Prior Authorization

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:     800-262-2567  or  970-255-5681

eviCore healthCare:  800-792-8750

  • Genetic Testing (Molecular Diagnostics)
  • Diagnostic Imaging when the procedure will be performed outside of Delta or Montrose County and within Colorado.

Behavioral Health Services

  • Medicaid Members - Colorado Health Partnerships at 800-804-5008
  • Commercial, CHP+, and Medicare Members - Beacon Health 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, contact Customer Service.

RMHP Customer Service:

If you are hearing impaired and use TTY/TDD equipment, dial 711 for Relay Colorado.

Language Assistance is available for Members to discuss preauthorization issues. Call 800-874-9426.

Email: customer_service@rmhp.org


Health Care Plan
Hours
Phone Number
Commercial

8:00 A.M. to 5:00 P.M.  970-243-7050
Toll Free at 800-346-4643

Para asistencia en español llame al 800-346-4643
CHP+
8:00 A.M. to 5:00 P.M.  970-244-7960
Toll Free at 855-830-1563

Para asistencia en español llame al 855-830-1563
Medicaid
8:00 A.M. to 5:00 P.M.  970-244-7860
Toll Free at 888-282-8801

Para asistencia en español llame al 888-282-8801 
PERA Medicare
8:00 A.M. to 5:00 P.M.  970-244-7818
Toll Free at 888-281-0720

Para asistencia en español llame al 888-281-0720   
Medicare

8:00 A.M. to 5:00 P.M.  970-244-7912
Toll Free at 888-282-1420

Para asistencia en español llame al 888-282-1420 Toll Free at 888-282-1420



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

Decisions regarding prior authorization are made as quickly as possible. RMHP staff will tell you in writing exactly what services are approved.
Please plan on the following response turn-around times from us.

•    CHP+ 10 days
•    Commercial 15 days
•    Medicaid 10 days
•    Medicare 14 days

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.