About Prior Authorizations and Referrals

Community Health Plan is a managed care health plan. This means that your primary care provider (PCP) and the Plan coordinate all of your care. You need to get services, drugs, equipment, and supplies from your PCP or another provider in our network.

A referral from your PCP is not the same as a prior authorization. For more information and to avoid charges you might have to pay for yourself, please see What Is a Referral? and What Is a Prior Authorization?

To find a provider or pharmacy in our network:

  • See the 2010 Community Health Plan Provider and Pharmacy Directory.
  • Visit the Provider Directory Search online, which is updated as provider and pharmacy lists change.
  • Phone the Community Health Plan customer service team at 1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.

For some services, drugs, and supplies you need to get a prior authorization. You may also need a referral from your PCP to see some other providers.

Important notes:

  • In most cases, if Community Health Plan does not approve a referral to a provider outside our network before you see the provider, the Plan will not pay for the service.
  • If you get a service on the Prior Authorization List without getting the authorization first, the Plan will not pay for it. This may include other services related to a service you got that was not authorized.
  • To make sure you have the most current list of what requires approval before the service and to avoid charges you don't expect, always ask your PCP or call our customer service team before you get a service or supplies. Please phone the Community Health Plan customer service team at 1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.

Most specialist services are covered by your plan. Talk to your PCP, who may submit a referral to an in-network provider or submit a referral to an out-of-network provider if an in-network provider is not available. Some services, whether from an in-network or out-of-network provider, require a prior authorization as well.

The list in the Prior Authorization List section provides a guideline to which services, drugs, supplies, and equipment require a prior authorization. For additional information, see the Basic Health Benefit Table.

What Is a Referral?

A referral is when one provider sends a patient to another provider, usually a specialist, for diagnosis and treatment. Before you see a specialist or another provider, talk to your primary care provider.

A referral is good only until the end of the period okayed by Community Health Plan.

If you have a complicated or serious medical problem, you have the right to a referral that lasts for a longer period of time than a regular referral. This is called an extended (or standing) referral. An extended referral, like a regular referral, is good only until the end of the period okayed by Community Health Plan.

To get a referral, you must talk to your PCP. Your PCP will tell us:

  • Which provider the PCP refers you to.
  • The length of time and number of visits your PCP says you may use the provider's services.

When Do I Need to Get a Referral?

Except in emergency care, if you get services or treatment from a provider outside our network without first getting a referral from your PCP, the Plan will not pay for it.

To find a provider or pharmacy in our network:

  • See the 2010 Community Health Plan Provider and Pharmacy Directory.
  • Visit the Provider Directory Search online, which is updated as provider and pharmacy lists change.
  • Phone the Community Health Plan customer service team at 1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY 1-866-816-2479 (toll free) or local 206-613-8875.

You do not need your PCP's referral for:

  • Emergency services, which also do not require prior authorization.
  • Routine and preventive women's health care services by providers in the Community Health Plan network, regardless of diagnoses.
  • Routine preventive eye care exams once every 24 months.
  • Family planning services and sexually transmitted disease screening and treatment services provided at family planning facilities such as Planned Parenthood or your local Public Health Department.
  • Immunizations provided by your local Public Health Department.
  • HIV screening and tuberculosis screening and follow-up at your local Public Health Department.

For more information about your benefits:

What Is a Prior Authorization?

Community Health Plan must approve some services, supplies, or equipment before the service, supply, or equipment is provided. Community Health Plan must also approve some drugs before you get them.

A prior authorization is an approval by Community Health Plan of a procedure or other service on the Prior Authorization List. The Plan decides whether these procedures or services meet the standard of medical necessity. (For more information about medical necessity standards, see Medically Necessary.) If you get such a procedure or service without a prior authorization from the Plan, the Plan might not pay for it.

When Do I Need to Get a Prior Authorization?

You will need an authorization by Community Health Plan before you get the services listed in Prior Authorization List, which follows this section. If you get a treatment that is not covered or get a service that requires approval before you get the authorization, the Plan will not pay for it. It is best to talk to your PCP before you get nonemergency services or supplies.

The prior authorization list includes many of the common services you might need, but it might not include every service and every detail about a service. It also can change as state regulations change, as services available from our providers change, and as medicine itself advances.

For more detailed information see the Prior Authorization List or see Your Basic Health Benefits or see the Basic Health Benefit Table.

If you have questions, phone the Community Health Plan customer service team at
1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY
1-866-816-2479 (toll free) or local 206-613-8875.

Prior Authorization List

The drugs, equipment, services, and supplies on this list must be reviewed for medical necessity and approved by Community Health Plan before you get the drugs, equipment, services, or supplies. Otherwise, Community Health Plan will not pay for them. If a service is not listed, it might not be a Community Health Plan covered benefit.

