Prior Authorization

Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services according to established criteria or guidelines. We use prior authorization, concurrent review, and post-review to ensure appropriateness, medical need, and efficiency of health care services, procedures, and facilities provided. This is known as utilization management. It ensures that medical necessity and appropriateness of care prior to services being rendered.

Please refer to the National Coverage Guidelines and/or Local Coverage Guidelines. 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 plan coverage guidelines.

Providers should submit prior authorization requests through our Care Management Portal, JIVA. In 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].

Access Portal  Request Portal Account

Prior Authorization Lists and Utilization Guidelines

Review our current utilization guidelines for each area requiring prior authorization.  These lists provide information on notification requirements for inpatient hospitalization, outpatient programs, and general authorization requirements and deadline. The Prior Authorization lists are not all-inclusive. Services are subject to benefit coverage, limitations and exclusions. Please contact Customer Service to verify member benefits and coverage. You can also verify coverage in the Care Management Portal. For Medicare coverage limitations, please refer to the National Coverage Guidelines and/or Local Coverage Guidelines.

• Medical and Surgical Services
• Behavioral Health Services
• Pharmacy
• Professionally Administered Medications
• Procedure Code Lookup Tool

Summary of  Prior Authorization Changes

• 2024 Prior Authorization List and Utilization Guidelines (Q1 update – effective: January 01, 2024)
• 2023 Prior Authorization List and Utilization Guidelines (Q1 update – effective: January 01, 2023)

Select Your Prior Authorization Type:

Additional Resources and Forms

Forms

• 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
• Clinical Trial Prior Authorization Request form

If you prefer to fax your prior authorization requests, fill out the appropriate form and fax it to the number listed on the form. If you do not see the appropriate form on the list, please check the Provider Resources page.

Clinical Coverage Criteria

We use several resources to determine whether a specific intervention is medically necessary. Each case is assessed using appropriate criteria, also taking into account individual case information.

We rely on the nationally recognized MCG Guidelines as the primary source for evidence-based recommendations for clinical coverage. In addition, we have created Clinical Coverage Criteria (CCCs) for situations not addressed by MCG Guidelines. For behavioral health medical necessity decisions we use Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) criteria, MCG criteria, and American Society of Addiction Medicine (ASAM) criteria for substance use disorders. You can refer to LOCUS/CALOCUS documents provided below.

CHPW utilizes the Centers for Medicare and Medicare Services (CMS) national coverage determinations (NCDs) and local coverage determinations (LCDs), if available. NCDs and LCDs are available through Noridian, Washington’s Medicare Fee-for-Service Contractor, or they are accessible on the CMS website. If CMS criteria are not available, then MCG Guidelines and/or CHPW’s CCCs are used.

Our medical directors will take into consideration the enrollee’s age, social situation, co-morbidities, and availability of services within the community when making utilization review determinations. These guidelines are available for reference below.

• Clinical Coverage Criteria (including last approval date and summary of change)
• Clinical Practice Guidelines (used to determine treatment plan)
• MCG Criteria
• CALOCUS
• CALOCUS Score Sheet
• LOCUS
• LOCUS Score Sheet
• LCD/NCD

You can also access criteria online through the Care Management Portal.

General Requirements and Disclaimers

Services for a specific program may not be a covered benefit. Please verify online through HealthMAPS, contact Customer Service, or consult the Member Benefit Grids.

How CHPW Determines Prior Authorization

Community Health Plan of Washington and its providers use care guidelines 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 the criteria used in making a decision, please contact customer service 7 days a week at 1-800-942-0247 from 8 a.m. to 8 p.m.

These resources can include MCG 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. An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any authorization or denial.

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 1-800-942-0247 (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 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.

Questions About the Prior Authorization Review Process?

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 1-800-942-0247 (TTY: Dial 711). If requested, language assistance will be provided free of charge. You can also consult our FAQ page for prior authorization questions.