Prior Authorization

This list applies to RMHP CHP+, Commercial PPO, HMO, and Indemnity Plan Members.

          Use this link to access the Medicare List or the Medicaid List
                   Effective Starting 7/1/2014

Our goal at RMHP is to make the prior authorization process as easy as possible for our Members.  We review your request to:

  • Determine if the treatment or service is covered by your health plan.
  • Consider whether it is the right care, at the right time, from the right health care practitioner or provider.
  • Compare your medical needs to criteria based on scientific evidence to make decisions.

A Rocky Mountain Medical Director or Clinical Pharmacist reviews all requests that do not meet these criteria.  The Medical Director consults with specialist physicians experienced in the type of care you requested, as needed.

Services for which prior authorization is required:                                      


Request Forms

Send your fax to RMHP unless we give you other direction with the specific procedure or item.
RMHP Fax:     877-201-7302  or  970-254-5738

Care Core National Phone:  800-792-8750

        Genetic Testing (Molecular Diagnostics)

Diagnostic Imaging when the procedure will be performed outside of Delta, Montezuma, or Montrose county and within Colorado.

Behavioral Health Services

       Value Options Phone: 855-886-2832



Get help with a question about prior authorization

To get answers to questions about coverage for procedures, DME, drugs, or other services.

RMHP Customer Service:
Hours:
Monday – Friday, 8:00 A.M. to 5:00 P.M.
Phone Number: 970-243-7050 or 800-346-4643.
If you are hearing impaired and use TTY equipment, call 711.
Email: customer_service@rmhp.org

If you have additional questions about our Care Management process, our Care Management team is available to answer questions. Let the Customer Service Representative know, and he or she will transfer your call to the Care Management Team.

Prior Authorization Process

  • You must receive the authorization before you receive the service.
  • RMHP will not authorize services that are not a benefit.

PPO and Indemnity Members:

  • The services on the lists require authorization.
  • When you get care from a network physician, he or she will make the request for prior authorization in writing and submit all necessary medical records to Rocky Mountain Health Plans.
  • When you go to a non-network physician, it is your responsibility to obtain prior authorization.

HMO Members:

  • In addition to the services on the lists, all other non-emergent services that you receive from non-network physicians, facilities, or other providers must be approved by RMHP.
  • When you get care from a network physician, he or she will make the request for prior authorization in writing and submit all necessary medical records to Rocky Mountain Health Plans.
  • When you go to a non-network physician, it is your responsibility to obtain prior authorization.

Time to Make the Decision

Once we receive the request, we make a decision in no more than 15 days.

The decision will be delayed if additional information is needed. The Care Management Team Member will notify you in writing of specific information that is needed, and you or your doctor will have at least 45 days to send it.

The Care Management Team will mail or fax a copy of the decision to the physician or provider and mail a copy to you.

Decisions are based on criteria that are available to you.

Decisions are based on whether the care or service is medically necessary, appropriate, effective or efficient, and if it is covered under your health plan.   

The criteria used to make a decision are available, upon request, at no cost to you and to your doctor. To get a copy of specific criteria, call toll-free 800-843-0719, extension 2092, or send your request in writing to Rocky Mountain Health Plans Care Management, 2775 Crossroads Blvd., Grand Junction, CO 81506.

We do not reward doctors or other individuals for issuing denials of coverage or care. RMHP offers no incentives for Pharmacy or UM decision makers to encourage decisions that result in underutilization.

Appeal Rights

In the event that coverage for a requested procedure, durable medical equipment, drug, or service is denied, a Member of the Care Management Team will call you and the physician or provider if the service has not already been received. You and the physician or provider will also receive a letter explaining the reason the request could not be approved. In the event of a denial of service, you have the right to appeal as outlined in your plan documents. Appeal information also will be included in the written notice.


NOTICE: Our Members and their medical providers decide what medical care Members receive and how they receive it. RMHP only determines what medical care will be covered or paid for under a Member’s health care plan. RMHP does not provide medical treatment or advice. We encourage you to talk to your doctor about any health concerns you may have. Medical providers are independent contractors, not employees or agents of RMHP.