Clinical Coverage Criteria

Deciding What Care to Use

The Community Health Plan of Washington Utilization Management team decides whether care is medically necessary by using clinical coverage criteria.

All employees who make clinical decisions regarding a member's care are licensed by the State of Washington. Supervisors of staff who make clinical decisions are also licensed and have at least five years of experience as clinicians. Proof of the current active status of clinical licenses is kept on file at all times.

Community Health Plan decides which treatments are most effective by:

  • Using guidelines such as the Milliman Care Guidelines® and the Washington State Health Care Authority Healthy Technology Assessment.
  • Looking at what works for our members over time.
  • Consulting internal and external doctors and experts, including specialists to help decide about complex cases.
  • Keeping track of government agency reports such as those from the FDA (Food and Drug Administration).
  • Asking for help from independent review organizations.

Community Health Plan keeps track of how you and your provider use services. If you or your provider use more or less of a particular service than the standard:

  • We might refer you to Case Management, which can help you manage complex health conditions.
  • We might recommend additional services.
  • We might deny approval for a service or drug if it does not conform to our guidelines.

Community Health Plan and its providers use clinical practice guidelines that are written by experts in the field of medicine and behavioral health. Clinical practice guidelines help providers to know when to use certain treatments and what problems to look out for.

These experts can include Milliman Care Guidelines®, evidence, national standards, and the expertise of board-certified practitioners in applicable specialties. These sources are equally weighted in consideration.

For more information, see clinical practice guidelines. IMPORTANT: This link takes you to the provider website. To return to the member website, please use your back button or use the orange tabs at the top of the screen.

Clinical Coverage Criteria

Clinical coverage criteria are applied by the Community Health Plan Utilization Department to guide decisions about medical necessity. We use these criteria to make sure you get the best care. For more information see Utilization Management.

To read up-to-date clinical coverage criteria online, you can visit Clinical Coverage Criteria. IMPORTANT: This link takes you to the provider website. To return to the member website, please use your back button or use the orange tabs at the top of the screen.

If you want a printed copy of any criteria sent to you, please contact the Community Health Plan customer service team at 1-800-440-1561 from 8:00 am to 5:00 pm Monday through Friday, or email customercare@chpw.org. If you are hearing or speech impaired, please call TTY Relay: Dial 7-1-1.