Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services according to established criteria or guidelines to ensure medical necessity and appropriateness of care are met prior to services being rendered.
We use prior authorization, concurrent review, and post-review to ensure appropriateness, medical need, and efficiency of health care services, procedures, and facilities being provided. This is known as utilization management.
Prior Authorization Lists and Utilization Guidelines
Emergency services do not require prior authorization
Emergency services are defined the following way.
Psychiatric: When the patient is a danger to themselves, others, or is gravely disabled.
Medical: A medical condition with acute symptoms of sufficient severity that the absence of immediate medical attention may result in placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, or serious impairment to bodily functions or serious dysfunction of any bodily organ or part.
For inpatient hospitalization and high intensity outpatient programs, notification is required.
Resources and Forms
Online prior authorization portal (JIVA)
We prefer that you submit prior authorizations through our Care Management Portal (JIVA). By using the portal, you can check eligibility and authorization status, print approval letters, and submit requests online 24/7. For registration issues or technical assistance contact Portal Support at [email protected].
Fax prior authorization and notification forms
If you prefer to fax your prior authorization requests, fill out the appropriate form and fax it to the number listed on the form.
- Express Scripts Pharmacy forms
- Inpatient Admission form
- Mental Health Service Request form
- ABA Therapy Initial Request form
- Psych/Neuropsych Testing Request form
- Substance Use Disorder Services Request form
- Prior Authorization Request form
- Synagis Universal Referral form
- Clinical Trial Prior Authorization Request form
If you do not see the appropriate form on this list, please contact CHPW Customer Service.
General Requirements and Disclaimers
Services for a specific program may not be a covered benefit. Please contact CHPW Individual and Family Customer Service to verify if a specific program is covered.
Providers Ordering DME
DME requests must be accompanied by physician signatures. Exceptions to this requirement that can be ordered by ARNP and PA-C are:
- Supplies and equipment necessary for or ancillary to the administration of pharmaceuticals or monitoring effectiveness, including glucose monitors or insulin pumps/continuous glucose monitors
- Respiratory supplies and equipment necessary for or ancillary to the administration or monitoring of medications, including oxygen, nebulizers, and spacers
- Breast pumps
- Enteral therapy
Please check our formulary to see which medications require prior authorization.
Documentation required to support decision-making
Please provide documentation with the request to support medical necessity. Examples of appropriate documents include:
- Current history and/or physician examination notes that address the problem and need for services requested. “Current” means within the past six months, or more recently depending on the condition.
- Relevant lab and/or radiology results
- Relevant specialty consultation notes
- Other pertinent information
CHPW requires notification of all inpatient admissions, planned and urgent, within 24 hours or the next business day.
All planned admissions require prior authorization.
Although CHPW does not require prior authorization for dialysis-related services, notification of dialysis is required. Please contact our Case Management team.
Benefit and coverage limitations
Failure to obtain the required prior authorization may result in a denied claim. Services are subject to benefit coverage, limitations, and exclusions as described in your plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) on our 2024 Plans page.
Please refer to the Prior Authorization Procedure Code Lookup Tool for additional details on services listed.
How CHPW Determines Prior Authorization
Community Health Plan of Washington and its providers use guidelines for care written by experts in the field of medicine and behavioral health. These guidelines help providers know when to use certain treatments and what problems to look out for.
To request a copy of criteria used in making a decision, please contact customer service at 1-866-907-1906 (TTY: 711) from 8 a.m. to 5 p.m., Monday through Friday.
We follow these rules:
- Utilization Management leadership encourages the involvement of network practitioners in the development, adoption, and review of all guidelines for care (criteria) used in determining coverage or care. Network providers who wish to discuss criteria with CHPW physicians are encouraged to contact customer service at 1-866-907-1906 (TTY: Dial 711) from 8 a.m. to 5 p.m., Monday through Friday and request a peer to peer to review specific criteria.
- 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 Network of Washington does not reward providers or others for denying coverage or care.
- Community Health Network of Washington does not offer financial incentives to encourage Utilization Management decision-makers to make decisions that result in under-using care or services.
- Community Health Plan of Washington Utilization Management (UM) staff are available to discuss this process. An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any authorization, denial, or UM issue at 1-866-907-1906 (TTY: Dial 711). If requested, language assistance will be provided free of charge.