Frequently Asked Questions
Health insurance can be complicated, but we can help. We’ve collected answers to some of our CHPW members’ most Frequently Asked Questions (FAQs).
Accessing and paying for care
I'm covered. How do I access care?
To make an appointment, call your clinic or doctor’s office. If you need help locating the phone number or finding a doctor, use our provider directory. Remember, CHPW Individual & Family is an Exclusive Provider Organization (EPO) plan, which means that we cover services only when you receive them from Network Providers, with limited exceptions such as emergency care.
When you call to make an appointment:
- Tell them you’re a CHPW Individual & Family member.
- Ask for an interpreter if you need one.
- Have your CHPW Member ID handy.
Need help making an appointment? Call our Customer Service team 1-866-907-1906 (TTY: 711), Monday through Friday, 8 a.m. – 5 p.m.
How do I know if I should see a doctor?
You can get care in a variety of ways. The type of care you seek largely depends on your medical issue.
- Primary Care Provider: See your primary care provider for routine care like checkups 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 don’t 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: 711). The Nurse Advice Line, powered by CHPW, can help you decide what type of care to seek.
- Virtual Care: Some health care providers and clinics offer doctor’s visits over phone or video. If your provider’s office doesn’t offer virtual care (also known as telehealth or telemedicine) or is closed, you can connect with a doctor at any time through CHPW’s 24/7 telehealth service, CHPW Virtual Care.
- Urgent Care: Urgent care offers non-emergency care 24 hours a day. It helps fill a vital gap for when you become sick or injured but your regular doctor is not available and you can’t wait for an appointment. Examples of urgent care issues: You suddenly get a fever, you experience vomiting or persistent diarrhea, you have small cuts that may require stitches.
- 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, shortness of breath, chest pain, severe stomach pain, bleeding that won’t stop.
How can I find cost information for treatment?
Cost information is available for common inpatient and outpatient treatments, diagnostic tests, and office visits. Members can access estimated costs for treatment:
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, or you can choose one from our directory. Coverage, including the amounts you are responsible to pay, depends on whether you see an in-network or out-of-network provider.
What is utilization management (UM)?
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 given (concurrent review), and after it’s given (post-service review). Certain services, such as visiting a PCP or an in-network specialist, do not require utilization management review.
Who does the UM review?
The review is done by the appropriate licensed staff, which includes nurses, social workers, pharmacists, and physicians. CHPW staff is available to discuss any utilization management process, authorization, or denial. All inpatient admissions and certain outpatient services and procedures require prior authorization.
My doctor submitted a prior authorization request. How long will it take to hear back?
Typically, for a standard request, we must make a decision and provide notification within five calendar days of receiving the request from your doctor. If we need more 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. Urgent requests will have a decision timeframe of within two calendar days of receipt of the request from your doctor. If we need more information from your provider, this time is extended.
Can I see a doctor who is not on your provider list?
As a CHPW member, you must choose an in-network Primary Care Provider (PCP) to get your medical care, with limited exceptions such as emergency care and cases where you have obtained prior authorization from your PCP. If a covered service is not available from a network provider, your PCP will assist you in getting a referral to an appropriate out-of-network provider. When you get a referral to an out-of-network provider, you will be covered the same as with an in-network provider.
How do I know if my medication is covered?
Each year, we publish a formulary, or list of covered drugs. 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?
You can have your prescriptions mailed to your home. Here are 3 simple ways to get started with home delivery.
- ePrescribe: Ask your doctor to send your prescriptions electronically to Express Scripts Pharmacy.
- Phone: Call 1-888-637-8383. Available 24 hours a day (including holidays), 7 days a week to talk about getting your long-term medicine delivered. TTY users: 1-800-759-1089.
- Online: Visit express-scripts.com or download our mobile app for free. You need to register with your member ID card. Follow the prompts to move your prescriptions to home delivery.
CHPW also has a network of pharmacies. Many of our Community Health Centers have their own pharmacies. To find the pharmacy closest to you, you can:
- Log in to your myCHPW account and search for a pharmacy
- Log in to your Express Scripts account*
- CHPW Virtual Care
Bring your CHPW ID card when you pick up your prescription.
*CHPW partners with Express Scripts to give you access to a large network of participating 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.
How do I submit a Prescription Drug or Medical Coverage claim?
Most providers will submit their bills to us directly. Sometimes when you get medical care or a prescription drug, you may pay directly. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back.
To be paid back for covered services or drugs, please send us your request along with your bill and documentation of the payment you made.
For Prescription Drug Coverage payments, please mail your request for payment together with any bills or receipts to us at this address:
Express Scripts, Inc.
Attn: Commercial Claims
P.O. Box 14711
Lexington, KY 40511-4711
Fax: (608) 741-5475
For Medical Coverage payments, please mail your request for payment together with any bills or receipts to us at:
Community Health Plan of Washington Individual & Family Plans
1111 3rd Ave Suite 400
Seattle, WA 98101
You should submit all claims within 90 days of the start of service, or within 30 days after the service is completed. The claim must be submitted to us within 365 days of the date you received the service, item, or drug.
Updating personal information and contacting the plan
How do I contact the plan?
CHPW is here to answer your questions and address your concerns:
- By phone. Call us at 1-866-907-1906 (TTY: 711). We’re available Monday through Friday, 8 a.m. to 5 p.m.
- By email. Email us at [email protected], and we’ll get back to you during regular business hours.
- 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 Washington Healthplanfinder know.
- Log in to Washington Healthplanfinder to report changes.
- Call Washington Healthplanfinder Customer Support at 1-855-923-4633.
Then call Community Health Plan of Washington. We’ll update your address and other information on our end. We can also help you choose a new Primary Care Provider, if necessary.
To get in touch with us, call Customer Service at 1-866-907-1906 (TTY: 711), 8 a.m. to 5 p.m., Monday through Friday.
What if my income changes?
Reporting changes is important so your information stays up to date and so that you get the right amount of financial help. The easiest way to report changes is through your Washington Healthplanfinder account.
- Log in to your Washington Healthpanfinder account.
- Select “Report a Change” on your dashboard.
- Select the change you’d like to report. Answer the questions that apply to you and follow the pages to update your information.
I've just had a baby and would like to enroll my child into CHPW Individual & Family. How do I do that?
Congratulations! Please call Washington Healthplanfinder at 1-855-923-4633, and they can get you started.
What is myCHPW?
myCHPW is our online portal that lets you view important coverage information.
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). An EOB is a statement that lists the services you got, the amount billed, and what was paid.
What if I am not happy with my services and care?
You have the right to excellent care. To file a grievance (a complaint) about services or care you’ve received, call us at 1-866-907-1906 (TTY: 711). We’re available Monday through Friday, from 8 a.m. to 5 p.m.
Didn’t find your answer above or need additional details? We’ve got you covered. Contact our friendly, local Customer Service at 1-866-907-1906 (TTY: 711), Monday through Friday, from 8 a.m. to 5 p.m.