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

• Medical & Surgical Services
• Behavioral Health Services
• Professionally Administered Medications

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

• Clinical Coverage Criteria
• MCG Criteria
• LOCUS document
• CALOCUS document
• Requests are reviewed by the appropriate licensed staff, which includes — but is not limited to — nurses, medical director, and pharmacists. They use the following standards when reviewing authorizations:
  1. Decision-making is based only on appropriateness of care and service and existence of coverage.
  2. CHPW does not reward practitioners or other individuals for issuing denials (adverse benefit determinations) of coverage.
  3. Financial incentives for decision-makers do not encourage decisions that result in underutilization (people using less of services that they are entitled to).

  Disagreeing with our decision

  If a request is denied when you think it should have been approved, you have the right to file an appeal. Visit our Grievances and Appeals page to learn how.

  For more information about prior authorization, utilization management, and how CHPW decides what services we can cover, please visit our Prior Authorization FAQ page.

  Substance Use Disorder (SUD) Care Clinical Guidelines

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.