Preauthorization Requirements
Preauthorization guidelines and downloadable forms are available below, for medical and pharmacy.
MEDICAL
The Rocky Mountain Health Plans preauthorization process helps members get the most successful health care treatment possible through:
- the right care
- from the right provider
- at the right time
- in the right setting
The treating doctor is responsible to ask for authorization for certain tests and treatments. RMHP staff will tell you in writing exactly what services are approved. Call RMHP Customer Service at 970-248-5036 or 800-854-4558 to ask about the preauthorization process or to get benefit quotations.
Some services that may require preauthorization are:
- Hospital or other facility admissions
- Home Health services
- Durable Medical Equipment
- Diagnostic tests such as PET scans
- Services from a non-participating provider
Click here to see the list of services requiring preauthorization. Click here to see the list of durable medical equipment and medical supplies that require preauthorization.
IMPORTANT:
The preauthorization list is updated periodically and subject to change. Failure to get preauthorization may result in nonpayment for the services, and the member cannot be balance billed.
How to Submit a Preauthorization Request
- Fax preauthorization requests as soon as you are aware the member requires services that need to be preauthorized. Fax to 877-201-7302.
- Also fax clinical notes with the request for review.
- If you are directing a member to a noncontracted provider, submit a request for authorization before any service is provided.
- The forms for requesting preauthorization must have all required fields completed, including applicable ICD, CPT, and/or HCPC codes.
Medical Preauthorization Forms
Click on the links below to download preauthorization request forms:
Preauthorization Request Form (*Pharmacy preauthorizations must be completed on the appropriate, medication-specific PA Form below or they will not be processed)
Home Health Authorization Form
DME Authorization Form
Notification of Admission
The admitting facility is responsible to notify RMHP of an inpatient or observation admission within twenty four (24) hours of admission, unless a weekend or holiday is involved, in which case notification must occur the first business day following the weekend or holiday.
Behavioral Health
Prior to September 1, 2005, members who reside on the Front Range receive behavioral health care services from providers and facilities contracted with Horizon Behavioral Services. Contact Horizon Behavioral Health at 800-466-1120 to arrange for services for these members or to discuss claims payment issues for services rendered prior to September 1, 2005.
Effective September 1, 2005, members who reside on the Front Range receive behavioral health care services from providers and facilities contracted with Life Strategies. Contact Life Strategies at 800-716-1166 to arrange for services for these members or to discuss claims payment issues for services rendered after August 31, 2005.
Members who reside on the Western Slope receive behavioral health services from providers and facilities contracted with RMHP. Contact RMHP Customer Service at 970-248-5036 or 800-854-4558.