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Provider Resources

Find resources and forms you need to care for our members. If you have any questions about filling out and submitting online or paper forms, please contact Customer Service for assistance.

Forms and Tools

Member Benefit Grids

The Member Benefit grids are a reference guide, not a guarantee of coverage. If a service or treatment is not listed in the grids, refer to the appropriate prior authorization category for more information.

2022 Benefit Grids – Coming Soon!

Provider Enrollment

If you want to join the Community Health Network of Washington’s provider network, please complete the Provider Enrollment Request Form and tell us about your practice. When we receive this information, a Contract Administrator will review your request and determine if we are currently accepting new providers in your county.

Pharmacy

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  • PHARMACY BILLING CODES

    RxBin 003858
    RxPCN  A4
    RxGrp P6TA

    CLAIMS BILLING AND COVERAGE DETERMINATION

    For pharmacy coverage determination, please call 1-800-753-2851.

    You can submit a request for a coverage determination review by sending in a Coverage Determination Request form.

    ➔ Download the Formulary Exception/Coverage Determination Request Form

    Language Assistance Cards

    Members have the right to access services in the language they speak. To help, CHPW has developed Language Assistance Cards that members can share with their provider to request interpretation. These language assistance cards are available for CHNW and CHPW members to download and print.

    ➔ View/Download the Language Assistance Cards

    Clinical Practice Guidelines for Chronic Medical Conditions and Preventive Services

    Community Health Network of Washington and Community Health Plan of Washington use guidelines for chronic diseases (including medical and behavioral health conditions) and for preventive services, as listed below. We cite references to the pertinent evidence-based, peer-reviewed guidelines from nationally recognized agencies. The guidelines are intended to help guide providers in their care of our members including CHNW Cascade Select, CHPW Medicare, CHPW Apple Health-Integrated Managed Care, and CHPW Behavioral Health Services Only members. The guidelines also ensure that the criteria used for utilization management decisions are current.

    All guidelines are reviewed at a minimum of once every two years. The Clinical Quality Improvement Committee (CQIC), which includes medical and behavioral health providers and quality specialists, participates in this review and approves any changes. Paper copies of the guidelines are available for members or providers on request, as well as at the links provided.

    ➔ Download the current Clinical Practice Guidelines

    Utilization Management

    Utilization management is a process of reviewing whether care is medically necessary and appropriate for patients. Our process includes the use of prior authorization, concurrent review, and post-service review to ensure appropriateness, medical need, and efficiency of health care services, procedures, and the appropriate place of service.

    WHO DOES THE REVIEW?

    The review is done by the appropriate licensed staff, which includes — but is not limited to — nurses, medical director, and pharmacist. Community Health Network of Washington staff is available to discuss any utilization management process, authorization, or denial.

    Prior Authorization review is the process of reviewing certain medical, surgical, and behavioral health services. This is to ensure the medical necessity and appropriateness of care are met prior to services being delivered.

    APPROVALS FOR SERVICES

    Community Health Network of Washington staff and providers determine whether services are approved or denied. We use information from your doctor to do this. We also look at medical standards. Our decisions are fair and equal. 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.

    How We Evaluate New Technologies

    Community Health Network of Washington is committed to keeping up with new technologies. This means we review new tests, drugs, treatments, and devices and new ways to use current tests, drugs, treatments, and devices.

    New technologies are evaluated on an ongoing basis. They are approved based on standards that protect patient safety.

    We handle new technology requests for a specific member in a timely manner. They are processed as prior authorization requests. All requests are subject to current benefits and coverage limitations. Members denied a service or referral have the right to submit an appeal.

    To learn more about the decision process or whether a specific new technology is covered by Community Health Network of Washington, please call our Customer Service team at at 1-866-907-1906 (TTY Relay: 711) Monday through Friday from 8 a.m. to 5 p.m.

    Provider Appeals

    With the exception of CHNW decisions related to DRG pricing, Fee Schedules, and member financial responsibility, a provider may appeal a CHNW decision that they believe is incorrect. Non-participating provider appeals must be in writing and submitted within ninety (90) days from the date of the notice of the denial; or initial payment of clean claim for Apple Health
    members; or within sixty (60) days for Medicare members.

    Par provider appeals must be in writing and submitted within twenty-four (24) months from the date of the notice of denial or initial payment of a clean claim. Second-level appeal requests will be reviewed if new information is provided to CHNW within sixty (60) days of the first level decision.

    An appeal must include:

    • Member name and member ID number
    • Claim number (if applicable)
    • Date of service
    • All supporting documentation pertinent to the reason for denial
    • Reason for requesting the appeal
    • Signed authorization (if filing on behalf of a member)

    Providers may submit appeals to:
    Community Health Network of Washington
    Attention: Appeals Department
    1111 Third Avenue, Suite 400
    Seattle, WA 98101
    Fax: (206) 613-8984
    Email: [email protected]

    Balance Billing Protection Act (BBPA) Provider Arbitration Steps

    • Following receipt of payment or notification of payment, Providers/Facilities have up to 30 days to engage in a good faith negotiation. If negotiation fails, the party seeking to initiate arbitration must notify CHNW no later than 10 days following completion of the good faith negotiation period.
    • CHNW’s payment stands if arbitration is not commenced by the end of the 10 days period.

    For rate disputes please call our Customer Service team at at 1-866-907-1906 (TTY Relay: 711) Monday through Friday from 8 a.m. to 5 p.m or email [email protected].

    Provider Orientation

    Community Health Plan of Washington (CHPW) offers provider orientation programs to help you get started with us. Established providers are welcome to review our orientation anytime.

    Provider Education and Training

    Community Health Plan of Washington (CHPW) provides mandatory and optional training resources for members of our provider network.

    Compliance

    All of our providers must be compliant with state and federal regulations. Find out more about our Member Rights and Fraud, Waste, and Abuse.

    Policies and Procedures

    Community Health Network of Washington makes certain policies and procedures available to providers. If you need hard copies of any of our materials, contact your Provider Relations Representative. Clinical policies and procedures that you need to care for members can be found in our Clinical Coverage Criteria.

DID YOU KNOW...?

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.