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Understanding Prior Authorization

Understanding Prior Authorization

At RMHP, we want to help you get the care that’s right for you, when you need it. Certain health care procedures, services, equipment and/or medications require approval from RMHP before you receive them. This is called prior authorization.

How Does Prior Authorization Work?

When you see a participating provider, your doctor obtains the necessary prior authorization for you. For services provided by a non-participating provider, it is your responsibility to start the prior authorization process. If you do not receive prior authorization for your care, you will not receive your maximum benefits as stated in your Member materials.

If your provider participates with RMHP, they can submit a prior authorization request 24 hours a day, 365 days a year through the secure RMHP provider portal. If you are on a PPO plan and receive services from a provider who is not part of the RMHP network, you will be responsible for submitting the prior authorization request yourself by faxing it to 800-262-2567 or 970-255-5681. Please call RMHP’s Customer Service for additional help in understanding or getting prior authorization.

To ensure your prior authorization request is completed in a timely manner, please allow:

Medicaid Medicare CHP+ Commercial
10 days 14 days 10 days 5 days

 

What Services or Equipment Require Prior Authorization?

You can view a list of services and durable medical equipment (DME) that require prior authorization by downloading the lists below or by contacting RMHP Customer Service. Information about prior authorization can also be found in your plan documents. Please note, these prior authorization lists are updated periodically and are subject to change.

Download list of services requiring prior authorization

Download list of DME requiring prior authorization

Download notification of admission to a facility document

What Criteria is Used for Making Prior Authorization Decisions?

RMHP considers your medical needs using criteria based on scientific evidence to make these decisions. An RMHP Medical Director or Registered Pharmacist reviews all requests that do not meet these criteria. The Medical Director consults as needed with specialists experienced in the type of care you requested.

The criteria used to make a decision are available, upon request, at no cost to you or your provider. If you have any questions or would like to request documentation, please contact RMHP Customer Service at 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
Attn: Care Management
2775 Crossroads Blvd.
Grand Junction, CO 81506

RMHP criteria for medical services and DME can be found by accessing the MCG Health tool. Please note, you will need to create a password and log in to access this tool.

Access the MCG Health tool

For some types of prior authorization, RMHP works with other organizations who review these requests for us. You can view the criteria used by selecting the below links. Please note, by selecting these links, you will be leaving rmhp.org.

View criteria used by eviCore healthCare

View criteria used by Optum