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How to Find Important Information

Including Health Plan Disclosure Information

Community Health Plan of Washington has written and online information about your plan. To see this information, click the links below. If you want a written copy of this information, contact Community Health Plan customer service at 1-800-440-1561 or email us at customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.

About your plan

• How to get a book or other material describing your plan (such as benefits, providers, rights and privacy, and decisions affecting your health care):
  • Basic Health
  • Medical Care Services (Disability Lifeline)
  • Healthy Options, SCHIP, and Basic Health Plus
  • Medicare Advantage
  • Washington Health Program
  
  
• How to find providers, specialists (including behavioral health providers), clinics, and hospitals in the Community Health Plan network. Includes:
  • Restrictions on access to providers or services.
  • The professional qualifications and specialty of primary care providers and specialists.
  • Medical school attended, residency completed, and board certification status.
  
  
• Definitions of words used to describe or explain your plan, your benefits, your claims, or your relationship with Community Health Plan.
  
• How to get an interpreter to help you communicate with the Plan or get Plan materials in the language you speak or read.

Getting care

• How to get care:
  • By appointment at your primary care clinic.
  • After your provider's clinic hours.
  • In an emergency. (How we define "emergency" depends on your plan. See the Medical Benefits Summary or State handbook for your plan.)
  • When you are outside the area where you normally get care.
    
• How to get a referral to a specialist or to hospital services.
  
• How you can get a referral to or refer yourself to case management and disease management services.

What your plan covers (benefits)

• Medical, pharmacy, and other services that your plan covers (will pay for). How to find out which services, medicine, and equipment are restricted, limited, or excluded. Benefits and programs covered by:
  • Basic Health
  • Medical Care Services (Disability Lifeline)
  • Healthy Options, SCHIP, and Basic Health Plus
  • Medicare Advantage
  • Washington Health Program
    
• A list of drugs that are covered by your plan (the formulary), and an explanation of how the drugs are approved (added to the formulary) or removed from the formulary.
  
• Which services need approval from Community Health Plan before you get the service (prior authorization), and how to get the prior authorization.
  
• Services that are covered outside of your area and what you must do to get them covered. Services that may be limited or not covered outside your service area.
  
• Information about payments, if any, or submitting claims for services you get. This includes copayments, coinsurance, visit or payment amount limits, and fee for service options.
  
• How we tell you how much we have paid toward your plan's payment or visit limits for the year.

How Community Health Plan manages care

• Standards that Community Health Plan uses to decide which benefits are medically necessary and that providers use to decide which treatment to use.
  
• How to get involved in decisions about the benefits covered by your plan.
  
• How Community Health Plan decides whether to include new technology as a covered benefit.
  
• How Community Health Plan manages its pharmacy programs.
  
• How we manage the use of health care services (utilization management):
  • How to reach somebody who can answer your questions about utilization management.
  • Our policy that prohibits us from offering any financial advantage to providers or decision-makers who limit use of services.
  • The independent external appeals process for utilization management decisions.
    
• Goals, processes, and outcomes of our programs to improve the quality of care and service, including:
  • How we monitor and report standard measures of health care effectiveness and member satisfaction, including HEDIS (Healthcare Effectiveness Data and Information Set). How you can see our HEDIS results.
  • Our accreditation status.
    
• How we find out which diseases and conditions are most common among our members and our plan to manage those disease and conditions.

Your rights and privacy

• Your rights and responsibilities as a member.
  
• How Community Health Plan protects the confidentiality of your health information, including:
  • Routine use and disclosure of PHI. What a "routine consent" is and how it allows us to use information about you.
  • Your right to approve the release of personal health information not covered by the routine consent.
  • How to request access to your personal health information.
  • How Community Health Plan protects the privacy of oral, written, and electronic information about you in all settings.
  • Our policy about sharing personal health information with employers and how we protect information disclosed to plan sponsors or employers.
  • The written policies and procedures we have adopted to protect the privacy of your health information.

How to complain about care or appeal a decision

• How to voice a complaint (grievance) about your care.
• How to appeal:
  • A denied claim or service, or
  • A decision that adversely affects your coverage, your benefits, or your relationship with Community Health Plan.