Prior authorization is an approval you must get before you a provider gives you a treatment or service or before you get medical equipment or medication.
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:
