Utilization Management

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Contact Us With Feedback

The Utilization Management Department is interested in provider feedback for UM processes that can be improved. Please feel free to email any comments or ideas for improvements to Requests-UM@chpw.org or phone Customer Service at 1-800-440-1561.

No Financial Incentives for Decision-Makers

Community Health Plan staff and providers okay or deny services, but there are no financial incentives for decision-makers. We do not pay them to decide in a certain way.

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 Plan does not reward providers or others for denying coverage or care.
  • Community Health Plan does not offer financial incentives to encourage Utilization Management decision-makers to make decisions that result in an underuse of care or services.

An appropriate peer reviewer (Medical Director, Pharmacist, or Associate Clinical Director) is available to discuss any Utilization Management denial decision by calling Customer Service at 1-800-440-1561. Policy is available upon request.

Referral Management

A referral is a primary care provider’s written statement of intent to refer an enrollee to specialty care or ancillary services. Plan approval of referrals is not required for Community Health Plan participating providers. Enter referrals to nonparticipating providers in our Care Management Portal at https://jiva.chpw.org for review. After they are are entered in our system, they can be reviewed and the provider’s claim can be paid.

Nonparticipating provider referrals are reviewed and compared to benefits to ensure that:

  • The proposed services are not available within our network of participating providers.
  • The number of visits does not exceed the approved guidelines.
  • The proposed services are medically necessary.
  • The services are a covered benefit.

Referral Form Document:

Preapproval (Prior Authorization)

Community Health Plan of Washington is accountable for our members' safety and to ensure appropriate care. It is important that the provider and the health plan work in partnership to ensure appropriate care for those we serve.

Certain predetermined services—such as home health care, home infusion therapy, certain durable medical equipment, certain medical pharmaceuticals, and certain surgical, diagnostic, and imaging procedures—require an approval by Community Health Plan of Washington in advance for the claim for these services to be paid.

The Utilization Reviewer uses approved criteria to review the request and clinical information provided to make a determination for the approval. The Utilization Reviewer may approve the services if they meet medical necessity criteria. If not, the case is referred to the Medical Director for review.

Prior Authorization Documents:

Changes to the Prior Authorization List and Utilization Guidelines for 2012. Changes to the Prior Authorization List are based on semi-annual reviews of factors such as utilization performance against benchmarks, changes in standards of medical care, new technology, or denial rate. See the lists below for a summary of the changes from 2011 to 2012 to the Prior Authorization List and Utilization Guidelines:

Pre-Admission Authorization

For all types of admissions with the exception of psychiatric and substance abuse, the Utilization Reviewer works with the primary care physician, the attending physician, and the hospital representative to determine whether:

  • Hospitalization is medically necessary and a covered benefit.
  • Another less costly mode of treatment is available and appropriate to manage the enrollee's medical problem.
  • A diversion to an alternative care facility or reduction in level of care is appropriate.
  • Admission to an inpatient rehabilitation program meets admission criteria.
  • Admission to a skilled nursing or subacute rehabilitation program meets admission criteria.

Requests for scheduled admission and/or surgery are submitted to Community Health Plan at least five days in advance of the admission or procedure by entering request information in the CHPW Care Management Portal at: https://jiva.chpw.org or by sending a written or faxed request to 206-652-7078. Community Health Plan reviews requests for hospital admissions each business day. The provider is notified of the determination and an authorization is placed in the payment system.

Hospital Inpatient Notification

Hospitals are required to notify Community Health Plan of all inpatient admissions within one business day of the admission. Notification does not guarantee payment; payment is subject to enrollee's eligibility and contract benefits (including pre-existing condition review for Basic Health enrollees, if applicable) at the time of service, as well as determinations of medical necessity and the presence of a prior authorization if applicable.

Member eligibility may be verified through One Health Port at www.onehealthport.com or through the CHPW care management portal at https://jiva.chpw.org. For those organizations that do not have internet access please contact Customer Service at 1-800- 440-1561. Benefit information may be viewed on our State Programs web site or on our Medicare Advantage web site.

Hospitals may enter information about hospital admission notifications via the Care Management Portal at https://jiva.chpw.org. or you may use Community Health Plan’s Hospital Notification form or you may submit your own form as long as the following information is included:

  • Enrollee’s full name
  • Enrollee’s date of birth
  • Enrollee’s Social Security Number
  • Enrollee’s Community Health Plan ID number (if known)
  • Date and time of admission
  • Discharge date (if known)
  • Admit type
    • Planned: routine or elective admission
    • Urgent: direct admission or transfer from another facility
    • Emergent: admitted through the emergency department
  • Newborn information: sex; date delivered, type of delivery (vaginal or C-section); bed type (regular or special care nursery/NICU)
  • Admitting provider name
  • Admitting diagnosis
  • Facility name
  • Facility contact’s name, phone, and fax numbers (usually the person responsible for submitting the notification)

The preferred method for notification is the Care Management Portal or notifications may be faxed to
206-652-7078.

Hospital Inpatient Notification Document:

Eligibility, benefit, and medical necessity evaluation may be done prior to admission, concurrently, or through the review of claims, as applicable. For all enrollees, including Medicare beneficiaries, Care Management staff will coordinate delivery of denial notices by hospital Utilization Review (UR) staff.

Outpatient hospital services do not require hospital notification to Community Health Plan, but may require prior authorization.

Concurrent Review

During the inpatient hospitalization, the enrollee's clinical progress is reviewed by a concurrent review coordinator using clinical criteria approved by Community Health Plan. Frequency of reviews varies according to the enrollee's clinical course. Reviews are accomplished through faxed records from the facility or via notes and documents submitted to Community Health Plan via the Care Management Portal.

Discharge Planning Coordination

Discharge planning needs are identified through the concurrent review process or by referral from someone on the enrollee's care team. The extent of the concurrent review coordinator’s direct role in planning and arranging post discharge care varies with the enrollee's needs and includes a collaborative approach with the hospital staff, care team, enrollee and family, and community resources as appropriate.

Emergency Room Care

No referrals or authorizations are required for treatment for an emergency medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following:

  • Placing the health of the patient, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.
  • Serious impairment of bodily functions.
  • Serious dysfunction of any bodily organ or part.

Pre-Existing Condition Review (Basic Health and Washington Health Plan Only)

A pre-existing condition waiting period exists for enrollees whose health coverage is provided by Basic Health or Washington health Plan. Generally, the pre-existing condition waiting period is nine months from the day coverage with Community Health Plan begins unless creditable coverage applies. The PEC waiting period applies to all services (including services provided by the PCP) except for maternity care, prescription drugs, and oxygen therapy. A patient’s pre-existing condition diagnoses are available for viewing through the Care Management Portal by hovering over the “Pre-Existing Condition” hyperlink in the “My Patients” view section.

PEC Documents: