Frequently Asked Questions for Providers

Frequently Asked Questions for Providers

Do you have questions about RMHP? We've compiled the answers to some of our most commonly asked questions so you can find the answers you're looking for. If you have other questions, please contact us; we're happy to help.

Behavioral Health

No. All non-emergent services provided by out-of-network behavioral health providers must be authorized prior to the service being provided.

Yes.  Optum provides behavioral health and utilization management services for RMHP Commercial, Medicare, and CHP+ Members. Effective July 1, 2018, RMHP is also responsible for connecting Health First Colorado Members with both primary care and behavioral health services as the Region 1 RAE.  The services previously performed by the regional Behavioral Health Organization (BHO), including managing covered services under the Medicaid Capitated Behavioral Health Benefit, are now included in the RMHP RAE. The term BHO will no longer be used. To learn more about RMHP RAE behavioral health services, please review the RMHP RAE Behavioral Health Guide.

Read the Guide

For RMHP Commercial, Medicare, and CHP+ Members, providers can reach Optum’s behavioral health clinicians by calling 855-886-2832.  For RMHP RAE or RMHP Prime Members, please call 888-282-8801. Licensed clinicians are available 24/7, 365 days per year.

Licensed clinicians are available 24/7, 365 days per year.

Outpatient authorization requests may be submitted through the secure RMHP provider portal, accessRMHP. For hospital notification, please call 855-886-2832.

Log in to accessRMHP

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 learn more about behavioral health prior authorization and the RMHP RAE, please review the RMHP RAE Behavioral Health Guide.

Read the Guide

The Optum criteria and RMHP guidelines/policies are reviewed and updated at least annually by the Chief Clinical Officer and Associate Medical Directors. RMHP involves appropriate, licensed practitioners with professional knowledge of clinical expertise in the relevant area when developing, adopting, and reviewing clinical policies used by RMHP or delegated entities in care management decision-making.

Review the levels of care

 

For Commercial, Medicare, and CHP+ Members, please submit claims directly to RMHP, filing electronically or by paper.

Submission of claims for RMHP RAE Covered Services

Effective July 1, 2018, RMHP is responsible for the behavioral health services historically covered under the Behavioral Health Organization. For RAE Members also enrolled with RMHP in RMHP Prime, RMHP continues responsibility for covering pharmacy and medical claims for RMHP Prime Members.

Below is where RMHP Members’ claims should be sent.

For RMHP RAE Members:

  • Behavioral health claims are submitted to RMHP.
  • Physical health claims are submitted to DXC, the fiscal agent for the Department.

For RMHP Prime Members:

  •  Behavioral health claims are submitted to RMHP.
  • Physical health claims are submitted to RMHP.

For services covered by RMHP, including behavioral health services for RMHP RAE Members, and medical services for RMHP Prime Members, providers familiar with submitting claims to RMHP should continue to submit claims to RMHP following standard RMHP policies and procedures.

To learn more about behavioral health claims submission and the RMHP RAE, please review the RMHP RAE Behavioral Health Guide.

Read the Guide

RMHP’s provider manual also includes more information to providers about how to bill RMHP for services.

Claims

We accept claims via mail, fax, or electronically. Simply complete the form and return it to us. Once we receive it, we’ll work quickly to process your claim.

Submission of claims for RMHP RAE Covered Services

Effective July 1, 2018, RMHP is responsible for the behavioral health services historically covered under the Behavioral Health Organization. For RAE Members also enrolled with RMHP in RMHP Prime, RMHP continues responsibility for covering pharmacy and medical claims for RMHP Prime Members.

For Health First Colorado services covered by RMHP, including behavioral health services for RMHP RAE Members, and medical services for RMHP Prime Members, providers familiar with submitting claims to RMHP should continue to submit claims to RMHP following standard RMHP policies and procedures.
RMHP’s provider manual also includes more information to providers about how to bill RMHP for services.