Important notes:

  • This section gives you general information. Whether your service or treatment can be covered depends on your diagnosis. It is always best to check with your provider or Community Health Plan before you get the service.
  • To make sure you have the most current list of what requires approval before the service and to avoid charges you don't expect, ask your PCP or call our customer service team before you get a service or supplies. (See "More Information" following this list.)

More information:

  • For more information about your benefits and your responsibilities, see Your Basic Health Benefits or see the Basic Health Benefit Table.
  • For more information about what "medically necessary" means, see the detailed definition of "medical necessity" in Appendix A: Schedule of Benefits, I. Medically necessary services, supplies, or interventions in the Washington State 2010 Basic Health Member Handbook.
  • For details about which services are offered by Community Health Plan, contact
    your provider or phone the Community Health Plan customer service team at
    1-800-440-1561 (toll free). If you are hearing or speech impaired, please call TTY
    1-866-816-2479 (toll free) or local 206-613-8875.

Care that requires a prior authorization includes

Accidental Dental (including TMJ treatment)

Alternative care

  • Acupuncture for more than 6 visits
  • Biofeedback for more than 6 visits
  • Chiropractic
  • Hypnotherapy for more than 6 visits
  • Massage for more than 6 visits
  • Naturopathy for more than 6 visits

Behavioral health care for more than 8 visits

Drugs/Injectables
(See important notes following the list.)

You need a prior authorization for:

  • 17 Alpha-hydroxyprogesterone  
  • Abatacept (Orencia)
  • Adalimumab (Humira) 
  • Amifostine (Ethyol)
  • Bevacizumab (Avastin) 
  • Botulinum toxin (Botox/Myobloc)
  • Certolizumab (Cimzia) NEW
  • Cetuximab (Erbitux)
  • Corticotropin (Acthar)  NEW
  • Docetaxel (Taxotere)
  • Erythropoeisis-stimulating agents (Darbepoetin and Epoetin)
  • Epoprostenol (Flolan)
  • Etanercept (Enbrel)
  • Gemcitabine (Gemzar)
  • Golimumab (Simponi)       NEW
  • GnRH agonists (such as Lupron)
  • Granulocyte-colony stimulating factor (G-CSF) (such as Pegfilgrastim)
  • Growth hormone (Somatropin)
  • Hyaluronic acid derivatives (such as Synvisc/Hyalgan)
  • Iloprost (Ventavis)
  • Infliximab (Remicade)
  • Intravenous immunoglobulin  NEW
  • Natalizumab (Tysabri) 
  • Octreotide (Sandostatin) 
  • Omalizumab (Xolair)
  • Oxaliplatin (Eloxatin)
  • Palivizumab (such as Synagis)
  • Pamidronate (Aredia) and Zolendronic Acid (Zometa)
  • Rituximab (Rituxan)
  • Trastuzumab (Herceptin)
  • Treprostinil (Remodulin)

Important notes about drugs:

  • If the drug can be self-administered, you need a prescription plus a Plan-approved prior authorization from the Community Health Plan pharmacy benefit manager.
  • If you cannot self administer the drug, you need an approved prior authorization from Community Health Plan.
  • To find out how to get a pharmacy prior authorization, see "Nonformulary and Prior Authorization Requests."

Home Health and Home Infusion, including enteral therapy

Hospice Care

Inpatient Facilities

  • Inpatient rehabilitation
  • Skilled nursing facility

Radiology

  • CT angiography
  • CT head (non-emergency)
  • MRI/MRA (NEW for extremities)
  • PET scan

Surgical Procedures
Community Health Plan requires prior authorization for all inpatient, planned procedures and for those outpatient procedures included in the list below.

Specific services that require authorization include:

  • Blepharoplasty
  • Breast prostheses or implants
    (Does not require prior authorization for treatment related to breast cancer.)
  • Breast reduction or mammoplasty
  • Bunionectomy
  • Capsule endoscopy
  • Cataract removal or lens implant
  • Endovenous laser or radiofrequency ablation
  • Hip, knee, or shoulder replacement
  • Hysterectomy
  • Knee arthroscopy
  • Rhinoplasty and septoplasty
  • Sclerotherapy, leg veins
  • Thoracic laminectomy
  • Thoracic spine fusion
  • Urethral suspensions (incontinence)
  • Uvulopalatopharyngoplasty (UPPP)

Therapies

  • Cardiac rehabilitation
  • Dialysis
  • Physical therapy

Transplants

  • Work-ups
  • Transplants (excluding corneal)
  • Donation

Other

  • Experimental or investigative services
  • Hyperbaric oxygen treatment
  • Oxygen