Community Health Plan of Washington Individual and Family Cascade Select Plans Community Health Plan of Washington Individual and Family Cascade Select Plans

Prior Authorization

What is Prior Authorization?

Community Health Plan of Washington (CHPW) covers many treatments and services. Some of these services require prior authorization from us before we will cover them. 

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 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, please see our Prior Authorization Lists and Utilization Guidelines below.
  • 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.
  • Any request to see a non-network provider requires a CHPW-approved referral. Any visit or service by a non-network provider requires authorization, regardless of whether the service typically requires prior authorization. You also need plan approval prior to seeing a non-network primary care provider (PCP) outside of your PCP’s group.

Prior Authorization Lists and Utilization Guidelines

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 in a timely manner. They are processed as prior authorization requests. All requests are subject to current benefits and coverage limitations. If you are denied a service or referral you 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 at 1-866-907-1906 (TTY Relay: 711) Monday through Friday from 8 a.m. to 5 p.m.

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® and Community Health Plan of Washington clinical coverage criteria documents.

Coverage Criteria

Have questions or need help?

Community Health Plan of Washington Utilization Management (UM) staff are available to discuss this process or any UM issues at 1-866-907-1906 (TTY: Dial 711). If requested, language assistance will be provided free of charge.


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