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].
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
- Procedure Code Lookup Tool
Summary of Prior Authorization Changes
- Prior Authorization List and Utilization Guidelines (Q1 update – effective: January 01, 2023)
Select Your Prior Authorization Type:
Treatment for mental health including outpatient programs, substance use disorder treatment, and residential treatment 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
- 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 Score Sheet
- LOCUS Score Sheet
You can also access criteria online through the Care Management Portal.
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.
CHPW requires notification of all inpatient admissions, planned and urgent, within 24 hours or the next business day.
All planned admissions require prior authorization.
Prior Authorization Information
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?
Consult our FAQ page for prior authorization questions.