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 will be reviewed within the 30-calendar day allowable time frame for Elevance Health (Anthem Blue Cross) and 90-calendar day allowable time frame for Alameda Alliance for Health, from the date of receipt of the request.
**HIPAA regulations require that patient identifiable health information be protected. Click here for a list of what is considered Protected Health Information.**