Prior Authorization for Surgeries, Procedures, Tests, Equipment and Supplies
Our goal at Rocky Mountain Health Plans (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 health care practitioner or provider.
- Compare the Member's medical needs to criteria based on scientific evidence to make decisions.
Prior authorization must be requested 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 noncontracted provider, submit a request for authorization before any service is performed.
Call RMHP Customer Service at 970-248-5036 or 800-854-4558 to ask about the prior authorization process or to get benefit quotations.
Prior authorization lists, effective:
Surgeries, Procedures, Tests (Use for Services as of 7/1/2013)
Durable Medical Equipment and Medical Supplies (Use for Services as of 7/1/2013)
Durable Medical Equipment and Medical Supplies (Use for Services as of 1/1/2014)
DME Category Identification List
NOTE: RMHP Commercial Plan Members enrolling or renewing coverage January 1, 2014 and after will have new coverage for DME. Prior authorization requirements and coverage guidelines apply.
Category A – Up to four (4) units per calendar year OR Category B – One (1) unit per calendar year.
The category and the number of units assigned to each item can be found on the DME Category Identification List. This limit does not apply to oxygen, oxygen equipment, or breast pumps. The category assigned to an item may vary, based on the specific model or type of an item or if it is new or used equipment that is being purchased. Customer Service Representatives are available to provide the category for a specific item. Please have the HCPCS code, including modifiers and the name of the item available when you call.
You or your DME provider can contact RMHP Customer Service:
Hours: Monday – Friday, 8:00 A.M. to 5:00 P.M.
Phone Number: 970-243-7050 or 800-346-4643.
If you are hearing impaired and use TTY equipment, call 711.
Prior authorization lists are updated periodically and are subject to change.
How to Submit a Prior Authorization Request
Fax your completed form and clinical notes to 877-201-7302 or 970-245-5782 except:
Prior authorization request forms Surgeries, procedures, tests
- Behavioral Health Service requests must be made through Life Strategies at 800-283-6871
- Advanced imaging procedures performed outside of Delta, Montezuma, or Montrose County and within Colorado, must be made through CareCore National. Telephone- 800-792-8750, Fax- 800-540-2406. Alternatively, you can submit your request online at www.carecorenational.com. By clicking this link, you will be leaving the RMHP website.
) Home Health Services Durable Medical Supplies and Medical Supplies Prior authorization response times from RMHP
Decisions regarding prior authorization are made as quickly as possible. RMHP staff will tell you in writing exactly what services are approved.
Please plan on the following response turn-around times from us.
Notification of Admission
The participating admitting facility is responsible to notify RMHP of an inpatient admission within twenty four (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 transfer to another facility must be approved prior to the transfer.
When admitted out of network, the Member is responsible to notify RMHP of an admission or transfer.
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.
RMHP considers the Member's medical needs using criteria based on scientific evidence to make utilization management decisions. A Rocky Mountain 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 get a copy of specific criteria, call toll-free 800-843-0719, fax your request to 970-244-7828, or send your request in writing to Rocky Mountain Health Plans Care Management, 2775 Crossroads Blvd., Grand Junction, CO 81506.
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.