Prior Authorization for 2019
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.
2019 Prior Authorization Lists and Utilization Guidelines
Resources and Forms
Online prior authorization portal (JIVA)
We prefer that you submit prior authorizations through our Care Management Portal (JIVA). By using the portal, you can check eligibility and authorization status, print approval letters, and submit requests online 24/7. For assistance, call 206-652-7178.
Fax prior authorization and notification forms
If you prefer to fax your prior authorization requests, fill out the appropriate form and fax it to the number listed on the form.
- Dialysis Notification form
- Exception to the Rule Request form
- Express Scripts Pharmacy forms
- Inpatient Admission 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
- Limited Extension Request form
- Prior Authorization Request form
- WISe Services Change Notification form
The following resources offer more details on listed services.
2018 Prior authorization information
- Prior Authorization List (Apple Health, IMC, Medicare)
- Behavioral Health Prior Authorization Guide
- Prior Authorization Code Lookup
- Summary of Changes: Removed Cardiac Stents, Extracorporeal Membrane Oxygenation, and Tympanostomy Tubes
- Integrated Managed Care Prior Authorization Code Lookup
- Integrated Managed Care Prior Authorization Crosswalk
General Requirements and Disclaimers
Providers Ordering DME
DME requests must be accompanied by physician signatures. Exceptions to this requirement that can be ordered by ARNP and PA-C are:
- Supplies and equipment necessary for or ancillary to the administration of pharmaceuticals or monitoring effectiveness, including glucose monitors or insulin pumps/ continuous glucose monitors
- Respiratory supplies and equipment necessary for or ancillary to the administration or monitoring of medications, including oxygen, nebulizers and spacers
- Breast pumps
- Enteral therapy
Any drug not listed in the formulary will require prior authorization.
Documentation required to support decision-making
Please provide documentation with the request to support medical necessity. Examples of appropriate documents include:
- Current history and/or physician examination notes that address the problem and need for services requested. Current means within the past six months, or more recently depending on the condition.
- Relevant lab and/or radiology results.
- Relevant specialty consultation notes.
- Other pertinent information.
The Plan requires use of in-network providers whenever possible. If a request is received from the member’s assigned Primary Care Physician (PCP) for an in-network provider, no Plan authorization is required.
- Referrals to Out-of-Network Providers: When circumstances arise that require a referral to an out-of-network specialist, authorization from the Plan is required.
- PCP to PCP Referrals: If you are not the member’s assigned PCP or group, an authorization to provide primary care is required from the Plan.
CHPW requires notification of all inpatient admissions, planned and urgent, within 24 hours or the next business day.
All planned admissions require prior authorization.
Although CHPW does not require prior authorization for dialysis-related services, notification of dialysis is required. Please complete and submit a Dialysis Notification form or contact our Case Management team.
Benefit and coverage limitations
This Prior Authorization list is not all-inclusive. Please refer to the HCA Provider Billing Guidelines Manual and/or Fee Schedule.
For Medicare coverage limitations, please refer to the National Coverage Guidelines and/or Local Coverage Guidelines.
Failure to obtain the required prior authorization may result in a denied claim. Services are subject to benefit coverage, limitations and exclusions as described in plan coverage guidelines.
Please refer to the Prior Authorization Code Lookup Tool for additional details on services listed.
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.
- Clinical Coverage Criteria
- MCG Criteria
- Forms and Tools Page: LOCUS document
- Forms and Tools Page: CALOCUS document
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.