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Prior Authorization

Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services according to established criteria or guidelines to ensure medical necessity and appropriateness of care are met prior to services being rendered.

We use prior authorization, concurrent review, and post-review to ensure appropriateness, medical need, and efficiency of health care services, procedures, and facilities being provided. This is known as utilization management.

Procedure Code Lookup Tool 

Prior Authorization Lists and Utilization Guidelines

➔ 2022 Prior Authorization Changes

View 2021 Prior Authorization Lists and Utilization Guidelines

Emergency services do not require prior authorization

Emergency services are defined the following way.

Psychiatric: When the patient is a danger to themselves, others, or is gravely disabled.

Medical: A medical condition with acute symptoms of sufficient severity that the absence of immediate medical attention may result in placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, or serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

For inpatient hospitalization and high intensity outpatient programs, notification is required.

 

Resources and Forms

Online prior authorization portal (JIVA)

We prefer that you submit prior authorizations through our Care Management Portal (JIVA). By using 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].

➔ Access Portal 
➔ Request Portal Account 

Fax prior authorization and notification forms

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 this list, please contact CHNW Customer Service.

 

General Requirements and Disclaimers

Services for a specific program may not be a covered benefit. Please contact CHNW Customer Service to verify if a specific program is covered.

Providers Ordering DME

DME requests must be accompanied by physician signatures. Exceptions to this requirement that can be ordered by ARNP and PA-C are:

  • Supplies and equipment necessary for or ancillary to the administration of pharmaceuticals or monitoring effectiveness, including glucose monitors or insulin pumps/continuous glucose monitors
  • Respiratory supplies and equipment necessary for or ancillary to the administration or monitoring of medications, including oxygen, nebulizers, and spacers
  • Breast pumps
  • Enteral therapy

Prescription Coverage

Please check our formulary to see which medications require prior authorization.

2022 Formularies Coming Soon

➔ Search our 2021 Gold and Bronze Plan Formulary

➔ Search our 2021 Silver Plan Formulary

➔ Download 2021 formulary as a PDF

Documentation 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

Inpatient hospitalization

CHNW requires notification of all inpatient admissions, planned and urgent, within 24 hours or the next business day.

All planned admissions require prior authorization.

Dialysis notification

Although CHNW does not require prior authorization for dialysis-related services, notification of dialysis is required. Please contact our Case Management team.

Benefit and coverage limitations

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 your plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) on our  2022 Plans page (2021 Plans page).

Please refer to the Prior Authorization Procedure Code Lookup Tool for additional details on services listed.

How CHNW Determines Prior Authorization

Community Health Network of Washington and its providers use guidelines for care 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 criteria used in making a decision, please contact customer service at 1-866-907-1906 (TTY: 711) from 8 a.m. to 5 p.m., Monday through Friday.

These resources can include MCG Guidelines®, Medicare coverage determinations, and Community Health Network of Washington clinical coverage criteria documents.

2022 Coverage Criteria Documents Coming Soon

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 Network of Washington does not reward providers or others for denying coverage or care.
  • Community Health Network of Washington does not offer financial incentives to encourage Utilization Management decision-makers to make decisions that result in under-using care or services.
  • Community Health Network of Washington staff is available to discuss this process. An appropriate peer reviewer (medical director, pharmacist, or associate clinical director) is available to discuss any authorization or denial at 1-866-907-1906 (TTY: 711) from 8 a.m. to 5 p.m., Monday through Friday.

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Required Training

Providers are required to complete a Fraud, Waste, and Abuse training within 90 days of contracting with CHPW and annually thereafter. All clinic staff – including CEOs, senior leaders, managers, clerical/admin staff, physicians, and other clinical staff – are required to receive this training. Training courses are available on the CMS Medicare Learning Network website.

More information can be found in our Provider Manual.