Prior Authorization - Washington State Local Health Insurance - CHPW

Prior Authorization

Some services need prior authorization

Community Health Plan of Washington (CHPW) covers many treatments and services. Some of these services require a referral, while others don’t. And some services need prior authorization.

Prior authorization means your provider has to check with us to make sure we will cover a treatment, drug, or piece of equipment. Prior authorization is part of our utilization management strategy.

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

What you need to know:

  • If you want to research which services typically require a prior authorization, visit our Provider Prior Authorization page.
  • Please talk to your doctor to confirm that a certain treatment requires prior authorization.
  • If a service requires prior authorization, you don’t have to submit anything. Your doctor or health care provider is in charge of submitting prior authorization requests to CHPW.
  • Some services need a referral. A PCP is not required to obtain approval for referring a member to a participating provider or out-of-network specialist. CHPW must review and provide a Plan Authorized Referral when a member needs to see a PCP outside of their assigned PCP or group. In addition, members in the Patient Review and Coordination (PRC) program require Plan Authorized Referrals from their PCP approving the care that member receives from other providers and specialists.

Approving or denying a request

Licensed CHPW staff review prior authorization requests based on clinical policies (otherwise known as criteria). These resources can include MCG Guidelines®, Medicare coverage determinations, and Community Health Plan of Washington clinical coverage criteria documents.

Requests are reviewed by the appropriate licensed staff, which includes — but is not limited to — nurses, medical director, and pharmacists. They use the following standards when reviewing authorizations:

  1. Decision-making is based only on appropriateness of care and service and existence of coverage.
  2. CHPW does not reward practitioners or other individuals for issuing denials (adverse benefit determinations) of coverage.
  3. Financial incentives for decision-makers do not encourage decisions that result in underutilization (people using less of services that they are entitled to).

Disagreeing with our decision

If a request is denied when you think it should have been approved, you have the right to file an appeal. Visit our Grievances and Appeals page to learn how.

For more information about prior authorization, utilization management, and how CHPW decides what services we can cover, please visit our Prior Authorization FAQ page.

 

 

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