Plan information for Medicare Advantage members

CHPW Medicare Advantage plan information

Below is a list of some useful information on our website about how we provide health care coverage and your rights as a CHPW Medicare Advantage member.

Getting started

• How to get language assistance services and auxiliary aids and services, or if you need this information in a different language or format*
• The availability of TTY services for members

Getting care

• How to get primary care services, including points of access*
• How to access 24/7 Nurse Advice Line and virtual care (telehealth) services*
• How to get care after normal office hours*
• How to get specialty care, behavioral health services, and hospital services*
• How to access emergency care and emergency rooms, including our policy if it involves or requires emergency services using 911*
• How to access care, services, covered and non-covered benefits outside the service areas*
• How to get information about in-network and out-of-network practitioners, including professional qualifications of in-network primary care and specialty care providers

Benefits and coverage

• Benefits and services included in, and excluded from, coverage*
• How we evaluate new technology to include as a covered benefit
• Premiums, Copayments and other charges for which you are responsible*
• How you may submit a claim for covered services, if applicable*
• Restrictions on benefits that apply to services obtained outside our service areas*
• Prescription drug coverage, formularies, generic substitutes, and how to locate a nearby in-network pharmacy*
• Pharmacy forms, medication management programs, and Pharmaceutical Management procedures*

Special programs

• Our Quality Improvement Program measures how well we are providing high-quality care and services, ensuring that our members and providers have the resources and information they need to improve health outcomes.
• Our Care Management Program provides support for your health from a dedicated CHPW Care team.
• Our Health Management Programs evaluate the quality of care our members receive. We identify risks, needs, and goals to create personalized action plans that deliver exceptional care to our most vulnerable members.

Utilization Management (UM)

• Utilization management (UM) is the process of assessing the medical necessity and appropriateness of care for patients. Certain services require prior authorization for coverage, and we work with your provider to make decisions based on medical needs and benefits.
• Community Health Plan of Washington (CHPW) policy for UM decision-makers:
  • UM decision-making is based only on appropriateness of care and service and existence of coverage.
  • CHPW policy does not reward providers or others for denying coverage or care.
  • CHPW policy does not offer financial incentives to encourage UM decision makers to make decisions that result in under-using care or services.
• Community Health Plan of Washington (CHPW) Utilization Management (UM) review process helps ensure you get the right care at the right time by checking that services and benefits are used appropriately.
• How to file an appeal or the availability of an independent external appeals process for a UM decision made by Community Health Plan of Washington.
• The toll-free number to call (1-800-942-0247; TTY: 711) when you have questions about UM issues, such as authorization dates, questions about denials or need language assistance.

Your rights and privacy

• Our Member Rights and Responsibilities statement
• How a member may complete an advance directive*
  • An advance directive puts a member’s health care choices into writing and may name someone to speak for the member, if he or she is unable to speak. Advanced directives may include a Health Care Directive, Living Will, or a Durable Power of Attorney.*
• How to appeal a decision that adversely affects coverage, benefits, or your relationship with us*
• How to file a grievance (complaint) if you have a problem with your health care provider or the service CHPW provided*
• How to report health care fraud, waste or abuse
• Our notice of privacy practices and confidentiality policies including:
  • How we use authorizations, and your right to approve the release of Protected Health Information (PHI)
  • How to request restrictions on the use or disclosure of PHI, amendments to PHI,access to your PHI, or an accounting of disclosures of PHI
  • Our commitment to protect your privacy
  • Our policy on sharing personal health information with Plan sponsors and employers*

If you have any questions about accessing our website, want more information, or would like paper copies of any of the above items, contact Customer Service at 1-800-942-0247 (TTY: 711), 8 a.m. – 8 p.m., 7 days a week.

*Information is found in your plan’s Evidence of Coverage (EOC). Available online at medicare.chpw.org/plan-documents.

Evidence of Coverage (EOC), located on our Plan Documents page

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