CHPW Individual & Family plan information
This page contains information about how we provide health care coverage and your rights as a CHPW Individual & Family Plan member. For more details or paper copies of any of these items, contact Customer Service at 1-866-907-1906 (TTY: 711), Monday through Friday, from 8 a.m. to 5 p.m.
Getting started
- How to get language assistance and if you need information in a different language or format
- The availability of TTY services for members
Getting care
- How to get primary care services, including points of access*
- How to access 24/7 virtual care services*
- How to get care after normal office hours*
- How to get specialty care, behavioral health services, and hospital services*
- How to access emergency care and emergency rooms, including our policy if it involves or requires emergency services using 911*
- How to access care, services, covered and non-covered benefits outside the service areas*
- How to get information about in-network and out-of-network practitioners, including professional qualifications of in-network primary care and specialty care providers
Benefits and coverage
- Benefits and services included in, and excluded from, coverage*
- How we evaluate new technology to include as a covered benefit*
- Copayments and other charges for which you are responsible*
- How you may submit a claim for covered services, if applicable*
- Restrictions on benefits that apply to services obtained outside our service areas*
- Prescription Drugs benefits and Pharmaceutical Management procedures*
Special programs
- Our Quality Improvement Program, including goals, processes, and outcomes in terms of care and service
- Our Care Management Program and how you and your caregiver may self-refer to the program
- Our Health Management Programs and how you may self-refer to the programs
Utilization Management (our process of reviewing whether care is medically necessary and appropriate)
- The toll-free number to call (1-866-907-1906; TTY: 711) when you have questions about Utilization Management (UM) issues, such as authorization dates or questions about denials*
- Information about how to obtain language assistance to discuss UM issues
- Our policy prohibiting financial incentives for UM decision-makers:
- UM decision-making is based only on appropriateness of care and service and existence of coverage.
- The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
- A description of the availability of an independent external appeals process for utilization management decisions made by Community Health Network of Washington
Your rights and privacy
- Our Member Rights and Responsibilities statement
- How a member may complete an advance directive. An advance directive puts a member’s health care choices into writing and may name someone to speak for the member, if he or she is unable to speak. Advanced directives may include a Health Care Directive, Living Will, or a Durable Power of Attorney
- How to submit a complaint*
- How to appeal a decision that adversely affects coverage, benefits, or your relationship with us*
- Our notice of privacy practices and confidentiality policies including:
- How we use authorizations, and your right to approve the release of personal health information (PHI)
- How to request restrictions on the use or disclosure of PHI, amendments to PHI, access to your PHI, or an accounting of disclosures of PHI
- Our commitment to protect your privacy
- Our policy on sharing personal health information with Plan sponsors and employers
*Information is found in your plan’s Evidence of Coverage (EOC), located on our Plan Documents page
