Together with CCHP contracted providers are responsible for obtaining prior authorization before they provide services to covered members.
- Effective January 1, 2019, your office may need to submit prior authorization requests for medications differently for Together with CCHP, depending on if the drug falls to the medical benefit or the pharmacy benefit. Please be sure to read these instructions.
- Prior Authorization List:
- HCPCS code E0156, for a walker's seat, was added to the prior authorization request list only if the retail cost for the code on the claim is $500 or greater.
- These new skin substitute codes have been added to the prior authorization list: Q4183; Q4184; Q4185; Q4186; Q4187; Q4188; Q4189; Q4190; Q4191; Q4192; Q4193; Q4194; Q4195; Q4196; Q4197; Q4198; Q4200; Q4201; Q4202; Q4203; and Q4204.This is effective March 1, 2019.
- These Diabetic and Neuropathy Procedure Codes for DME and Foot Care, and A5514, have been added to the prior authorization list. This is effective March 1, 2019.
- These DME codes have been added to the prior authorization list: E0447, E0467 and L8698. Prior authorization is required if the purchase price or the monthly rental price is greater than $500. This is effective March 1, 2019.
- No Prior Authorization List:
- The following codes have been added to the no prior authorization list: 77301; 77338; 77385; 77386; G6015; G6017. Effective December 1, 2019.
- The following codes have been added to the no prior authorization required list: A9589; B4105; C9407; C9754; C9755; G2011; and J0841.This is effective March 1, 2019.
- Non-covered List:
- These codes were added to the non-covered list with an effective date of December 1, 2019: 0129U; 0130U; 0131U; 0132U; 0133U; 0134U; 0135U; 0136U; 0137U; 0138U; 19105; 22526; 22527; 22856; 22858; 22861; 22864; 27279; 28446; 31627; 31660; 31661; 33368; 33369; 33548; 37252; 37253; 41512; 41530; 43257; 43647; 43648; 43881; 43882; 46607; 53860; 55706; 55899; 62287; 72159; 73225; 75571; 76936; 78350; 78351; 78499; 78647; 78807; 83037; 83698; 83876; 91111; 92132; 95060; 95803; 95905; 95980; 95999; 97610; 99174; A4305; C1821; C9360; C9361; C9362; C9363; C9364; G0428; Q0035; E0446; E0740; E0745; E0764; E0766; E0770; E1801; E1806; E1811; E1815; E1816; E1818; E1821; E1831; E1840; E1841; E2120; L5973; L8605; Q4103; Q4107; Q4111; Q4112; Q4113; Q4115; Q4117; Q4118; Q4122; Q4123; Q4124; Q4125; Q4126; Q4127; Q4128; Q4130; Q4132; Q4133; Q4134; Q4135; Q4136; Q4137; Q4138; Q4139; Q4140; Q4141; Q4142; Q4143; Q4145; Q4146; Q4147; Q4148; Q4149; Q4150; Q4151; Q4152; Q4153; Q4154; Q4155; Q4156; Q4157; Q4158; Q4159; Q4160; S9034; S9090; S2118; S2348; S2102; S3852.
- These codes were added to the list with an effective date of October 1, 2019: 0084U, 0085U, 0086U, 0087U, 0088U, 0089U, 0090U, 0091U, 0092U, 0093U, 0094U, 0095U, 0096U, 0097U, 0098U, 0099U, 0100U, 0101U, 0102U, 0103U, 0104U, 0543T, 0544T, 0545T, 0546T, 0547T, 0548T, 0549T, 0550T, 0551T, 0552T, 0553T, 0554T, 0555T, 0556T, 0557T, 0558T, 0559T, 0560T, 0561T, 0562T, C9756
- These codes were added to the list with an effective date of July 1, 2019: J7318; J7320; J7321; J7322; J7323; J7324; J7325; J7326; J7327; J7328 and J7329.
- HCPCS code E0156, for a walker's seat, was removed from the non-covered code list.
- These codes were added to the list: G2001, G2002, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, and G2015. These codes are for in-home visits post-discharge and care plan oversights. This is effective June 1, 2019.
- These lab codes were added to the non-covered code list: 0001U; 0002U; 0003U; 0005U; 0006U; 0007U; 0008U; 0009U; 0010U; 0011U; 0012U; 0013U; 0014U; 0016U; 0017U; 0018U; 0019U; 0021U; 0022U; 0023U; 0024U; 0025U; 0026U; 0027U; 0029U; 0030U; 0031U; 0032U; 0033U; 0034U; 0035U; 0036U; 0037U; 0038U; 0039U; 0040U; 0041U; 0042U; 0043U; 0044U; 0045U; 0046U; 0047U; 0048U; 0049U; 0050U; 0051U; 0052U; 0053U; 0054U; 0055U; 0056U; 0058U; 0059U; 0060U; 0061U; 0062U; 0063U; 0064U; 0065U; 0066U; 0067U; 0068U; 0069U; 0070U; 0071U; 0072U; 0073U; 0074U; 0075U; 0076U; 0077U; 0078U; 0079U; 0080U; 0081U; 0082U and 0083U. This is effective June 1, 2019.
Submit Authorizations Online
All authorization requests must be submitted via the CareWebQI Authorization tool on the Provider Portal, including all supporting documentation.
- If it is determined at the time of claims submission that the request for the authorization was submitted after the date of service, the claim will deny.
- Out-of-network providers need to call 844-450-1926 for instructions on submitting their requests.
- Retro- and post-service requests: CCHP does not review requests for services that have already been provided.
- For services that need an authorization, CCHP requires a prior authorization to be submitted for review before the date of service.
- Inpatient admissions require notification within 24 hours of admission in the Authorization tool.
- Post-service requests will be returned to the provider to be adjudicated on appeal, except for emergency or urgent care services.
- Authorization does not guarantee either payment of benefits or the amount of benefits.
Step Therapy Protocol
Together with CCHP utilizes a step therapy process to ensure our members can get the medication they need at the most reasonable cost. Step therapy is the practice of using specific medications first when beginning drug therapy for a medical condition. Step therapy is a type of prior authorization. In most cases, the preferred first course of treatment may be a generic drug(s) or drug(s) that is considered as the standard first-line treatment. Preferred first courses of treatment are also standard clinical practice and based on clinical practice guidelines. When trying to fill a drug that is part of a step therapy protocol, it may be automatically approved if your records show that you have already tried the preferred first course of treatment. If there is no record of you having tried the preferred first course of treatment, your physician must submit relevant clinical information to the Together with CCHP Pharmacy Department to determine if the requested drug will be covered.
If you feel that an exception to the step therapy process should be granted, your provider may file an exception request by completing the form found in the Pharmacy Authorization section of our website.
For questions or assistance with your authorization request, call Together with CCHP Clinical Services Department at 844-450-1926
Affirmative Statement - Children’s Community Health Plan (CCHP) wants its members to get the best possible care when they need it most. To ensure this, we use an auto authorization process, which is part of our Utilization Management (UM) program. UM decision-making is based only on appropriateness of care and service, and existence of coverage. CCHP does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.