Helpful Resources for Members

Helpful Resources for Members

At RMHP, we're committed to providing the quality of care that helps our Members live their healthy best. Below are some of the ways that RMHP maintains that quality, as well as additional resources to help you understand your health coverage.



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RMHP maintains our tradition and commitment by constantly looking for ways to improve the quality of care and level of service provided to our Members. We understand that health care is personal, and we take our responsibility for providing access to care very seriously. The objective of the RMHP Quality Improvement Program is to monitor, measure, and take effective actions on identified opportunities to improve the quality and safety of health care and services through the cycle of objective evaluation, intervention, and reevaluation. These activities are the summation of efforts by several departments including Quality Improvement, Care Management, Pharmacy, Provider Network Management, Customer Service, Health Promotions, Claims, Home Health, Member Administration, Marketing, Information Technologies, and effective professional peer review. Pertinent activities from all of these processes are reported and integrated into the QI Program.

Additional information about our Quality Improvement Program is available upon request by contacting Customer Service.

 

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Learn more about our QI standards

 

RMHP participates with the Colorado Immunization Information System (CIIS), Colorado’s immunization registry. CIIS is a secure, confidential, computer-based system used to keep track of statewide immunizations and is a part of the Colorado Department of Public Health and Environment. RMHP sends immunization data collected from claims to the registry.

One of the benefits of CIIS is that immunization data is stored in one place. If you have received shots from more than one provider, CIIS consolidates the information into one record. Your health care provider can access your record on CIIS and learn which shots you have had and which ones you need.

You may request copies of your immunization record or your child’s immunization record directly from the registry. If you do not want your information shared with the registry, you may choose to opt out of the system. Contact your health care provider for more information about opting out.

For more information, visit www.ColoradoIIS.com or call CIIS at 1-888-611-9918 (toll-free) or 303-692-2437.

Colorado Department of Public Health and Environment
Colorado Immunization Information System
DCEED-IMM-A3
4300 Cherry Creek Drive South
Denver, CO 80246

 

Our goal at RMHP is to make the preauthorization process as easy as possible for our Members. You can view a list of services that require preauthorization here or by calling Customer Service at 970-243-7050 / 800-346-4643. Your RMHP provider will submit a preauthorization request for you. You or your provider can submit a prior authorization request here 24 hours a day, 365 days a year. 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 preauthorization 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.

 

View prior authorization services
When RMHP makes benefit and medical necessity decisions that affect our Members,

 

  • We make our decision on whether the services or supplies are medically necessary, appropriate, effective, efficient, and are covered under your health plan;
  • We do not reward our decision makers for issuing denials of coverage; and
  • Financial incentives for utilization management reviewers do not encourage decisions that result in under-utilization.

 

There may be several parties involved in your care, including doctors, nurses, RMHP, and Members themselves. RMHP makes it a priority to have everyone involved work together to get you the care you need and deserve.

An important part of this is for you to follow up with your Primary Care Physicians after all appointments with specialists, emergency room visits, or admissions to a hospital. RMHP also recommends that specialists send summaries of recommendations to primary care providers, including medications prescribed. You can help by asking your specialist to send information about your visits to your PCP as soon as possible.

 

You may have questions about your health condition, and our Care Management team is here to get you the answers you need. While business hours are Monday - Friday from 8:00 a.m. to 5:00 p.m., you can call 24 hours a day, 7 days a week at 970-243-7050 (TTY:711) or toll free 800-346-4643 (TTY: 711). RMHP Care Management staff have password protected, confidential voice mail in order to receive inbound calls after normal business hours. For all Members who request language services, RMHP provides interpreter services, free of charge in the requested language.

You may also make arrangements in advance to speak to Care Management after normal business hours. If a message is left after hours, your call will be returned as soon as possible, but no later than within one business day. 


If needed, you may also fax Care Management at 970-254-5738 or toll free 877-201-7302. 

 

RMHP reviewers are the decisions makers and are available to discuss any Utilization Management decisions. You may call 800-854-4558 or 970-248-5036 or write to:

 

Rocky Mountain Health Plans
Attn: Preauthorization Department
PO Box 10600
Grand Junction, CO 81502-5600 

In the event of a denial of service, you have the right to appeal as outlined in your plan documents. Appeal information also will be included in the written notice.

