Flags of Identity Theft) Policy and Procedure (CO302, CO303)
- Sanction Screening (CO318)
- HIPAA Security Policy (CO330)
- HIPAA Privacy Policy and Procedures (CO298, CO315, CO316, CO317)
- Privacy Incidents and Breach Notifications Policy (CO311)
- HIPAA Violations Policy (CO325)
Understanding Relevant Laws
- Understanding Relevant Laws
- Federal False Claims Act
- Federal Anti-Kickback Law
- Stark Law (Physician Self-Referral Law)
Patient Rights and Advance Directives
- Advance Directives
- Patients' Bill of Rights: Member Rights and Responsibilities
Interpreter Services
- About Interpreter Services
- Medical Provider Responsibilities
- Other Provider Responsibilities
Billing and Claims Payment
- Where to Send Claims
- Electronic Claims Submission
- Newborn Claims
- Claims Documents
- Coordination of Benefits
- Third Party Liability (Subrogation/Reimbursement)
- Provider Obligations in Third Party Liability
Appeals
- Enrollee Appeals
- Consent Document
- Appeals Glossary
- Provider Appeals
- DRG and Fee Schedule Disputes
Care Management
- Utilization management
- Prior authorizations
- Member Review and Intervention Program
- Case management
- Disease management
- Clinical care management criteria
- Transition of care
Utilization Management
- How Community Health Plan Evaluates New Technology
- No Financial Incentives for Decision-Makers
- No Financial Incentives for Decision-Makers
- Referral Management
- Referral Form Document
- Preapproval (Prior Authorizations)
- Prior Authorization List
- Prior Authorization Documents
- Prior Authorization for Scheduled (Planned) Admissions
- Outpatient Facility Services Notification
- Facility Inpatient Notification
- Concurrent Review
- Discharge Planning Coordination
- Emergency Room Care
- Pre-Existing Condition Review (Washington Health Program Only)
- Pre-Existing Condition Documents
Prior Authorization List and Utilization Guidelines
- Deleted from the 2012 Prior Authorization List
- Changed on the 2012 Prior Authorization List
- Added to the 2012 Prior Authorization List
- Clarified on the 2012 Prior Authorization List
Case Management
- Case Management Referral Overview for Providers
- What Is Case Management?
- Who Is Appropriate for CHPW-Level Case Management
- How Can I Make a Referral to Case Management?
- What Happens When I Make a Referral?
- For What Reasons Would an Enrollee’s Case Not Be Opened for CHPW-Level Case Management?
- What to Expect While an Enrollee’s Case Is Open in CHPW-Level Case Management
- Why Is a Case Closed to CHPW-Level Case Management?
- What Happens After a Case Is Closed to CHPW-Level Case Management?
Member Review and Intervention Program (MRIP)
- The Role of the Primary Care Provider in MRIP
- The Role of the Pharmacy in MRIP
- The Role of the Hospital in MRIP
- MRIP Documents
Disease Management Program
- Disease Management Program
- How the Disease Management Program Works
- Disease Management Referral Process
Clinical Care Management Criteria
- Clinical Care Management Criteria
- Clinical Care Criteria list
- Clinical Practice Guidelines list
- Transition of Care
Pharmacy Management
- Drug Formulary and Medication Utilization
- Prior Authorization, Step Therapy, Nonformulary, and Quantity Override Requests
- Pharmacy Benefit Exclusions
Quality Improvement Program
- Overview
- Program Scope
- Program Structure and Leadership
Get More Information
- Directory of Services and Contacts
- CHPW Contacts
- Additional Contacts Outside of CHPW
- How to Get More Information

If you have questions regarding any policies and procedures explained in this manual, please contact our Provider Relations team: Phone 1-800-440-1561 toll free or fax 206-613-5018.