Submission of Medical Claims for RAE Members Not Enrolled in RMHP Prime

Claims for RAE Members who are not enrolled in RMHP Prime should be created and submitted to DXC, the fiscal agent for the Department.

Wraparound Services

Certain wrap-around services should continue to be billed to Health First Colorado or a Department-contracted vendor following Health First Colorado rules and regulations. These wrap-around services include, but are not limited to: most dental services, long term care services, non-emergent medical transportation, and hospice care. More information about these wrap-around services is available in RMHP’s provider manual.

Please contact your RMHP Provider Relations Representative with any questions about submitting claims.

Download a claim form

Check the status of a claim at any time by logging into your provider portal. You may also contact us during normal business hours for assistance.

Log in to your provider portal

Coverage

No. We believe the decision of which specialists may be needed should be one between you and your patients. Referrals are not required.

You can verify your patient's eligibility by logging into your provider portal and searching for your patient’s information online, or you can call Customer Service.

To confirm a the eligibility of a RAE Member, we encourage you to use the system available through the State of Colorado, the Colorado interChange.  A user name and password is required. The State’s interChange is updated in “real time” and serves as the most accurate method for determining eligibility. Documentation relating to eligibility verification for Members enrolled in the Health First Colorado Accountable Care Collaborative, including RAE Members and RAE Members also enrolled in RMHP Prime, should be retained by the RMHP network provider. These documents will be required to support a provider appeal if a claim is denied due to patient eligibility and enrollment status. If the State retroactively adjusts eligibility, claims payment may be retracted if you are unable to demonstrate eligibility was verified at the time of service.

Access the Colordao interChange

If you have questions, we’re happy to help.

Log in to your portal     Contact Customer Service

Yes, for certain procedures. We do everything we can to make this process straightforward.

View services requiring preauthorization  Download Preauthorization Form

For services covered by the State, rather than by RMHP, for RAE Members, requests are submitted to the ColoradPAR Program following Health First Colorado rules. All PARs processed by the ColoradoPAR portal.

Learn more about ColoradoPAR

Network of Care

Below are general guidelines; however, you may always contact Customer Service with any questions.

Participating Providers

Medicare Part A plans
(HMO Standard, Value or Gold)
Bill Medicare first

Medicare Part B plans
Bill RMHP first

Non-Participating Providers

Medicare Part A plans
(HMO Standard, Value or Gold)

Bill Medicare first

Medicare Part B plans
Bill Medicare first

Once you file with Medicare, please file the claim with us as well so we can apply appropriate coinsurance and deductibles.

Commercial Plans

For patients with Medicare coverage through a commercial plan, Medicare may or may not be billed first.  It is best to contact Customer Service in these circumstances.  They will review the plan and advise the best way to file the claim.

Yes. We work exclusively with some providers and others give our Members discounts.  When referring your patients, keep these providers in mind.

Chiropractic
EviCore Healthcare Colorado, Inc. (exclusive provider)

Outpatient therapy
Theraphysics (exclusive provider)

Vision
UnitedHealthcare (Commercial Members) and VSP (Medicare Members)

Acupuncture
American Specialty Health Networks

Dental
UnitedHealthcare (Commercial & Medicare Members)

Regional Accountable Entity (RAE)

In October 2017, the Colorado Department of Health Care Policy and Financing (Department) awarded RMHP the contract to serve as the RAE for Region 1 of the Health First Colorado Accountable Care Collaborative (ACC), effective July 1, 2018.

As the RAE, RMHP is responsible for connecting Health First Colorado Members with both primary care and behavioral health services for Region 1, which includes Western Colorado and Larimer County. This builds upon our foundation of our previous services as a Regional Care Collaborative Organization (RCCO), growing our community-oriented approach for Health First Colorado Members as RMHP Community.

The RAE (pronounced “RAY”) for Region 1 includes:
  • the services previously performed by RMHP as the Regional Care Collaborative Organization (RCCO), including the primary care medical provider network and care coordination services;
  • the services previously performed by the regional Behavioral Health Organization (BHO), including managing covered services under the Medicaid Capitated Behavioral Health Benefit;
  • the Western Colorado payment reform initiative known as RMHP Prime; and
  • additional services to support whole person care, including activities to address social determinants of health.

