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 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.

Prior Authorization List: To see if a particular service requires Prior Authorization, please see the:

2017 Documents

2016 Documents

Benefits: For a full listing of member benefits, please see the:

Submitting Requests: The Medical Management Portal allows you to submit Prior Authorization requests and Inpatient Notifications online. Providers can check eligibility and authorization status, print approval letters, and submit requests online 24/7. Login today:

Providers may also submit requests via fax using the:

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.

These resources can include Milliman Care Guidelines®, Medicare coverage determinations, national standards, the expertise of board-certified practitioners in applicable specialties, and Community Health Plan of Washington clinical coverage criteria documents. 

We follow these rules:

  • 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 Plan of Washington does not reward providers or others for denying coverage or care.
  • Community Health Plan 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 staff is available to discuss this process. An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any authorization or denial at 1-800-942-0247 (TTY 711).

 

Page Last Updated December 21, 2016.