Provider Manual

Community Health Plan of Washington makes annual changes to the benefits for our CHPW Medicare Advantage Plans.

Note: The vision benefit continues to be administered through Vision Service Plan (VSP), offering our members a number of options to receive frames and basic lenses within the benefit amount allowed per plan utilizing the VSP Advantage Network of providers.

To learn more about general covered services, services requiring prior authorization and cost-sharing amounts for Medicare Advantage plans, refer to the member benefits grids.

• To be treated with dignity and respect by our members.
• To receive accurate and complete information and medical history for members’ care.
• To expect members to follow treatment plans and protocols.
• To file a complaint or file an appeal against CHPW and/or a member.
• To file a grievance on behalf of a member, with the member’s consent.
• To have access to CHPW’s quality improvement programs, including goals, processes,
  and outcomes that relate to member care and services.
• To collaborate with other health care professionals who are involved in the care of
• To have access to Provider Relations and/or Customer Care for questions, issues and/or
  concerns

• Inform members of their right to self-refer for certain services.
• Provide or arrange interpretive services for members who are hearing impaired or
  whose primary language is not English.
• Obtain informed consent from the member or from a person authorized to consent on
  behalf of the member, prior to treatment.
• Inform members of their right to file a grievance and how to do so. In the case of a
  member grievance regarding behavioral health services offer the assistance of the
  Behavioral Health Ombuds in the region where the member resides.
• Utilize research-based practices for individuals, including those with a co-occurring
  mental health and chemical dependency diagnosis.
• Provide adult members with written information about advance directives and the right
  to make anatomical gifts.
• Assist members in receiving health care services not covered by CHPW.
• Must not be excluded or sanctioned by the Office of Inspector General (OIG) and the
  General Services Agency (GSA).
• Ensure that members have a voice in developing individualized service plans, advance
  directives and crisis plans. This shall include children and their families (e.g. caregivers
  and significant others, parents, foster parents, assigned/appointed guardians, siblings),
  and adults. At a minimum, treatment goals shall include the words of the individual and
  documentation must be included in the clinical record describing how the individual sees
  his/her progress. An Individual Peer Support Plan may be incorporated into or appended
  to the Individual Service Plan, for members receiving behavioral health services.
• Demonstrate efforts to coordinate care with crisis services and other allied systems and
  have a process to convey all necessary information to ensure continued delivery of
  medically-necessary services. Medicare Advantage providers must not be opted out of Medicare. Providers that have
  opted out of Medicare may be admitted to the network for the other lines of business.
  Facilities must notify CHPW of all inpatient admissions in a timely manner as described
  in the “Care Management” section of this manual, as a condition of payment. Inpatient
  and emergency services must be available 24 hours a day, 7 days a week. Accept payment in full and not request payment for covered services from the member.
  To access CHPW’s Member/Balance Billing Training Program, go to the Provider Resources page.

Providers who have been or are in the process of being credentialed by CHPW have the right to review credentialing information collected during credentialing, re-credentialing and ongoing review processes. Providers are notified of this right in the cover letter that accompanies CHPW’s credentialing and re-credentialing applications.

The cover letter describes the intent of the process and the steps a provider must take to review the information collected. This notification is also made available to the provider as part of this Provider Manual.

If the information provided on the application is inconsistent with information obtained via primary source verification, the CHPW Credentialing Specialist will send the provider written notification of the discrepancy and request formal written clarification.

The notification will include a summary of the inconsistent information and a request to have the provider’s response returned within fourteen (14) business days. Notification will be sent electronically or certified return receipt requested and the correspondence will be marked “Confidential” as applicable.

The provider may not make any corrections to an application that has already been submitted and attested to be correct and complete. However, the provider has a right to submit an addendum to correct erroneous information submitted by another party. If preferred, the provider may add an explanation for the erroneous information on his or her application, including a signed and dated statement attesting to the accuracy of the information provided, and then return the information to the CHPW Credentialing Specialist.