With the transition to the RAE, the terms RCCO and BHO will no longer be used.

Learn more about the RAE

Yes. Similar to historical RCCO and RMHP Prime payments, primary care practices can provide services to Health First Colorado Members and receive fee-for-service reimbursement, even if the Member is not attributed to the practice. The Department’s established fee schedule applies.

The Department now allows and encourages the provision of up to six sessions of short-term behavioral health services in a primary care setting per episode of care. These short-term behavioral health services must be provided by a licensed behavioral health provider. The services will be reimbursed Fee-for-Service as a Health First Colorado covered physical health benefit when billed by a primary care provider. If it is necessary to provide more than six behavioral health visits, the visits will be reimbursed from the Capitated Behavioral Health Benefit. Services beyond the six sessions within a primary care practice for RMHP RAE Members require RMHP prior authorization.

  • RMHP will serve as a central point of contact regarding Health First Colorado services and programs, regional resources, clinical tools, and general administrative information.
  • RMHP will support providers that are interested in integrating primary care and behavioral health services; addressing social determinants of health; enhancing the delivery of team-based care by leveraging all staff and incorporating patient navigators, peers, promotoras, and other lay health workers; advancing business practices and use of health technologies; participating in APM; and other activities designed to improve Member health and experience of care.
  • RMHP will offer general information and administrative support, provider training, data systems and technology support, practice transformation, and financial support.

RMHP is implementing a value-based payment model for all participating RAE Region 1 PCMPs. This payment model outlines a clear delineation of provider responsibilities as well as resources available for different levels of accountability. The levels of participation and accountability, identified as Tiers 1-4, reflect this effort to align payment with activities that lead to better patient outcomes and mitigate against growing costs and limited resources.

Provider payments for RAE Region 1 Members are as follows:

  • RMHP maintains the PCMP network and an advanced payment model. PCMP medical home payments are paid at a minimum $2 per member per month.
  • Physical healthcare claims for RAE Members continue to be paid by the Department.
  • Behavioral healthcare services covered under the behavioral health capitation benefit for RAE Region 1 Members are paid by RMHP.
  • For RAE Members enrolled in the Health First Colorado payment reform initiative known as RMHP Prime, primary care practices continue under an RMHP Prime advanced payment model. Physical healthcare services and behavioral healthcare services are paid by RMHP.

Learn more about this payment model by viewing the RMHP RAE Orientation Guide, or contact your RMHP Provider Relations Representative.


Read the guide
  • All Region 1 PCMPs currently participating with RMHP have the opportunity to continue as a PCMP with RMHP as the RAE for Region 1 provided they remain actively enrolled as a Health First Colorado provider. At a minimum, all PCMPs will participate as a Tier 4 participating provider. Providers have the option to participate at a higher tier level by completing an attestation process.
  • PCMPs that have a practice site in Region 1 and are not yet participating with RMHP should sign a participating agreement with RMHP. Practices and/or practice sites must complete the Health First Colorado validation process prior to signing an RMHP RAE participating agreement.
  • Behavioral health providers that wish to participate with RMHP must complete RMHP’s standard credentialing process and agree to accept RMHP’s RAE fee schedule agreement to be a participating RMHP RAE provider. Current RMHP credentialed providers are not required to complete additional credentialing by RMHP; however, they must agree to accept RMHP’s RAE fee schedule agreement to be a participating RMHP RAE provider.

Value-Based Payment

RMHP is dedicated to strengthening primary care. We reward high-quality, high-value care and reimburse through a payment structure designed to achieve better care, more efficient spending, and healthier communities.

We are committed to supporting and continuing these value-based payments. We understand that healthcare is complex and resources may be limited. Our strategy is designed to provide maximum resources to the practices that assume the highest level of accountability for whole person care and that provide the highest level of access for RMHP Members.