Some Services Need Prior Authorization
We cover many treatments and services, but some of those need what's called a prior authorization. That means your provider needs to check with us to make sure we can cover the treatment, drug, or piece of equipment.
If you want to research which services typically require a Prior Authorization, visit our Prior Authorization page. Please talk to your doctor to confirm that a certain treatment requires Prior Authorization.
Your doctor or health care provider is in charge of submitting Prior Authorization requests to CHPW.
Approving or Denying a Request
Licensed CHPW staff review Prior Authorization requests based on official policy. You can read our policy on the Policies and Procedures page.
Requests are reviewed by Utilization Reviewers. They use criteria to make sure the recommended treatment is medically necessary. If these criteria are met, the Utilization Reviewer may approve the request. If they do not, the case goes to our Medical Director for review.
Utilization Management uses the following standards of quality when reviewing authorizations:
1. UM decision-making is based only on appropriateness of care and service and existence of coverage;
2. CHPW does not specifically reward practitioners or other individuals for issuing denials (adverse benefit determinations) of coverage; and
3. Financial incentives for UM decision makers do not encourage decisions that result in underutilization
If a request is denied when you think it should have been approved, you can file an appeal. Visit our Grievances and Appeals page to learn how to do this.