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 assistance, call 206-652-7178.
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
- Professionally Administered Medications
- 2019 Prior Authorization Code Lookup Tool
- 2019 Summary of Changes
Select Your Prior Authorization Type:
Referrals for mental health care including outpatient programs, applied behavioral analysis and substance abuse, may require prior authorization or notification. If you are not sure if a service is covered, refer to the utilization guidelines for behavioral health services.
Some medications, including professional administered drugs, require prior authorization. Find information about step therapy, medication management, or quantity limit override. Access a current list of in-network pharmacies and find out which drugs are covered on the formulary.
Certain services, procedures, or treatments may require prior authorization. Most inpatient services are covered, but not all. Patients will need to meet certain requirements for prior authorizations to be granted. Medical supplies, durable medical equipment, and prosthetics may also require prior authorization. Provider service representatives can help verify benefits and coverage.
Additional Resources and Forms
- Dialysis Notification form
- Exception to the Rule Request form
- Express Scripts Pharmacy forms
- Inpatient Admission form
- Integrated Managed Care Mental Health Service Request form
- Integrated Managed Care Psych/Neuropsych Testing Request form
- Integrated Managed Care Substance Use Disorder Services Request form
- Limited Extension Request form
- 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.
2018 Prior Authorization Guidelines
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. You can also access them online through the Care Management Portal.
- Clinical Practice Guidelines (used to determine treatment plan)
- MCG Criteria
- CALOCUS Score Sheet
- LOCUS Score Sheet
MM126 External Peer Review
MM127 Arthroscopic Debridement or Lavage of Osteoarthritic Knee
MM128 Orthoptic-Pleoptic Training
MM129 Neuropsychological Testing
MM130 Cardiac Stents
MM131 Transplants and Transplant Work-ups, Donor Search, Donation
MM132 Complementary Alternative Care
MM134 Program of Assertive Community Treatment (PACT) Program Criteria
MM135 Positive Airway Pressure Devices
MM136 Durable Medical Equipment
MM139 Skilled Nursing Facility Comprehensive Outpatient Rehab Facility
MM140 Occupational Therapy
MM142 Speech Therapy
MM143 Sterilization and Hysteroscopic Sterilization
MM144 Home Oxygen
MM145 Bariatric Surgery
MM147 Enteral Therapy Products for Enrollees with Inherited Metabolic Disorders
MM148 Extracorporeal Membrane Oxygenation Therapy
MM149 Spinal Injections
MM151 Nonpharmacologic Treatments for Treatment-Resistant Depression
MM152 Intensity Modulated Radiation Therapy IMRT
MM153 Proton Beam Therapy
MM156 Administrative Days
MM158 Ankle Foot Orthotics and Ankle Knee Orthotics
MM160 MTHFR Polymorphism Genetic Testing
MM161 New Technology Evaluation
MM162 Medical Appropriateness for Service or Medication
MM163 Hospice Care, Pediatric Concurrent Care, and Pediatric Palliative Care
MM164 Clinical Trials for Treatments and Devices
MM165 Genetic Testing Medical Policy for Non Pregnancy-Related Scenarios
MM166 Gender Transition Policy
MM167 Speech Generating Devices (Augmentative Communication Devices)
MM168 Hearing Assist Devices
MM169 Bathroom and Toilet DME and Supplies
MM170 Urine Drug Testing in Addiction Treatment
MM171 Inpatient Rehabilitation
MM172 Home Health Skilled Services
PM103 Ipilimumab (Yervoy)
PM104 Pemetrexed (Alimta)
PM105 Brentuximab vedotin (Adcetris) for injection, for intravenous use
PM106 Ecallantide (Kalbitor)
PM108 Pertuzumab (Perjeta)
PM109 Palivizumab (Synagis)
PM110 Nanoparticle albumin bound paclitaxel (Abraxane)
PM112 Ramucirumab (Cyramza)
PM114 Epoprostenol (Flolan, Veletri, generics)
PM115 Cetuximab (Erbitux)
PM116 Ado-trastuzumab emtansine (Kadcyla)
PM117 Pembrolizumab (Keytruda)
PM118 Alemtuzumab (Lemtrada)
PM119 Nivolumab (Opdivo)
PM121 Zoledronic acid (Reclast)
PM122 Treprostinil (Remodulin)
PM124 Zoledronic acid (Zometa)
PM126 Natalizumab (Tysabri)
PM127 Panitumumab (Vectibix)
PM128 Pegfilgrastim (Neulasta)
PM129 Rituximab (Rituxan)
PM130 Sargramostim (Leukine)
PM131 Tbo-filgrastim (Granix)
PM132 Trastuzumab (Herceptin)
PM133 Ziv-aflibercept (Zaltrap)
PM134 Denosumab (Prolia)
PM135 Denosumab (Xgeva)
PM136 Epoetin Products
PM137 Filgrastim Products
PM138 Ibandronate (Boniva)
PM139 Immune globulin subcutaneous
PM140 Darbepoetin alfa (Aranesp)
PM141 Omalizumab (Xolair) injection for subcutaneous use
PM142 Ocrelizuman (Ocrevus) injection for intravenous use
PM144 Hyaluronic acid derivatives (Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz/Supartz FX, Synvisc, Synvisc-One)
PM145 Immune Globulin Intravenous (IVIG) (Bivigam, Carimune NF Nanofiltered, Flebogamma DIF, Gammagard Liquid, Gammagard S/D < 1 mcg/dL in 5% solution, Gammaked, Gammaplex, Gamunex-C, Octagam, Privigen Liquid)
PM147 Cytokine & CAM Antagonists
PM149 Antiasthmatic Monoclonal Antibodies-IL-5 Antagonists
PM150 Soliris (eculizumab injection for intravenous use – Alexion)
PM151 Buprenorphine for subcutaneous use
PM152 Enzymes for Gaucher Disease
PM153 Romiplostim (Nplate)
PM154 Corticotropin (H.P. Acthar Gel)
PM567 Hereditary Angioedema Agents
PM568 Patisiran (Onpattro) intravenous injection
PM569 Triamcinolone ER (Zilretta)
PM570 OnabotulinumtoxinA (Botox) for Migraine
General Requirements and DisclaimersDocumentation 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.
The plan requires use of in-network providers whenever possible. No Plan authorization is required if the request is from the member’s assigned Primary Care Physician (PCP) for an in-network provider.
- Referrals to Out-of-Network Providers: When circumstances arise that require a referral to an out-of-network specialist, authorization from the Plan is required.
- PCP to PCP Referrals: If you are not the member’s assigned PCP or group, an authorization to provide primary care is required from the Plan.
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, we require notification of dialysis. Please complete and submit a Dialysis Notification form or contact our Case Management team.
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 at 1-800-440-1561 from 8 am to 5 pm, Monday through Friday.
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 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?
Consult our FAQ page for prior authorization questions.