Member FAQs - Washington State Local Health Insurance - CHPW
Community Health Plan of Washington Apple Health Medicaid Plan Community Health Plan of Washington Apple Health Medicaid Plan

Member FAQs

Member FAQs

Before you can make the right health care choices for you and your family, you should have the information you need. On this page, Community Health Plan of Washington (CHPW) has answered some common member questions.

➔ See general Apple Health (Medicaid) FAQs

➔ See Behavioral Health FAQs.

Getting care and services

How do I make an appointment?

To make an appointment, call your clinic or doctor’s office. If you need help locating the phone number, use our online provider directory.

When you call to make an appointment:

  • Tell them if you’re a new CHPW member.
  • If you need an interpreter, please don’t hesitate to ask for one.
  • Have your CHPW Member ID handy in case the clinic staff need information from it. To view or download your card, set up or log onto your member account.

If you need help getting an appointment, getting to or from your provider’s office, making a care plan to support your health needs, or if there are other things that make it hard for you to get care, we can help. CHPW has a program called Case Management for addressing these kinds of needs.

Case management is available at no extra cost to all of our members. Call Customer Service to get started with case management or to learn more.

How do I know if I should see a doctor?

When you have a medical issue, you can get care in many ways.
➜ Find out which one is right for your needs | Spanish  | Chinese | Russian | Vietnamese | Arabic | Somali | Dari

If you think you or someone you are taking care of is having a medical or psychiatric emergency, call 911 or go to the nearest hospital.

  • Primary Care Provider: See your primary care provider for routine care like check-ups and immunizations, if you’re managing a chronic illness, if you need a referral to a specialist, or if you get something like mild allergies or a cold and you do not need immediate attention.
  • Nurse Advice Line: CHPW members have access to advice from professional nurses 24 hours a day, seven days a week at 1-866-418-2920 (TTY: Dial 711). You can call the Nurse Advice Line with many different health questions. For instance, you might call to ask if a crying baby needs medical attention, or if your own symptoms require a visit to your doctor.
  • Virtual Care: A growing number of health care providers and clinics let you schedule doctor’s visits over phone or video calls. Not only can you get medical care without leaving your home, but these virtual care visits may have more flexible hours than your nearest clinic. CHPW also provides virtual care service through CHPW Virtual Care.
  • Urgent Care: Urgent care offers non-emergency care 24 hours a day. An example of an urgent care issue is if your child wakes up in the middle of the night with a fever or vomiting.
  • Emergency Room: The emergency room is open 24 hours a day, seven days a week. It is for serious injuries or issues with life-threatening symptoms. Some examples of issues that would need emergency care are: severe burns, auto accidents, suicide attempts, shortness of breath, chest pain, severe stomach pain, bleeding that won’t stop.

What if I want a second opinion about my health care?

You have the right to get a second opinion.

Tell your primary doctor that’s what you want. They will refer you to a different provider within the CHPW network with similar credentials, or you can choose one from our provider list.

What is utilization management?

Utilization management is a process of reviewing whether care is medically necessary and appropriate for patients.

We evaluate care before it’s given (prior authorization), while it’s being given (concurrent review), and after it’s given (post-service review). Our process is designed to ensure appropriateness, medical need, and efficiency of health care services, procedures, and the appropriate place of service.

Who does the review?

The review is done by the appropriate licensed staff, which includes — but is not limited to — nurses, medical director, and pharmacists. Community Health Plan of Washington staff is available to discuss any utilization management process, authorization, or denial.

Prior authorization review is the process of reviewing certain medical, surgical, and behavioral health services. This is to ensure the medical necessity and appropriateness of care are met prior to services being delivered.

My doctor submitted a prior authorization request. How long will it take to hear back?

Typically, a standard request must have a decision and provide notification within five calendar days of receiving the request from your doctor. If we need additional information from your provider this time is extended. You will be notified via mail once a decision is made.

In some instances, your provider may determine that coverage of a certain request should be decided urgently. In these cases, an urgent request will have a decision within two calendar days of receipt of the request from your doctor. If we need additional information from your provider this time is extended.

Can I see a doctor who’s not on your provider list?

As a CHPW member, you must choose an in-network Primary Care Provider (PCP) to get your medical care.

The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the service area), out-of-area dialysis services, and cases where you have obtained prior authorization from your CHPW doctor.