NOTICE: Our Members and their medical providers decide what medical care Members receive and how they receive it. RMHP only determines what medical care will be covered or paid for under a Member's healthcare plan. RMHP does not provide medical treatment or advice. We encourage you to speak to your doctor about any health concerns you may have. Medical providers are independent contractors and are not employees or agents of RMHP.


Stay up-to-date on recent Formulary changes or additions, including new drugs and recent generics. View our Formulary updates, or contact us and we will mail you a copy of the latest update.

View Formulary updates

 

If your family doctor (general, family and internal medicine or pediatrics) is no longer in the RMHP network, or if you would like to make a change, RMHP can help you select a new doctor. We want to make sure you have the opportunity to choose another doctor from our network. If you have not already chosen a new primary care doctor, please review your provider directory, RMHP’s online directory, or call our Customer Service Department at 970-243-7050 / 800-346-4643 to have the directory sent to you. After you choose a doctor, please call Customer Service with your new doctor’s name, and you will be issued a new ID card. If you have any questions, please contact Customer Service.

 

RMHP Provider Search     Change your provider online

RMHP understands that there may be occasions where treatment may still be required from a doctor who has left the RMHP network. If you are pregnant and in your second or third trimester of pregnancy, we will allow you to continue seeing the same provider through the post-partum period.

 

RMHP will also approve, with prior authorization, continuation of treatment through the current period of active treatment, or for up to 90 calendar days (whichever is less), for Members undergoing active treatment for a chronic or acute medical condition. An active course of treatment typically involves regular visits with the practitioner to monitor the status of an illness or disorder, provide direct treatment, prescribe medication or other treatment, or modify a treatment protocol.

 

If your coverage of services ends while you still need care, RMHP has Case Managers available to provide education about alternatives for continuing care.  Our Case Managers can help transition your care and identify available resources within your local community that may be able to help you obtain and afford the costs of the needed care.  You may contact us at 970-243-7050 or toll free 800-346-4643 (TTY: 711) to speak to a Case Management nurse.

Our Members have: 

  • A right to receive information about Rocky Mountain Health Plans (RMHP), our services, our practitioners and providers and Member rights and responsibilities.
  • A right to be treated with respect and recognition of their dignity and their right to privacy.
  • A right to participate with practitioners in making decisions about their health care.
  • A right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
  • A right to voice complaints or appeals about RMHP or the care we provide.
  • A right to make recommendations regarding our Member rights and responsibilities policy.
  • A responsibility to supply information (to the extent possible) that RMHP and our practitioners and providers need in order to provide care.
  • A responsibility to follow plans and instructions for care that they have agreed to with their practitioner.
  •  A responsibility to understand their health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible. 


RMHP evaluates changes in medical equipment and services. New technology is constantly being developed, and this review determines if a new technology has been sufficiently tested to know when it is safe and effective to use and what a patient may reasonably expect from it.

The RMHP Medical Directors review the current evidence-based medicine decisions and scientific studies on the new technology. They consult with RMHP providers who specialize in the services or equipment being reviewed. The RMHP Medical Directors use all of this information to decide which services will be considered experimental and which are ready to be included as covered benefits. For the items that have been approved for use, the RMHP Medical Directors determine what the criteria will be for the new service or equipment based on their findings in the review.

The purpose of this rigorous review is to ensure RMHP Members receive services and equipment that are safe and can be expected to improve their health.

The list of experimental procedures does not include every experimental procedure, as new procedures are developed regularly. You can see what procedures are experimental below or by calling Customer Service at 800-346-4643. Rocky Mountain Health Plans reserves the right to change this list at any time without notice.  Rocky Mountain Health Plans does not guarantee that this list is complete or current.


View experimental procedures

 

RMHP respects the privacy of your protected health information. Our HIPAA Notice of Privacy Practices describes your rights and how medical information about you may be used or disclosed. To obtain a copy of our privacy practices, click here or contact us.

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