Capital Health Plan, Prior Authorization

Capital Health Plan, prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• CHP uses prior authorization/precertification for certain medical, surgical, and behavioral health services. Official provider guidance says providers should use the Universal Prior Authorization Form, and incomplete forms are not processed. CHP states determinations are communicated within 15 calendar days after receipt of all necessary information. Some services may not require an authorization number if they can be completed with a referral or PCP/specialist order, and the exact list of services requiring authorization varies by plan/service context.
• Authorization requirements vary by service and can differ for local participating practitioner services.
• The reviewed sources do not provide a single comprehensive service-level authorization grid for all lines of business.
• The official materials emphasize that some services may be completed with a referral or order rather than a separate authorization number.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3
• Verification resource 4

How to submit prior authorization requests

• Universal Prior Authorization Form

• Provider/member request for approval before service

• Contact Member Services / Network Services for plan-specific guidance

• Submission resource 1

• Submission resource 2

• Submission resource 3

Information commonly required

• Complete the Universal Prior Authorization Form in full
• Do not submit incomplete requests
• Supporting clinical/medical necessity information as needed for the service

Turnaround notes and caveats

• All requests for prior authorization are processed and a determination is communicated within 15 calendar days of receipt of all necessary information.
• Authorization requirements vary by service and can differ for local participating practitioner services.
• The reviewed sources do not provide a single comprehensive service-level authorization grid for all lines of business.
• The official materials emphasize that some services may be completed with a referral or order rather than a separate authorization number.

Provider resources

• Provider Care Resources (official)
• Network Support Services (official)
• Provider FAQ (official)
• Provider Directory (official)
• Referrals and Prior Authorization (official)

Sources