Prior Authorization FAQs

Prior authorization is advanced approval of specific procedures, services, medical devices, supplies, and medications by a patient’s health plan.  Prior authorization review is the process to determine medical necessity of said services accordingly to clinical care guidelines and utilization management criteria. Prior Authorization is required for all scheduled  (planned) inpatient admissions, and certain predetermined services, medical pharmaceuticals, surgical, diagnostic, therapy and imaging procedures.

The prior authorization process gives the health plan a chance to review how necessary certain services or medications may be in treating your medical condition. For example, some brand name medications are very costly. During the review, the health plan may decide a generic or another lower cost alternative may work equally well in treating your medical condition.

Prior authorization restricts access to costly services and therapies – particularly new treatments. It is also used to determine medical necessity and appropriateness of care.

Providers should submit prior authorization through our care management portal, JIVA. 

You can also fax prior authorization requests to 206-652-7065. Please check the fax number located at the top of each form as it may differ depending on the request. Find the prior authorization forms here.

For pharmacy, providers should submit requests via ExpressScripts for prior authorization, step therapy, non-formulary, or quantity limit override. Call them at1-844-605-8168 to speak with a PA specialist.

All other PA requests will be handled by CHPW staff. Please contact your provider relations representative for more information.

No referrals or authorizations are required for treatment in an Emergency Room.

If CHPW denies your request to administer certain services, treatments, equipment, or prescriptions drug, the member can appeal the decision and should follow the protocol on  the appeal and grievances pages.

If a drug is denied by Express Scripts, providers may appeal the decision by sending a letter and clinical
documentation, including the date and reason for the denial given by ESI, to:

Community Health Plan of Washington
Attn: CHPW Medicare Advantage Appeals
1111 Third Avenue, Suite 400
Seattle, WA 98101
Fax: (206) 613-8983

Expedited appeals are reserved for emergency situations only; call 1 (800) 942-0247 (Toll Free).

CHPW strives to process authorization requests within Washington State and Federal contractual
requirements for timeliness, and in accordance with our member’s health care needs. Periodic
increases in request volume may affect turnaround times. CHPW strives to adhere to the
following processing timelines:

• Standard prior authorization requests are processed within 14 calendar days.
• Clinically urgent requests are processed within 72 hours.

Documentation to support medical necessity must be submitted with Prior Authorization requests. This information supports the need for the treatment and submitting detailed information on initial submission helps to ensure the request can be processed in a timely manner.

Examples of appropriate documents include:

• Current history and/or physician examination notes that address the problem and need for services requested
• Relevant lab and/or radiology results
• Relevant specialty consultation notes
• Other pertinent information to aid in decision making process

CHPW Utilization Management staff may request specific additional clinical information via fax or telephonically to complete the authorization process.