How can I change my doctor?

You can change your doctor because you’ve moved, or if you would feel more comfortable with another doctor. Whatever the reason, you can change from one in-network CHPW provider to another at any time:

How do I know if my medication is covered?

Each year, we publish a formulary, also known as a “preferred drug list.” You should review this list to determine what tier your drug is on and if there are any restrictions on it.

Where can I fill my prescriptions?

Have prescriptions mailed to your home

Order your prescriptions from Costco Pharmacy for convenient delivery by mail.

How to get started with Costco Pharmacy

There are three ways you can set up prescription home delivery.

  • Call: Dial 1-800-607-6861 and Costco will set up your profile over the phone and put your prescriptions into their system.
  • Mail: Fill out the Prescription Order Form. Mail your original written prescriptions and the Order Form to the address on the form.
  • Talk to your prescriber: Ask your prescriber to call in your prescriptions or fax in the Prescription Order Form.
How to refill your prescriptions with Costco Pharmacy
  • Call: Dial 1-800-607-6861 and follow the automated prompts.
  • Mail: Send your name, RX BIN Number (see your prescription ID card), and phone number to:
    • Costco Mail Order Pharmacy
      802 134th St. SW, Suite 140
      Everett, WA 98204-9935
  • Fax: Send your your name, RX BIN Number (see your prescription ID card), and phone number to: 1-877-258-9584

Read more about the Costco home delivery program at pharmacy.costco.com.

Find a pharmacy

CHPW also has an extensive network of pharmacies across Washington, Oregon, and Idaho, including locations at many of our partnering Community Health Centers. To find the pharmacy closest to you, you can:

Bring your CHPW ID card when you pick up your prescription. If you don’t have your card, you can log in to CHPW Member Center to view, download, and print a copy of it.

*CHPW partners with Express Scripts to give you access to a large network of pharmacies and range of covered prescriptions. Go to Express Scripts to log in or create an account. From your account, you can manage prescriptions, search for pharmacies, and learn important safety information about your medicine.

If you need help finding a pharmacy or have questions about our pharmacy network, please call our Customer Service at 1-800-440-1561 (TTY Relay: Dial 711), from 8 a.m. to 5 p.m., Monday through Friday.

My coverage has been terminated. How do I get it back?

Updating personal information and contacting the plan

How do I contact the plan?

CHPW is here to answer your questions and address your concerns, so you can choose the easiest way to get in touch:

  • By phone. Call us at 1-800-440-1561 (TTY Relay: Dial 711). We’re available to take your calls Monday through Friday, from 8 a.m. to 5 p.m.
  • By email. Email us any time of day or night at [email protected], and we’ll get back to you Monday through Friday, from 8 a.m. to 5 p.m.
  • Through the myCHPW portal. In your myCHPW dashboard, navigate to Member Self Services > Secure Messages. Secure messages are like emails, but they can only be accessed through myCHPW.

I’ve moved. How do I change my address and/or phone number?

When you move, be sure to let the following state organizations know:

Then call Community Health Plan of Washington! We’ll update your address and other information. We can also help you choose a new Primary Care Provider, if necessary.

To get in touch with us, call Customer Service at 1-800-440-1561 (TTY Relay: Dial 711), 8 a.m. to 5 p.m., Monday through Friday.

I’ve changed my name. Who do I contact?

When you change your name, you’ll need to update your personal information:

  • Call CHPW Customer Service at 1-800-440-1561 (TTY Relay: Dial 711), 8 a.m. to 5 p.m., Monday through Friday.
  • Call Washington Healthplanfinder at 855-923-4633.

I have just had a baby and would like to enroll them into Apple Health. How do I do that?

Congratulations! Please call Washington Healthplanfinder at 855-923-4633, and they can get you started.

What is myCHPW/the member portal?

myCHPW is our online portal that lets you view important coverage information. It can be accessed from a phone, tablet, or computer.

With myCHPW, you can:

  • See information for all your different insurance plans, not just ours.
  • See your coverage information and benefits.
  • See your claims.
  • Check the status of your authorizations and referrals.
  • Order a copy of your CHPW ID card.
  • Search for providers and facilities.
  • Ask us to change your primary care provider.
  • Update your contact information.
  • Ask our Customer Service team questions through our secure system.
  • Get private notifications and general updates.
  • Learn more about benefits and claims.
  • Review your explanations of benefits (EOB) in myCHPW. An EOB is a statement that lists the services you got, the amount billed, and what was paid.

