Our Care Management team is dedicated to identifying risks, needs, and goals to develop action plans and provide exceptional levels of care. We offer a robust approach to evaluating the effectiveness of care members receive.
Our Care Management Team uses clinical and evidence-based guidelines as tools in the care management process.
We monitor the care management process with care-usage reviews as well as analysis that identifies potential for care coordination, disease management, and members who may be at risk for improper use of care resources. Our providers can access care management resources for patients in several ways, through prior authorization requests, our customer service department or through a case management referral.
The Care Management Team consists of clinical and nonclinical staff in the following areas:
- Case Management
- Patient Review and Coordination (PRC) Program
- SSI Referrals
- Utilization Management / Prior Authorization
- Disease Management
- Health Homes
Our goal is to provide care that takes the challenge out of managing complex health conditions.
We offer a variety of programs that follow specific guidelines to ensure our health care services are efficient and effective.
Provider Criteria and Guidelines
- Clinical Coverage Criteria (used to decide medical necessity)
- Clinical Practice Guidelines (used to determine treatment plan)
- 2017 Provider Manual
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.
Staff members are available to discuss the care management process, and appropriate peer reviewers (medical director, pharmacist, or associate clinical Director) are available to discuss any management authorizations or denials. Relevant policies and/or clinical criteria are available upon request.
To contact our staff and peer reviewers, please call 1-800-440-1561 (TTY Relay: Dial 7-1-1), from 8 a.m. to 5 p.m., Monday through Friday.