Before submitting your authorization request, please review the most recent list below for exclusions and other important information. The code status column will either be NPA for No Prior Authorization Required, PA for Prior Authorization Required, or NC for non-covered code with some codes having POS for Place of service. Please pay close attention to those specifics. For the most up to date configuration please click on the "View the Current Coverage and Limitation List" hyperlink below.
View the Current Coverage and Limitation List
View IFP UM Authorization Guidelines
Archived list(s) from 2023 can be referenced by clicking the previously updated versions of the list below.
Coverage and Limitation list
Effective January 1, 2019, your office may need to submit prior authorization requests for medications differently for Individual and Family Plans, depending on if the drug falls to the medical benefit or the pharmacy benefit. Please be sure to read these instructions. The Medication List below indicates which benefit applies to the code.
View the Individual and Family Plan Medication List
Submit Authorizations Online
All authorization requests must be submitted via the GuidingCare 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
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 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.
Questions?
For questions or assistance with your authorization request, call the CCHP Clinical Services Department at 844-450-1926
Affirmative Statement
Chorus Community Health Plans (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.