Providers may request a review of their credentials file by calling the Manager of Credentialing at (206) 613-8951 to schedule an appointment. All reviews must be performed onsite at the CHPW office. The Manager of Credentialing or a member of the Credentialing Team will accompany the provider during the file review.
Documents available for review are:

• Items submitted by the applicant
• Malpractice Insurance information
• Licensing boards’ information
• American Medical Association (AMA) or the American Osteopathic Association (AOA) query response

Peer review documents, references or other information that is peer review protected will not be shared with the applicant. CHPW is not required to reveal the source of information that is not obtained to meet the primary source verification requirements, or when the law prohibits disclosure. Upon request, CHPW will provide the provider with the status of his or her application. The provider is notified of this right when he or she receives the cover letter that accompanies CHPW’s Credentialing and Re-credentialing Application.

The provider may contact the Credentialing Specialist for information about the status of their credentialing application. The Credentialing Specialist will explain where the application is at in the process. The Credentialing Specialist may share other permitted information with the provider regarding his or her application.

Note: As a reminder, while a provider is in the credentialing process, the provider cannot provide health care services to CHPW members. Claims will be denied if the provider has not completed the credentialing process.

Provider shall permit reasonable access to financial records, medical records, and any other records that relate to their Provider Agreement to authorized representatives of CHPW, Payers, and state/federal agencies with the applicable authority. Access to such records shall be to the extent permitted by law and as necessary to fulfill the terms of the Provider Agreement, CHPW’s state and federal contracts, and legal and accreditation requirements.

Provider shall permit CHPW to conduct audits of member medical records for covered services rendered under their Provider Agreement. Such inspection, audit, and duplication of records shall be allowed upon reasonable notice during regular business hours.

Providers have the right to reasonable access to CHPW claim payment records for the purpose of auditing their claim payment history and claim denials pursuant to WAC 284-43-324. Provider shall maintain all member information in compliance with their Provider Agreement and with applicable state and federal laws and regulations. Member information includes, but is not limited to, medical records, claims, benefits, and other medical or administrative data that is personally identifiable to the member.[

CHPW and the provider must each develop, implement, maintain, and use administrative, technical, and physical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of every member’s protected health information. This applies to all formats that CHPW or the provider creates, receives, maintains, or transmits in performing duties under the Provider Agreement to protect member safety, and the privacy and security of member protected health information.

Further, CHPW and the provider must safeguard all member medical information including the paper and/or electronic health record against loss, defacement, theft, tampering, and from the use by unauthorized individuals.

A provider must construct and maintain a medical record for each CHPW member while the member is an active patient. If the member becomes an inactive patient, the medical record may be moved to storage. The provider must retain and maintain medical records for ten (10) years. This includes all medical records, x-ray films, tissue specimens, slides, and photographs which are the property of the provider. All paper-based notes, reports, etc. in the medical record must be secured in the member’s folder or electronically attached to the member’s file/record.

An active member’s medical record should be kept at each provider’s office. If the member becomes an inactive patient, the medical record may be kept offsite. Records must be easily retrievable. All medical records, active and inactive, must be supplied within 30 days of a request by CHPW. Urgent requests should be met according to the clinical situation.

The provider must comply with all federal, state, and local laws and regulations pertaining to medical records and medical record requests. All medical record information must be released only by trained personnel and only with a completed and signed HIPAA compliant Patient Authorization Form for Release of Information.

All CHPW providers must give notice to CHPW at least sixty (60) days in advance of any provider
changes including, but not limited to:

• Tax identification
• NPI (National Provider Identifier) number (individual and/or group)
• Billing (vendor) address, office, and fax phone numbers
• Clinic contact information (name, phone number, fax, and email)–i.e., Credentialing Coordinator, Billing Manager, Clinic Manager)
• Provider additions (include provider effective date)
• Changes to providers locations within a group
• Provider terminations (include provider termination date)
• Clinic/facility location additions/changes (if applicable, include effective and termination dates for your clinics and/or facility)

60-day Advance notice for changes will provide CHPW ample time to update all systems, notify members, and prevent claims payment delays. Provider and group changes should be reported to CHPW by completing a Provider Add Change Term (PACT) Form and/or Clinic and Group Add Change Term Form (available on the Provider Forms and Tools page of our website. Email your completed form(s) to [email protected]. For new providers requiring credentialing, please send a request to [email protected].

For Delegated Credentialing provider groups, please refer to and follow your delegated credentialing agreement. Delegated Credentialing provider groups should submit provider updates via email to [email protected].