2019 Summary of Changes
There will be changes to our Prior Authorization list effective January 1, 2019. View Summary of Changes.
Prior Authorization for 2018
Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services according to established criteria or guidelines to ensure medical necessity and appropriateness of care are met prior to services being rendered. We use prior authorization, concurrent review, and post-review to ensure appropriateness, medical need, and efficiency of health care services, procedures, and facilities being provided. This is known as utilization management.
In addition to the Prior Authorization requirements listed under each linked category below, the following services require a Prior Authorization:
- All clinical trials require prior authorization
- All experimental or investigational drugs and services require prior authorization
- All genetic testing not related to pregnancy requires prior authorization (may also require additional forms, found below)
- All inpatient and outpatient substance use disorder treatment for Medicare patients requires prior authorization
- All unlisted codes with a charge greater than $500 require a prior authorization
- All unclassified biologics require a prior authorization
Check which services and supplies require Prior Authorization in the categories below:
Pharmaceutical Formulary (any drug not listed in the formulary will require prior authorization)
Summary of Changes to Prior Authorization requirements for 2018: Removed Cardiac Stents, Extracorporeal Membrane Oxygenation, and Tympanostomy Tubes. Note: There may be additional changes to the 2018 Prior Authorization list.
Submitting a Prior Authorization Request
- ONLINE (preferred) through the Care Management Portal
Request a Care Management Portal account to check eligibility and authorization status, print approval letters, and submit requests online 24/7. For assistance, call (206) 652-7178.
- Fax: Fill out the form matching your request and fax to the number listed on the form.
- Express Scripts Pharmacy forms
- Prior Authorization Request form
- Limited Extension Request form
- Exception to the Rule Request form
- Integrated Managed Care Mental Health Service Request form
- Integrated Managed Care Psych/Neuropsych Testing Request form
- Integrated Managed Care Substance Use Disorder Services Request form
- Inpatient Admission form
- 2017 Prior Authorization List
- 2017 Prior Authorization Code Lookup
- 2017 Summary of Changes
- 2017 Integrated Managed Care & BHSO Prior Authorization List
- Integrated Managed Care Prior Authorization Code Lookup
- Integrated Managed Care Prior Authorization Crosswalk
How CHPW determines prior authorization
Community Health Plan of Washington and its providers use guidelines for care written by experts in the field of medicine and behavioral health. These guidelines help providers know when to use certain treatments and what problems to look out for. To request a copy of criteria used in making a decision, please contact customer service at 1-800-440-1561 from 8 am to 5 pm, Monday through Friday.
These resources can include MCG Guidelines®, Medicare coverage determinations, national standards, the expertise of board-certified practitioners in applicable specialties, and Community Health Plan of Washington clinical coverage criteria documents.
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 of Washington does not reward providers or others for denying coverage or care.
• Community Health Plan of Washington does not offer financial incentives to encourage Utilization Management decision makers to make decisions that result in under-using care or services.
Community Health Plan of Washington staff is available to discuss this process. An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any authorization or denial at 1-800-440-1561.