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 Summary of Changes 

2019 Prior Authorization Lists and Utilization Guidelines

Medical & Surgical Services     Behavioral Health Services    Professionally Administered Medications

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.

Access Portal Request Portal Account

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.

If you do not see the appropriate form on this list, please check our Forms and Tools page or contact customer service.

Resources

The following resources offer more details on listed services.

2018 Prior authorization information

General Requirements and Disclaimers

Services for a specific program may not be a covered benefit. Please verify online through HealthMAPS or HIP, contact Customer Service, or consult the Member Benefit Grids.

Pharmaceuticals

Any drug not listed in the formulary will require prior authorization.

Medicaid Formulary Medicare Formularies

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.

Referral policies

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.

Inpatient hospitalization

CHPW requires notification of all inpatient admissions, planned and urgent, within 24 hours or the next business day.

All planned admissions require prior authorization.

Dialysis notification

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

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.

Read more about Utilization Management or contact us with questions.