Resources for Providers

Resources for Providers

The people at Rocky Mountain Health Plans value our relationship with our providers. That's why we work to provide you the tools and resources you need to deliver covered healthcare services to our Members. Find information below about some important topics, as well as access to commonly used forms.


Forms

Find the forms and documents you need quickly and easily by viewing the Commonly Used Forms page.

Common Forms for Providers


Publications for Providers

Find publications with helpful information in one convenient location. View editions of RMHP's Provider Newsletter, Prudent Prescriber Newsletters, and PharamSuitables on the Publications for Providers page.

Publications for Providers

Prior Authorization

Our goal at 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 healthcare 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 non-contracted provider, please submit a request for authorization prior to any service being performed.
Please contact RMHP Customer Service Monday - Friday, 8:00 a.m. to 5:00 p.m. at 970-248-5036 or 800-854-4558 (TTY: 711) for questions about the prior authorization process or to receive benefit quotations.

Email Customer Service

Staff can receive inbound communication regarding prior authorization issues after normal business hours by emailing CMresearchteam@rmhp.org, or by calling our prior authorization line at 970-248-8718 or 800-793-1339. Please leave a voice mail for a return phone call.

Prior authorization lists are updated periodically and are subject to change.

Prior authorization lists, effective October 1, 2016.

Surgeries, procedures, tests
DME and medical supplies

 

How to Submit a Prior Authorization Request

Prior authorization must be requested online through the secure Provider Portal by completing information about your patient's condition to receive an immediate response regarding approval or denial. Telephone submission may also be available, as below.

Log in to the provider portal
Instructions for website registration
Online prior auth training manual
Training webinar


To submit a request to eviCore healthCare

  •  Advanced imaging procedures performed outside of Delta or Montrose County and within Colorado must be made through eviCore healthCare online.
  • Genetic testing must be submitted through eviCore healthCare online.

eviCore healthCare website
By clicking this link, you will be leaving the RMHP website. For additional information access the RMHP Lab Quick Reference Guide.

To submit a behavioral health service request to Beacon Health Options

  • Contact Beacon Health Options at 855-886-2832
  • Submit online at ProviderConnect. Providers not already registered for ProviderConnect should register today. By clicking these links, you will be leaving the RMHP website.

Register for ProviderConnect
Log in to ProviderConnect

Criteria

RMHP considers the Member's medical needs using criteria based on scientific evidence to make utilization management decisions. An RMHP 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 receive a copy of specific criteria, call 800-834-0719, fax your request to 800-262-2567 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 eviCore healthCare can be accessed using this guide.

View radiology criteria used by eviCore healthCare here.

Access criteria used by Beacon Health Options here.

Prior authorization request forms for Non-Contracted Providers only

Surgeries, procedures, tests
English   Español
DME and medical supplies

Prior authorization response times from RMHP

Decisions regarding prior authorization are made as quickly as possible. RMHP staff will inform you in writing the exact approved services.
Please anticipate the following response turn-around times from us:

Medicaid          10 days

Medicare          14 days

CHP+                  10 days

Commercial    15 days

Notification of Admission

The participating admitting facility is responsible to notify RMHP of an inpatient admission within 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 phoned to Beacon Health Options at 855-886-2832. This includes Acute Inpatient Psych; Inpatient Detox; Observation; Residential Treatment; Structured Outpatient/IOP; Partial Hospitalization; and Outpatient Detox.

Notification of transfer to another facility must be approved prior to the transfer.

When admitted out-of-network, the Member is responsible for notification to RMHP of an admission or transfer.

Prior Authorization for Pharmacy

RMHP covers a wide variety of medications. The RMHP Formulary Guidelines include information about RMHP drug coverage. RMHP drug coverage is determined with active participation from the RMHP physician/pharmacist committee (Pharmacy and Therapeutics Committee).

RMHP Outpatient Formulary Guidelines:

  • Include the coverage level for drugs (whether prior authorization is required, copayment tier, quantity limits, etc.)
  • Encourage the use of appropriate generic drugs
  • Are updated monthly
View our Formularies
View Formulary changes for Commercial and Medicaid Formularies
View Formulary changes for Medicare Part D Formularies

Certain drugs must be prior authorized by the Pharmacy Department. To request prior authorization, submit the online request form below, or download and complete the appropriate prior authorization drug request form. For Commercial and Medicaid members, fax the completed form to RMHP at 858-357-2538. For Part D members, send the fax to 858-790-7100. To speak to a representative call 970-248-5031 or 800-641-8921. Once all required information is received, you will receive your authorization decision within 48 hours.

Submit a prior authorization request online
Commercial & Medicaid prior auth drug list
Medicare Part D drugs prior authorization list
Commercial and Medicaid Drugs requiring Step Therapy
Medicare Prescription Drugs requiring Step Therapy
View Printable Commercial & Medicaid Prior Auth Drugs
View Printable Medicare Part B Prior Auth Drugs

 

Important Information


Communication

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.

Affirmative Statement

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.

Electronic Data Interchange - EDI

We make it easy for you to submit insurance claims—and to get reimbursed quickly. You can submit claims electronically from your practice or clearinghouse. With each interaction, you receive remittance advice and acknowledgement that your claim has been filed. Once we receive your claim, we will process it as quickly as possible.

EDI Clearinghouses

We accept submissions from most major clearinghouses.

  • ClaimLogic
  • Cortex EDI
  • CPSI
  • Healthcare Administration Technologies, Inc.
  • McKeson (also known as Relay Health)
  • Navicure
  • NDCHealth (also known as Relay health)
  • Practice Insight
  • QuadraMed (also known as Health Fusion)
  • The SSI Group
  • ViaTrack Systems
Email your EDI representative