Member FAQs

Member FAQs

Before you can make the right health care choices for you and your family, you should have the information you need. On this page, Community Health Plan of Washington (CHPW) has answered some common member questions.

➔ See general Medicaid/Apple Health FAQs
➔ See Behavioral Health FAQs.

Getting care and services

How do I make an appointment?

To make an appointment, call your clinic or doctor’s office. If you need help locating the phone number, use our online provider directory.

When you call to make an appointment:

  • Tell them if you’re a new CHPW member.
  • If you need an interpreter, please don’t hesitate to ask for one.
  • Have your CHPW Member ID handy in case the clinic staff need information from it. To view or download your card, set up or log onto your member account.

If you need help getting an appointment, getting to or from your provider’s office, making a care plan to support your health needs, or if there are other things that make it hard for you to get care, we can help. CHPW has a program called Case Management for addressing these kinds of needs.

Case management is available at no extra cost to all of our members. Call Customer Service to get started with case management or to learn more.

How do I know if I should see a doctor?

When you have a medical issue, you can get care in a variety of ways.

  • Primary Care Provider: See your primary care provider for routine care like check-ups and immunizations, if you’re managing a chronic illness, if you need a referral to a specialist, or if you get something like bronchitis or a cold and you do not need immediate attention.
  • Urgent Care: Urgent care offers non-emergency care 24 hours a day. An example of an urgent care issue is if your child wakes up in the middle of the night with a fever or vomiting.
  • Nurse Advice Line: CHPW members have access to advice from professional nurses 24 hours a day, seven days a week at 1-866-418-2920 (TTY: Dial 711). You can call the Nurse Advice Line with many different health questions. For instance, you might call to ask if a crying baby needs medical attention, or if your own symptoms require a visit to your doctor.
  • Emergency Room: The emergency room is open 24 hours a day, seven days a week. It is for serious injuries or issues with life-threatening symptoms. Some examples of issues that would need emergency care are: severe burns, auto accidents, suicide attempts, shortness of breath, chest pain, severe stomach pain, bleeding that won’t stop.
  • Telehealth: A growing number of health care providers and clinics let you schedule doctor’s visits over phone or video calls. Not only can you get medical care without leaving your home, but these telehealth visits may have more flexible hours than your nearest clinic. CHPW also provides telehealth service through Teladoc.
What if I want a second opinion about my health care?

You have the right to get a second opinion.

Tell your primary doctor that’s what you want. They will refer you to a different provider within the CHPW network with similar credentials, or you can choose one from our provider list.

What is utilization management?

Utilization management is a process of reviewing whether care is medically necessary and appropriate for patients.

We evaluate care before it’s given (prior authorization), while it’s being given (concurrent review), and after it’s given (post-service review). Our process is designed to ensure appropriateness, medical need, and efficiency of health care services, procedures, and the appropriate place of service.

Who does the review?

The review is done by the appropriate licensed staff, which includes — but is not limited to — nurses, medical director, and pharmacists. Community Health Plan of Washington staff is available to discuss any utilization management process, authorization, or denial.

Prior authorization review is the process of reviewing certain medical, surgical, and behavioral health services. This is to ensure the medical necessity and appropriateness of care are met prior to services being delivered.

My doctor submitted a prior authorization request. How long will it take to hear back?

Typically, a standard request must have a decision made within 72 hours (including weekends and holidays), unless we need additional information from your provider. You will be notified via phone and mail once a decision is made.

In some instances, your provider may determine that coverage of a certain medication should be decided urgently. In these cases, a decision will be made within 24 hours (including weekends and holidays).

Can I see a doctor who’s not on your provider list?

As a CHPW member, you must choose an in-network Primary Care Provider (PCP) to get your medical care.

The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the service area), out-of-area dialysis services, and cases where you have obtained prior authorization from your CHPW doctor.

How can I change my doctor?

You may need to change your doctor because you’ve moved or you’re no longer satisfied with your care. Whatever the reason, you can change from one in-network CHPW provider to another at any time:

How do I know if my medication is covered?

