How to Use Your EPO Plan
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EPO SERVICE AREA
Rocky Mountain Health Plans offers several group exclusive provider organization (EPO) plans, which offer the advantages of HMO plans and yet allow members to use providers who generally serve only PPO plans.
RMHP serves most Colorado counties.
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GETTING CARE
Show your RMHP Member ID card
Each time you need health care, show your ID card at the provider's office.
Choosing a PCP
All RMHP EPO members must select a primary care physician (PCP). Each covered member of your family may select a different PCP. If you are new to the PCP you pick, call the doctor's office to be sure they are accepting new patients. Be sure the PCP you pick serves the type of plan you are enrolled in. For your convenience, you can use our on-line Provider Directory or call RMHP Customer Service at 970-243-7050 or 800-346-4643 for names of providers in your area. Click here for the Select PCP Form to submit your PCP selection on-line.
Changing your doctor is easy
Click here for the Change PCP Form to submit your PCP change on-line. Each covered member of your family may select a different PCP. Changing your PCP is easy. Be sure the new doctor's office is accepting new patients. Contact us by phone or on-line to tell us who your new PCP will be. You must tell us about the change before you see your new PCP. Arrange to have your medical records transferred to your new PCP.
Using participating providers for care
Participating providers are providers that contract with RMHP and thereby become part of the RMHP provider network. Each time you need health care, show your ID card at the provider's office. To be covered, all health care must be provided by participating providers except in medical emergencies and urgent care situations.
Generally, you pay less for care from your PCP than from other providers. If the service you need is covered by your plan but cannot be provided by a participating provider, you may be referred to a nonparticipating provider. Your PCP will work with us to get your care approved and arranged.
Did You Know?
- Registered Members may use access|RMHP (access now) to search for, select, or change a PCP. Members who have not yet registered can sign up here.
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Preauthorization
RMHP must preauthorize certain services before you receive them, even if you receive them from a participating provider. Participating providers are responsible for obtaining required preauthorizations. Examples of services that may require preauthorization include hospital admissions, surgery, computerized tomography (CT) scans, and some durable medical equipment.
Click here to see the list of services requiring preauthorization. Click here to see the list of durable medical equipment and medical supplies that require preauthorization.
RMHP offers an extensive formulary of prescription drugs to members who have prescription drug coverage. Click here to see the Formulary for all prescription drugs, including those that require preauthorization.
Medical Preauthorization Forms
Click on the links below to download preauthorization request forms:
Preauthorization Request Form (*Pharmacy preauthorizations must be completed on the appropriate, medication-specific PA Form or they will not be processed)
Home Health Authorization Form
DME Authorization Form
Click on the link to the left to learn more about Prescription Drug Information.
Did You Know?
- Registered Members may use access|RMHP (access now)to check the status of prequthorization requests. Members who have not yet registered can sign up here.
To ensure your pre-service request is completed in a timely manner, please allow:
Medicaid — 10 days Medicare — 14 days CHP+ — 15 days Commercial —15 daysTop
Payment For Services
The primary geographic location of the provider determines whether a provider is a Front Range or Western Slope provider. Providers include hospitals, physicians, and ancillary services. The copay collection map below shows which region each county is in for deductible and copayment collection at the time of service.
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Services from participating providers on the Western Slope
Usually, members do not pay the provider at the time of service. However, some statewide providers for services such as oxygen and DME will collect the copayment from you. RMHP will send you a Member Billing Statement for any deductible or copayment amounts you owe.
Services from participating providers on the Front Range
Members pay the provider at the time of service. RMHP will send you an Explanation of Benefits that shows the amount the provider charged, the portion of the bill RMHP paid, and any remaining amounts you owe.
Services from nonparticipating providers are not covered unless the services are not available from a participating provider and are preauthorized by RMHP.
In this limited instance, members pay the provider at the time of service. You may have to pay the provider in full and submit a reimbursement form to RMHP. For a copy of the RMHP Direct Reimbursement Form, see Commonly Requested Forms in Member Services.
Did You Know?
- Registered Members may use access|RMHP (access now) to check the status of claims. Members who have not yet registered can sign up here.
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Mental Health Services
Mental health services are a benefit of most RMHP plans. See your plan materials for your mental health coverage. Members who have a PCP located on the Western Slope must use RMHP participating mental health providers. For a provider in your area, see our on-line Provider Directory.
Members who have a PCP located on the Front Range must use Life Strategies mental health providers. For a listing of Life Strategies providers, call 1-800-382-6871.
To determine if the member is in the Western Slope or Front Range, reference the map in the Payment for Services section of this page.
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