Find resources and forms you need to care for our members. If you have any questions about filling out and submitting online or paper forms, please contact Customer Service for assistance.
Forms and Tools
Member Benefit Grids
Member Benefit grids act as a reference guide and not a guarantee of coverage. If a service or treatment is not listed in the member benefit grid, refer to the appropriate prior authorization category for more information.2022 Benefit Grids2021 Benefit Grids
- Browse Apple Health Formulary
- Browse Medicare Advantage Formularies
- Formulary Exception / Coverage Determination Request Form
- Drug Recall Report
PHARMACY BILLING CODES
CLAIMS BILLING AND COVERAGE DETERMINATION
For pharmacy coverage determination, please call 1-800-417-8164.
You can submit a request for a coverage determination review by sending in a Coverage Determination Request form or filling out the online form.
Apple Health (Medicaid) requires authorization for inpatient admission for dental diagnosis. Providers can include the authorization number in the claim or send a copy of the authorization with their claim.
Authorizations are not required for facility charges related to the following common, routine dental services:
- Members age eight (8) years old and younger at date of service.
- Members identified in ProviderOne with a Developmental Disabilities Administration
- These specific cleft palate surgeries/CPT codes performed in an inpatient, outpatient, or Ambulatory Service Center (ASC) setting: 42200, 42205, 42210, 42215, 42225, 42226,42227, 42235, 42260, 42280, and 42281 with a diagnosis of cleft palate.
Access to Baby & Child Dentistry (ABCD)
The Access to Baby & Child Dentistry (ABCD) program is for Apple Health-eligible clients ages 5 years and younger. Non-dental ABCD certified providers must bill Family Oral Health Education (FOHE), application of topical fluoride, and periodic oral evaluations with the following CPT codes and modifiers:
- 99188 with modifier DA: Application of Topical Fluoride Varnish
- 99499 with modifier DA: Unlisted E&M Service – to be used for Periodic Oral Evaluations
- 99429 with modifier DA: Unlisted preventative service – to be used for ABCD FOHE by PCP
Clinical Practice Guidelines for Chronic Medical Conditions and Preventive Services
Community Health Network of Washington and Community Health Plan of Washington use guidelines for chronic diseases (including medical and behavioral health conditions) and for preventive services, as listed below. Reference is made to the pertinent evidence-based, peer-reviewed guidelines from Nationally recognized agencies. The guidelines are intended to help guide providers in their care of our members including CHNW Cascade Select, CHPW Medicare, CHPW Apple Health Managed Care, and CHPW Behavioral Health Services Only members. The guidelines also ensure that the criteria used for utilization management decisions are current.
All guidelines are reviewed at a minimum of once every two years. The Clinical Quality Improvement Committee (CQIC), which includes medical and behavioral health providers and quality specialists, participates in this review and approves any changes. Paper copies of the guidelines are available for members or providers on request, as well as at the links provided.
Utilization management is a process of reviewing whether care is medically necessary and appropriate for patients. Our process includes the use of prior authorization, concurrent review, and post-service review 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 pharmacist. 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.
APPROVALS FOR SERVICES
Community Health Plan of Washington staff and providers determine whether services are approved or denied. We use information from your doctor to do this. We also look at medical standards. Our decisions are fair and equal. 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.
How We Evaluate New Technologies
Community Health Plan of Washington is committed to keeping up with new technologies. This means we review new tests, drugs, treatments, and devices and new ways to use current tests, drugs, treatments, and devices.
New technologies are evaluated on an ongoing basis. They are approved based on standards that protect patient safety.
We handle new technology requests for a specific member in a timely manner. They are processed as prior authorization requests. All requests are subject to current benefits and coverage limitations. Members denied a service or referral have the right to submit an appeal.
To learn more about the decision process or whether a specific new technology is covered by Community Health Plan of Washington, please call our Customer Service team at 1-800-440-1561 (TTY Relay: Dial 711), Monday through Friday, 8:00 a.m. to 5:00 p.m.
With the exception of CHPW decisions related to DRG pricing, Fee Schedules, and member financial responsibility, a provider may appeal a CHPW decision that they believe is incorrect. Non-participating provider appeals must be in writing and submitted within ninety (90) days from the date of the notice of the denial; or initial payment of clean claim for Apple Health members; or within sixty (60) days for Medicare members.
Par provider appeals must be in writing and submitted within twenty-four (24) months from the date of the notice of denial or initial payment of a clean claim. Second-level appeal requests will be reviewed if new information is provided to CHPW within sixty (60) days of the first level decision.
An appeal must include:
- Member name and member ID number
- Claim number (if applicable)
- Date of service
- All supporting documentation pertinent to the reason for denial
- Reason for requesting the appeal
- Signed authorization (if filing on behalf of a member)
- To access CHPW’s appeal cover sheet go to our Forms and Tools page.
Providers may submit appeals to:
Community Health Plan of Washington
Attention: Appeals Department
1111 Third Avenue, Suite 400
Seattle, WA 98101
Fax: (206) 613-8984
Email: [email protected]
You can find general information and updates about compliance in CHPW’s Compliance Newsletter, published quarterly as a resource for our providers.
To learn more about CHPW’s Compliance Program, please see the CHPW Provider Manual.
Policies and Procedures
Community Health Plan of Washington makes certain policies and procedures available to providers. If you need hard copies of any of our materials, contact your Provider Relations Representative. Current policies that you need to care for members can be found on the Policies and Procedures page.