Prior Authorization FAQs - Washington State Local Health Insurance - CHPW

Prior Authorization FAQs

Click through the common questions below to learn more about Community Health Plan of Washington’s (CHPW) prior authorization policies and procedures.

Common questions about prior authorization

What is prior authorization?

Prior authorization is advanced approval of specific procedures, services, medical devices, supplies, and medications by CHPW. Prior authorization review is the process to determine medical necessity of said services, according to clinical care guidelines and utilization management criteria.

Prior authorization is required for all scheduled inpatient admissions, as well as certain predetermined services, medical pharmaceuticals, surgical, diagnostic, therapy, and imaging procedures.

Why does CHPW require prior authorization?

The prior authorization process gives CHPW the chance to review how necessary certain services or medications may be in treating medical conditions. For example, some brand name medications are very costly. During review, CHPW may decide a generic or other lower-cost alternative may work equally well in treating a medical condition.

Prior authorization restricts access to costly services and therapies – particularly new treatments. It is also used to determine medical necessity and appropriateness of care.

How do I obtain prior authorization?

Providers should submit prior authorization through our care management portal, JIVA. 

You can also fax prior authorization requests to 206-652-7065. Please check the fax number located at the top of each form as it may differ depending on the request. Find CHPW prior authorization forms here.

For pharmacy, providers should submit requests via ExpressScripts for prior authorization, step therapy, non-formulary, or quantity limit override. Call them at 1-800-922-1557 to speak with a prior authorization specialist. For professionally administered drugs follow instructions here.

All other prior authorization requests will be handled by CHPW staff. Please contact your provider relations representative for more information.

Is prior authorization required for emergency services?

No referrals or authorizations are required for treatment in an emergency room.

What happens if my prior authorization is denied?

If CHPW denies your request to administer certain services, treatments, equipment, or prescription drugs, the member can appeal the decision and should follow the protocol on the Grievances and Appeals page.

If a drug is denied by Express Scripts, providers may appeal the decision by sending a letter and clinical documentation, including the date and reason for the denial given by ESI, to:

Community Health Plan of Washington
Attn: CHPW Apple Health Appeals
1111 Third Avenue, Suite 400
Seattle, WA 98101
Fax: 206-613-8983

Expedited appeals are reserved for emergency situations only; call 1-800-440-1561.

How long does it take to obtain prior authorization?

CHPW strives to process authorization requests within Washington State and Federal contractual
requirements for timeliness, and in accordance with our member’s health care needs. Periodic
increases in request volume may affect turnaround times. CHPW strives to adhere to the
following processing timelines:

  • Standard prior authorization requests are processed within 5 to 14 days.
  • Clinically urgent requests are processed within 2 to 5 days.
What documentation do I need to submit with my request?

Documentation to support medical necessity must be submitted with prior authorization requests. This information supports the need for the treatment and submitting detailed information on initial submission helps to ensure the request can be processed in a timely manner.

Examples of appropriate documents include:

  • Current history and/or physician examination notes that address the problem and need for services requested
  • Relevant lab and/or radiology results
  • Relevant specialty consultation notes
  • Other pertinent information to aid in decision making process

CHPW Utilization Management staff may request specific additional clinical information via fax or telephonically to complete the authorization process.

 

If you still have questions, call Customer Service for help. Our representatives are available at 1-800-440-1561 (TTY Relay: Dial 711) Monday through Friday, from 8 a.m. to 5 p.m.

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