Utilization Management: Working to Get You Covered and Necessary Care

Note: The content on this page, and its follow-on links, applies to all Community Health Plan of Washington products, including our Community HealthFirst Medicare Advantage Plans.

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The Utilization Management program makes sure that you and your provider use services in a way that promotes the highest quality, most cost-effective care that results in the best health for you. Utilization Management supports Community Health Plan providers in their efforts to provide the right amount and type of services—not too much and not too little. The Plan looks at the research and medical information to decide which services, medications, and treatments are best for you and are the most cost effective.

To help you use services correctly, Community Health Plan recommends that your primary care physician (PCP) manages all of your health care needs.

Utilization Management's goals are to:

  • Teach providers how to use health care resources in the most proper and cost- effective way.
  • Teach you how to use services effectively.
  • Make sure that decisions about services used are fair, and that all providers use the same criteria.
  • Promote the highest quality of care.
  • Quickly find and solve any problems with how services are used.

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 before services are received. A peer reviewer—the Medical Director or Director of Behavioral Health—is available to discuss utilization management service denials.

If you want to discuss a utilization management decision, please call the Community Health Plan customer service team at 1-800-440-1561, Monday through Friday from 8 am to 5 pm, or email customercare@chpw.org. If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.

For more information, see What Is a Prior Authorization and "Medically Necessary".

Contact Utilization Management

If you have a question about a utilization management issue or you want to learn more about utilization management processes, please talk to our staff.

To contact the Utilization Management staff, call the Community Health Plan customer service team at 1-800-440-1561 toll free. If you are hearing or speech impaired, please call TTY 1-866-816-2479 toll free or local 206-613-8875.

If you are calling from a location that does not accept toll-free calling, Community Health Plan will accept your collect call.

If you need information about any health issue and you cannot reach your provider, call our Nurse Advice Line at 1-866-418-1002 toll free, 24 hours a day and seven days a week. For more information, see Nurse Advice Line.

Deciding What Care to Use

Prior authorization is the process of reviewing certain services and treatments before you get the services, to make sure they meet Community Health Plan criteria as medically necessary and appropriate care.

Community Health Plan decides which treatments are most effective by:

  • Using guidelines such as the Milliman Care Guidelines®, Hayes Health Technology Briefs, and the Washington State Health Care Authority Health Technology Assessments.
  • 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 use more or less of a particular service than our criteria call for:

  • 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 criteria.

Medically Necessary

A health care provider decides if a service or treatment is medically necessary. Medically necessary health care services are used to evaluate, diagnose, or treat an illness, injury, or disease or its symptoms.

A covered service is “medically necessary” if it is recommended by your treating provider and the Community Health Plan medical director or provider designee, and if all of the following conditions are met:

  • The purpose of the service, supply, or intervention is to treat a medical condition.
  • It is the most appropriate level of service, supply, or intervention considering the potential benefits and harm to the patient.
  • The level of service, supply, or intervention is known to be effective in improving health outcomes.
  • The level of service, supply, or intervention recommended for this condition is cost-effective compared to alternative interventions, including no intervention.
  • For new interventions, effectiveness is determined by scientific evidence. For existing interventions, effectiveness is determined first by scientific evidence, then by professional standards, then by expert opinion.

For more information and definitions, please see "Appendix A, Schedule of Benefits," in the Washington State Basic Health Member Handbook.

Behavioral Health (Mental Health)

The Behavioral Health program works with medical providers to coordinate care. Behavioral Health includes mental health care and treatment for alcohol and drug abuse. The Behavioral Health program researches and monitors use of services. This helps you and your providers use resources in the highest quality, most cost-effective way.

Community Health Plan uses criteria for treating chronic diseases, including mental or behavioral health conditions. To decide which treatments to approve, we look at evidence-based, peer-reviewed standards from nationally recognized agencies. The Community Health Plan Medical Directors and providers in our network review the list of treatments annually, along with a review by other providers if needed.

For more information about criteria, see Clinical Practice Guidelines.

Community Health Plan offers our Nurse Advice Line at 1-866-418-1002 if you have behavioral health issues and cannot reach your provider. If you think that the issue might be life threatening, dial 911 or go to the nearest emergency room.

You might be referred or you can refer yourself for Case Management with one of our licensed social workers in the Behavioral Health program.

Evaluation of New Technology

Community Health Plan is committed to keeping up with news and research about new tests, drugs, treatments, and devices and new ways to use current procedures, drugs, and devices.

A provider or member can ask the Plan to cover a new technology. A Community Health Plan doctor leads the review of the new technology and may ask an outside reviewer to give an opinion, too.

For more information about how the Community Health Plan uses research and outside experts to decide, see "Clinical Criteria" in this book.

New technologies are approved based on standards that protect patient safety. To learn more about the decision process or the specific standards, please call our Utilization Management team. For more information, see Contact Utilization Management.

Policy Prohibiting Financial Incentives

Community Health Plan staff and providers approve or deny services. We use information from your doctor to do this. We also look at medical standards. We do not offer decision- makers money to decide either way. We do not stop using providers if they disagree with our decisions. Our decisions are fair and equal.

We follow these rules:

  • Utilization Management decision makers approve or deny based only on whether the care and service are appropriate and whether the care or service is covered.
  • Community Health Plan does not reward providers or others for denying coverage or care.
  • Community Health Plan does not offer financial incentives to encourage Utilization Management decision makers to make decisions that result in underusing care or services.