Each year, we publish a formulary, also known as a “preferred drug list.” You should review this list to determine what tier your drug is on and if there are any restrictions on it.

Where can I fill my prescriptions?

CHPW has an extensive network of pharmacies across Washington, Oregon, and Idaho. Many of our Community Health Centers have their own pharmacies. To find the pharmacy closest to you, you can:

Bring your CHPW ID card when you pick up your prescription. If you don’t have your card, you can log in to CHPW Member Center to view, download, and print a copy of it.

My coverage has been terminated. How do I get it back?
  • If you have lost coverage within the past 60 days, call CHPW customer service.
  • If you lost coverage more than 60 days ago, call Washington Healthplanfinder at 855-923-4633.

Updating personal information and contacting the plan

How do I contact the plan?

CHPW is here to answer your questions and address your concerns, so you can choose the easiest way to get in touch:

  • By phone. Call us at 1-800-440-1561 (TTY Relay: Dial 711). We’re available to take your calls Monday through Friday, from 8 a.m. to 5 p.m.
  • By email. Email us any time of day or night at CustomerCare@chpw.org, and we’ll get back to you Monday through Friday, from 8 a.m. to 5 p.m.
  • Through the myCHPW portal. In your myCHPW dashboard, navigate to Member Self Services > Secure Messages. Secure messages are like emails, but they can only be accessed through myCHPW.
I’ve moved. How do I change my address and/or phone number?

When you move, be sure to let the following state organizations know:

  • Your local Community Services Office. Call 1-877-501-2233.
  • Washington Healthplanfinder. Call 855-923-4633.

Then call Community Health Plan of Washington! We’ll update your address and other information. We can also help you choose a new Primary Care Provider, if necessary.

To get in touch with us, call Customer Service at 1-800-440-1561 (TTY Relay: Dial 711), 8 a.m. to 5 p.m., Monday through Friday.

I’ve changed my name. Who do I contact?

When you change your name, you’ll need to update your personal information:

  • Call CHPW Customer Service at 1-800-440-1561 (TTY Relay: Dial 711), 8 a.m. to 5 p.m., Monday through Friday.
  • Call Washington Healthplanfinder at 855-923-4633.
I have just had a baby and would like to enroll them into Medicaid. How do I do that?

Congratulations! Please call Washington Healthplanfinder at 855-923-4633, and they can get you started.

What is myCHPW/the member portal?

myCHPW is our online portal that lets you view important coverage information. It can be accessed from a phone, tablet, or computer.

With myCHPW, you can:

  • See information for all your different insurance plans, not just ours.
  • See your coverage information and benefits.
  • See your claims.
  • Check the status of your authorizations and referrals.
  • Order a copy of your CHPW ID card.
  • Search for providers and facilities.
  • Ask us to change your primary care provider.
  • Update your contact information.
  • Ask our Customer Service team questions through our secure system.
  • Get private notifications and general updates.
  • Learn more about benefits and claims.
  • Review your explanations of benefits (EOB) in myCHPW. An EOB is a statement that lists the services you got, the amount billed, and what was paid.
What to do if I receive a bill?

Under a CHPW Apple Health plan for individuals, you should not be billed for covered services (including those you’ve gotten prior authorization for).

If your child is covered under a low-cost Apple Health for Kids plan, you’ll receive a bill for a low monthly premium.

If you get a bill that you don’t understand or think is incorrect, contact us at 1-800-440-1561 (TTY Relay: Dial 711), Monday through Friday, from 8 a.m. to 5 p.m.

What if I am dissatisfied with my services and care?

You have the right to excellent care. We’re sorry to hear that you didn’t have that experience with CHPW.

To file a grievance (a complaint) about services or care you’ve received, call us at 1-800-440-1561 (TTY Relay: Dial 711). We’re available to take your calls Monday through Friday, from 8 a.m. to 5 p.m.

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