Prior Authorization

Prior Authorization

At RMHP, our goal is to make the prior authorization process as easy as possible. Read on to learn more.

About Prior Authorization

 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. For RMHP RAE or RMHP Prime Members, providers should call 888-282-8801. 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, 2017.

Surgeries, procedures, tests
DME and medical supplies

How to Submit a Prior Authorization Request

For RMHP Commercial, Medicare, and CHP+ Members, providers may call 970-248-5031 or 800-641-8921 to speak to a representative. For RMHP RAE or RMHP Prime Members, providers should call 888-282-8801.  Once all required information is received, you will receive your authorization decision within 48 hours.

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

Prior Authorization for RMHP RAE & RMHP Prime Members

For RMHP RAE Member prior authorizations:

  • Prior authorization requests for behavioral health services are submitted to RMHP
  • Prior authorization requests for physical health services are submitted to ColoradoPAR following Health First Colorado rules.
    • All PARs processed by the ColoradoPAR program are submitted through the Colorado PAR web portal.
    • Providers can contact ColoradoPAR at 888-801-9355

For RMHP Prime Member prior authorizations:

  • Prior authorization requests  for behavioral health services are submitted to RMHP.
  • Prior authorization requests  for physical health services are submitted to RMHP.

For Prior Authorization requests, or any questions from Members/Providers about RMHP as the Region 1 RAE, call 888-282-8801.

Prior authorization is required for inpatient hospitalizations, partial hospitalizations, acute treatment units, short and long-term residential, day treatment, intensive outpatient programs, testing, and electroconvulsive therapy.

For Notifications by the Admitting Facility, call 888-282-8801.

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 prior authorization request to Optum for RMHP Commercial, Medicare, and CHP+ Members

  • Access the secure RMHP provider portal, accessRMHP, for outpatient authorization requests
  • Contact Optum at 855-886-2832 for hospital notification

Log into accessRMHP

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.

To view Utilization Management criteria used by Optum, please refer to these policies.

Prior authorization request forms for Non-Contracted Providers only

Surgeries, procedures, tests

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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 for RMHP Commercial, Medicare, and CHP+ Members must be phoned to Optum at 855-886-2832. This includes Acute Inpatient Psych; Inpatient Detox; Observation; Residential Treatment; Structured Outpatient/IOP; Partial Hospitalization; and Outpatient Detox. For notification of RMHP RAE or RMHP Prime Members, providers should call 888-282-8801.

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.