What is 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 Plan 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 Plan 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 Plan of Washington does not reward providers or others for denying coverage or care.
  • Community Health Plan 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 Plan 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 Plan of Washington, please call our Customer Service team at 1-800-440-1561 (TTY Relay: Dial 7-1-1), Monday through Friday, 8 a.m. to 5 p.m.

Contact us

Call Customer Service at 1-800-440-1561, TTY Dial 711. You may request relevant policies and clinical criteria.