What to do if I receive a bill?

Under a CHPW Apple Health plan for individuals, you should not be billed for covered services (including those you’ve gotten prior authorization for).

If your child is covered under a low-cost Apple Health for Kids with Premiums plan, you’ll receive a bill for a low monthly premium.

If you get a bill that you don’t understand or think is incorrect, contact us at 1-800-440-1561 (TTY Relay: Dial 711), Monday through Friday, from 8 a.m. to 5 p.m.

What if I am dissatisfied with my services and care?

You have the right to excellent care. We’re sorry to hear that you didn’t have that experience with CHPW.

To file a grievance (a complaint) about services or care you’ve received, call us at 1-800-440-1561 (TTY Relay: Dial 711). We’re available to take your calls Monday through Friday, from 8 a.m. to 5 p.m.

Alternative Treatments Benefit

How the benefit works

Is this benefit available for CHPW BHSO members? What about Medicare or Cascade Select members?

This benefit is for CHPW Apple Health members only.

Is there any age limit for this benefit?

No. There is no age restriction on who can use this benefit.

Do I need a referral from my doctor?

No. You do not need a referral or prior authorization to use your 20 visits.

Is there a copay?

No. Like all CHPW services, you do not pay anything for this benefit. Your provider should bill CHPW for all charges.

What does the Alternative Treatment benefit cover?

This benefit covers a combined total of up to 20 visits per year for acupuncture, chiropractic, and massage therapy.

  • You can use your visits in any combination you choose. You can get 5 acupuncture visits, 5 chiropractic, and 10 massage. Or you can use all 20 visits for acupuncture.
  • Massage therapy is measured in 30-minute sessions. That means that if you get a 90-minute massage, it will count as 3 visits towards your total 20.
  • Any tip you wish to add is out of pocket and is not included in the benefit.

Can I get 20 visits each for acupuncture, chiropractic, and massage?

The 20-visit limit is a combined limit per year. That means any combination of visits adding up to 20 in a calendar year.

What about an initial evaluation, is that included?

The benefit covers an Evaluation & Management session for acupuncture and chiropractic (not for massage). This session does not cost you anything and does not count toward your 20-visit limit.

Finding a provider

Does my Alternative Treatment provider have to be in-network?

No. You can seek care from any provider who is licensed in Washington State to practice acupuncture, chiropractic, or massage.

How do I find a licensed Alternative Treatment provider?

The Washington State Department has a search tool that can help you find a licensed provider. Use the search tool here.

Keeping track of my visits

Can I carry over my unused visits to the following year?

You must use up your 20 visits within the calendar year. You start each year with another 20 visits.

The benefit starts July 1. Does that mean I have 20 visits available between now and the end of the year?

Yes. You have 20 visits available between 07/1/2022 and 12/31/2022. A new 20-visit limit would start at the beginning of 2023.

How do I keep track of the number of visits I have remaining throughout the year?

Members are responsible for tracking their overall number of visits; CHPW will also be tracking your number of visits. If you are unsure, call Customer Service for your latest total.

I've used up some (or all) of my six acupuncture visits this year under CHPW’s Acupuncture-only benefit. Do those count against the new benefit’s 20-visit limit?

No. You’re in luck! As of 7/1/2022, you get to start with the new benefit’s annual 20-visit limit (through 12/31/2022).

If I need more than 20 visits, can I get more?

Yes. These additional visits will require prior authorization from your doctor. Learn more about prior authorization.

Claims and billing

What do I do if my Alternative Treatment provider has questions or says my insurance doesn’t cover the treatment?

If your provider has questions, ask them to call CHPW Customer Service at 1-800-440-1561, Monday through Friday, 8am-5pm, or email us at [email protected].

How will my provider know when I’ve reached my 20-visit limit?

CHPW will be tracking your number of visits. If you are unsure, call Customer Service for your latest total.

Do you have a question that hasn’t been answered here? Call CHPW Customer Service at 1-800-440-1561, Monday through Friday, 8am-5pm. Or email us anytime at [email protected].

More FAQs for our members are available below:

➔ See general Apple Health (Medicaid) FAQs

➔ See Behavioral Health FAQs.

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