When a Service is Denied

Date: 12/03/18

Any time California Health & Wellness Plan (CHWP) decides to deny, reduce, suspend, or stop coverage of certain services, we will send you and your patient written notification. The denial notice includes information on the availability of a medical director to discuss the decision.

Peer-to-Peer Reviews

If a request for medical services is denied because of a lack of medical necessity, a provider can request a peer-to-peer review with our medical director on the member’s behalf. The medical director may be contacted by calling CHWP at 1-877-658-0305. A utilization management care manager may also coordinate communication between the medical director and the requesting practitioner as needed.

Filing Appeals

The denial notice also informs you and our member about how to file an appeal. Providers will need written permission to file an appeal on behalf of the member. In urgent cases, an expedited appeal is available and can be submitted verbally or in writing.

Please remember to always include sufficient clinical information when submitting prior authorization requests to allow CHWP to make timely medical necessity decisions based on complete information.