Prior Authorization FAQs - Cascade Select powered by CHPW - Cascade Select

Prior Authorization FAQs

Click through the common questions below to learn more about Community Health Network of Washington’s (CHNW) prior authorization policies and procedures.

Common questions about prior authorization

What is prior authorization?

Prior authorization is advanced approval of specific procedures, services, medical devices, supplies, and medications by CHNW. Prior authorization review is the process to determine medical necessity of said services, according to clinical care guidelines and utilization management criteria.

Prior authorization is required for all scheduled inpatient admissions, as well as certain predetermined services, medical pharmaceuticals, and surgical, diagnostic, therapy, and imaging procedures.

Why does CHNW require prior authorization?

The prior authorization process gives CHNW the chance to review how necessary certain services or medications may be in treating medical conditions. For example, some brand name medications are very costly. During review, CHNW may decide a generic or other lower-cost alternative may work equally well in treating a medical condition.

Prior authorization restricts access to costly services and therapies – particularly new treatments. It is also used to determine medical necessity and appropriateness of care.

How do I obtain prior authorization?

Providers should submit prior authorization through our care management portal, JIVA.

You can also fax prior authorization requests to 206-652-7065. Please check the fax number located at the top of each form as it may differ depending on the request. Find CHNW prior authorization forms here.

For pharmacy, providers should submit requests via ExpressScripts for prior authorization, step therapy, non-formulary, or quantity limit override. Call them at 1-800-753-2851 to speak with a prior authorization specialist. For professionally administered drugs, follow instructions here.

All other prior authorization requests will be handled by CHNW staff. Please contact your provider relations representative for more information.

Is prior authorization required for emergency services?

No referrals or authorizations are required for treatment in an emergency room.

What happens if my prior authorization is denied?

If CHNW denies your request to administer certain services, treatments, equipment, or prescription drugs, the member can appeal the decision and should follow the protocol on the Grievances and Appeals page.

If a drug is denied by Express Scripts, providers may appeal the decision by sending a letter and clinical documentation, including the date and reason for the denial given by ESI, to:

Community Health Network of Washington
Attn: CHNW Cascade Select Appeals
1111 Third Avenue, Suite 400
Seattle, WA 98101
Fax: 206-613-8983

Expedited appeals are reserved for emergency situations only; call 1-866-907-1906 (TTY: 711) Monday through Friday, from 8 a.m. to 5 p.m.

How long does it take to obtain prior authorization?

CHNW strives to process authorization requests within Washington State and Federal contractual requirements for timeliness, and in accordance with our member’s health care needs. Periodic increases in request volume may affect turnaround times. CHNW strives to adhere to the following processing timelines:

  • Standard prior authorization requests are processed within 5 to 14 days.
  • Clinically urgent requests are processed within 2 to 5 days.
What documentation do I need to submit with my request?

Documentation to support medical necessity must be submitted with prior authorization requests. This information supports the need for the treatment and submitting detailed information on initial submission helps to ensure the request can be processed in a timely manner.

Examples of appropriate documents include:

  • Current history and/or physician examination notes that address the problem and need for services requested
  • Relevant lab and/or radiology results
  • Relevant specialty consultation notes
  • Other pertinent information to aid in decision-making process

CHNW Utilization Management staff may request specific additional clinical information via fax or telephonically to complete the authorization process.

 

If you still have questions, call Customer Service for help. Our representatives are available at 1-866-907-1906 (TTY: 711) Monday through Friday, from 8 a.m. to 5 p.m.

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.