MCO Authorization forms

Forms and resources about the MCO’s authorization processes will be posted below as they are received.

Combined MCO Prior Authorization summary


Amerigroup
SUD Inpatient Prior Auth & Continued Care Form

Coordinated Care
Contact Information and PA Check Tool
Prior Authorization Summary Guide

Molina
Molina BH Auth Request Form
Contact Information - Behavioral Health UM Team information
BH Provider Lists Landing Page on Member Public Website
Spokane BH Provider Grid - In Network Agencies and Community Health Centers

CHPW
Notification - Inpatient notification to CHPW is done one of two ways, fax or via our online portal. 

Prior Auth page - the below link is to our prior auth website which contains the information providers need to know on what requires prior authorization as well as links to the various forms that we provide for submission via fax and information to guide providers how to sign up and start sending authorizations online.
https://www.chpw.org/for-providers/prior-authorization-and-medical-review/

The specific forms (which are on the website above) are:
Inpatient Notification: https://www.chpw.org/resources/Forms_and_Tools/Inpatient_Admission_Form_Updated_9.24.2018.pdf
SUD Request Form: https://www.chpw.org/resources/Providers/Prior_Authorization/IMC_SUD_Service_Request_Form_1.pdf
Mental Health Request Form: https://www.chpw.org/resources/Providers/Prior_Authorization/Mental_Health_Service_Request_Form.pdf

Where to look to identify network providers for CHPW. Our provider directory is located on the website and provides the most accurate and real time information for our network providers and facilities: https://www.chpw.org/provider-search/

Provider Manual Link : https://www.chpw.org/for-providers/provider-manual1/