Appeal Request Coversheet
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This document provides the appeals request form and instructions for submitting provider or member appeals to Community Health Plan Washington Medicare Advantage; it affects providers and members filing first- or second-level appeals related to prior authorization, medication, or claim payment denials.
No material clinical or coverage changes in this revision.
Appeal Form Criteria
Appeal form criteria
Appeal types and denial reasons captured on the form.
Appeal level
- 1st Level (checkbox)
- 2nd Level (checkbox)
Denial category
- Prior Authorization/Referral/Inpatient Notification (checkbox)
- Medication (checkbox)
- Claim Payment (checkbox)
If Claim Payment selected, ONE or more claim payment reasons may be checked
- No Prior Authorization/Referral (checkbox)
- Late Inpatient Notification (checkbox)
- Post Payment Review (checkbox)
- Billing/Coding (checkbox)
- Pre-existing condition (checkbox)
- Not medically necessary (checkbox)
- Duplicate (checkbox)
Claim Denial Reasons / Codes
| No codes listed |
How to Submit Appeals
How to submit appeals
Submit appeal requests using either email or fax. Send routine or non-urgent appeals to appealsgrievances@chpw.org or fax to (206) 652-7010. For medically urgent appeals, use fax to (206) 652-7011.
- Email: appealsgrievances@chpw.org
- Fax (routine/non-urgent): (206) 652-7010
- Fax (medically urgent): (206) 652-7011
Medically Urgent Definition
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