Prior Authorization for Surgeries, Procedures, Tests, Equipment and Supplies
Our goal at Rocky Mountain Health Plans (RMHP) is to make the prior authorization process as easy as possible. We will review your request to:
- Determine if the treatment or service is covered by a Member's health plan
- Consider whether it is the right care, at the right time, from the right health care practitioner or provider.
- Compare the Member's medical needs to criteria based on scientific evidence to make decisions.
Prior authorization must be requested and review completed before the service is performed. Failure to get prior authorization will result in nonpayment for services, and the Member cannot be balance billed.
If you are directing a Member to a noncontracted provider, submit a request for authorization before any service is performed.
Call RMHP Customer Service at 970-248-5036 or 800-854-4558 to ask about the prior authorization process or to get benefit quotations.
Hours: Monday - Friday, 8:00 a.m. to 5:00 p.m.
If you are hearing impaired and use TTY equipment, call 711.
Language assistance is available by calling 800-874-9426.
Staff can receive inbound communication regarding preauthorization issues after normal business hours by email to CMresearchteam@rmhp.org or leave a voice mail on our preauthorization line – 970-248-8718 or toll free 811-793-1339.
Prior authorization lists are updated periodically and are subject to change.
Prior authorization lists, effective:
Surgeries, Procedures, Tests (for use starting 10/1/2015)
Durable Medical Equipment and Medical Supplies (for use starting 10/1/2015)
How to Submit a Prior Authorization Request
To submit request to RMHP
Instructions for registering your office for website use
Training manual for Online Preauthorization
Training Webinar recorded for training
Request prior authorization on-line by answering a few questions regarding your patient's condition and obtain an immediate response regarding approval or denial. Telephone submission may also be available, as below.
- Submit requests on-line at access|RMHP Provider Portal. If you haven't received training, log in to learn how to sign up.
To submit request to CareCore National, LLC, d/b/a eviCore healthCare
- Advanced imaging procedures performed outside of Delta or Montrose County and within Colorado, must be made through CareCore National, LLC, d/b/a eviCore healthCare online at www.carecorenational.com or by telephone 800-792-8750. By clicking this link, you will be leaving the RMHP website.
- Genetic testing must be submitted through CareCore National, LLC, d/b/a eviCore healthCare online at www.carecorenational.com or by telephone 800-792-8750. By clicking this link, you will be leaving the RMHP website. For additional information access the RMHP Lab Quick Reference Guide.
To submit request to Value Options
- Behavioral Health Service requests: Contact Value Options at 855-886-2832 or submit on-line at ProviderConnect. Providers not already registered for ProviderConnect should register today. By clicking this link, you will be leaving the RMHP website.
RMHP considers the Member's medical needs using criteria based on scientific evidence to make utilization management decisions. A Rocky Mountain Medical Director or Registered Pharmacist reviews all requests that do not meet these criteria. The Medical Director consults as needed with specialist physicians experienced in the type of care you requested.
The criteria used to make a decision are available, upon request, at no cost to the Member, practitioner, or provider. To get a copy of specific criteria, call toll-free 800-834-0719, fax your request to 800-834-0719 or 970-255-5681, or send your request in writing to Rocky Mountain Health Plans Care Management, 2775 Crossroads Blvd., Grand Junction, CO 81506.
Genetic testing criteria used by CareCore National, LLC can be accessed at Rocky Mountain Health Plan Lab Management Criteria.
Radiology criteria used by CareCore National, LLC can be accessed at Rocky Mountain Health Plan.
Criteria used by Value Options can be accessed by clicking here.
Prior authorization request forms for Non-Contracted Providers only
Surgeries, procedures, tests English
| Español Durable Medical Supplies and Medical Supplies Prior authorization response times from RMHP
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.
Notification of Admission
The participating admitting facility is responsible to notify RMHP of an inpatient admission within twenty four (24) hours of admission. If a weekend or holiday is involved, then notification must occur the first business day following the weekend or holiday.
Notification of behavioral healthcare admissions must be called to Value Options 855-886-2832 starting 7/1/2014. This includes Acute Inpatient Psych; Inpatient Detox; Observation; Residential Treatment; Structured Outpatient/IOP; Partial Hospitalization; Outpatient Detox.
Notification of transfer to another facility must be approved prior to the transfer.
When admitted out of network, the Member is responsible to notify RMHP of an admission or transfer.
RMHP staff is available during normal business hours Monday through Friday, 8:00 a.m. to 5:00 p.m. for calls, faxes and secure e-mails including Care Management (CM) issues. You may also arrange in advance to speak to Care Management staff after normal business hours by calling your provider relations representative at 970-248-5036.
RMHP CM staff have password protected, confidential voice mailboxes to receive inbound calls after normal business hours. Calls will be returned as soon as possible but no later than one business day.
Coordination of Care
RMHP strongly encourages Primary Care Physicians to follow up with your patients after all specialist visits or episodes of care.
RMHP strongly encourages specialists to send summaries of recommendations to your patients’ primary care providers, including medications prescribed.
RMHP decision making is based only on the benefit structure and appropriateness of care and services. RMHP does not offer incentives to encourage inappropriate under-utilization or reward providers for issuing denials.