Review the medical and surgical utilization guidelines for an overview of services that require prior authorization.
Certain procedures may require prior authorization such as those for genetic testing not related to pregnancy, outpatient and specialty services, transplants, imaging/radiology, surgical procedure, and inpatient services. Treatments subject to prior authorization include durable medical equipment, prosthetics, medical supplies, experimental investigational services and drugs, private duty nursing and home health.
When submitting a prior authorization request for any of these examples, you must submit appropriate documentation to support decision-making and show medical necessity.
Relevant documents include:
- Current patient history and/or physical exam notes that demonstrate the problem
- Relevant lab or radiology results
- Relevant specialty consultation notes
- Other pertinent information
Professionally administered drugs
Community Health Plan of Washington (CHPW) requires prior authorization for certain professionally administered medications. MCG guidelines are used to determine medical necessity in the absence of CHPW Clinical Coverage Criteria.
Durable medical equipment and other supplies
CHPW considers durable medical equipment (DME), orthotics, and prosthetics medically necessary when the applicable criteria are met. DME items have the following characteristics and should meet the following requirements:
- Is prescribed by a physician
- The order contains the physician’s signature, not a stamp
- Can withstand repeated use
- Is primarily and customarily used to serve a medical purpose
- Is appropriate for use in the client’s place or residence
- Meets the definition of DME
Exceptions: DME order can be signed by provider other than a physician in certain circumstances.
- Medication administration or monitoring (such as blood glucose testing, continuous glucose monitoring, or insulin pumps), or home infusions
- Respiratory supplies (such as CPAP mask or tubing)
- Breast pumps
- DME requests while member is in a facility (SNF, Inpatient Rehab, Long Term Acute Care or hospital). Signature will be required for members in custodial care, adult family home, or long-term care.
Rental: CHPW follows HCA guidelines by applying DME rental fees toward the eventual purchase of a device. (Some DME are for purchase only. Rules regarding rental versus purchase should be checked.)
- The repair of any DME must meet relevant criteria for medical necessity, including prior authorization if required for similar new equipment.
- Repair is considered only for client-owned equipment after expiration of warranty period. Any repair for DME must meet relevant criteria for medical necessity, including prior authorization if required for similar new equipment.
- It is the provider’s responsibility to check warranty coverage before submitting a request for a DME repair. Warranty coverage will be reviewed, along with repair cost, at the time of assessment for prior authorization.
- Repairs do not require a face-to-face evaluation with the physician but do require a physician signature on the order.
- Replacement of any DME must meet relevant criteria for medical necessity, including prior authorization if required for similar new equipment.
- Any requests for DME replacement must include documentation of a current (within 3 months) face-to-face evaluation by the treating physician and therapist, as applicable, showing medical need for the device by the member.
- CHPW does not pay for the replacement of equipment, devices, or supplies, which have been sold, gifted, lost, broken, destroyed, or stolen as a result of the client’s carelessness, negligence, recklessness, deliberate intent, or misuse unless otherwise allowed under HCA program rules.
More information on Care Criteria for Durable Medical Equipment can be found in this policy.
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 registration Issues or technical assistance contact Portal Support at [email protected].
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
- Mental Health Service Request form
- Psych/Neuropsych Testing Request form
- Substance Use Disorder Services Request form
- Limitation Extension Request form
- Prior Authorization Request form
- WISe Services Change Notification form