CHCN conducts utilization review of requested procedures to establish that appropriate level of care and appropriate providers of care are being utilized to provide medically necessary services. Utilization review is done only by licensed clinical staff. Denials are only done by the medical director. Certain services need to be authorized prior to the member receiving these services. Please see the Referral and Authorization Grid to determine what needs prior authorization. All referrals must be authorized using the CHCN Prior Authorization and Referral Forms, linked below.

NOTE: effective July 2014, CHCN introduced a new electronically fillable authorization form. The new form will improve readability, turnaround time and communication between providers and CHCN Utilization Management (UM) staff. CHCN requests end users refrain from submitting handwritten forms.  

Referral and Authorization Grid (Download PDF)

Prior Authorization and Referral Form (Download PDF)

Prior Authorization Form for Durable Medical Equipment (Download PDF for Anthem Blue Cross members only)

Retro Authorizations

Retro-authorizations within 30 days of service are reviewed for medical necessity determination and within the ICE turnaround standards – 30 calendar days from receipt of request.

 

**HIPAA regulations require that patient identifiable health information be protected. Click here for a list of what is considered Protected Health Information.**