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The following is a summary of Colorado Access' authorization rules and does not guarantee coverage. Additional information can be obtained through:

Prior Authorization – Facility-Based Behavioral Health Care (revised 09/2016)

Access to the Authorization List requires a Colorado Access username and password. If you do not have a Colorado Access username and password, you can request one here or Calling Coordinated Clinical Services at (720) 744-5100, toll free 1-800-511-5010

NOTE: For those services that require authorization, failure to request authorization within the timelines noted below will result in an administrative denial.

Participating vs. Non-Participating Providers
In general, all services rendered by non-participating providers require prior authorization for payment except where specifically noted in the rules below.

Submitting an Authorization Request

Some services require prior authorization in order to obtain payment. Refer to the list below under General Authorization Rules and the Colorado Access Authorization List* for detailed information. It is best to plan ahead and submit an authorization request well in advance of the service being rendered. Authorization requests are processed as expeditiously as the enrollee's health condition requires, but no later than 14 calendar days after the date the request was received at Colorado Access.

Colorado Access cannot retrospectively deny benefits for treatments that have been pre-authorized except in cases of fraud, abuse, or if the member loses eligibility.

Steps for Requesting an Authorization

  1. Verify the member's eligibility via our website or by calling our Customer Service Department.
  2. Fax the completed Service Authorization Form to our Coordinated Clinical Services (CCS) Department at:
    • (303) 755-4135 or 1-877-232-5976 for physical health authorizations
    • (720) 744-5127 for pharmacy authorizations
    • (720) 744-5130 for behavioral health authorizations
      NOTE: Required fields are indicated by bold face type. Incomplete forms will not be accepted, and will be returned to the sender.
  3. You will be notified if additional information is needed, if the service is authorized, or if services will not be authorized
  4. If you have questions or need assistance with an authorization please call our Customer Service Department

General Authorization Rules

Participating vs. Non-Participating Providers:

In general, all services rendered by non-participating providers require prior authorization for payment by Colorado Access except where specifically noted in the rules below.

Specialists Referrals

Specialty office visits for participating specialty providers do not require a referral to be submitted to Colorado Access from the member's Primary Care Provider. Colorado Access encourages PCPs to direct care for specialty office-based care through clinical referrals. Colorado Access considers a clinical referral to be communication between the PCP and the specialty provider for the purposes of care continuity and treatment planning. Office visits for non-participating specialists do require a prior authorization from Colorado Access and will be considered on a case-by-case basis for particular clinical needs.

Note: Certain services, such as visits with physical, occupational and speech therapists require authorization. Please read the General Authorization Rules listed below for more information.

Primary Care:

Services provided by participating PCP's do not require prior authorization.

Inpatient Care:

All inpatient care (place of service 21) requires prior authorization at a facility level. Professional services and ancillary services rendered during an inpatient stay are considered downstream and do not require separate authorization for both participating and non-participating providers. Initial authorization and concurrent review determinations are based on medical necessity as determined by InterQual© criteria.

Emergency and Urgent Care:

Emergency services (place of service 23) and urgent care services (place of service 20) do not require prior authorization if the service would be considered urgent or emergent as determined by a prudent layperson.

Ambulance:

Emergency ground or air ambulance transport does not require prior authorization. Scheduled ambulance transport from facility to facility is covered, but does require prior authorization.

Outpatient Hospital / Ambulatory Surgery:

Procedures that are performed in an outpatient hospital (place of service 22) or ambulatory surgery center (place of service 24) may require prior authorization for the professional services. Refer to the Colorado Access authorization list* to determine whether a procedure requires authorization. Facility and ancillary services are considered downstream to the procedure and do not require separate authorization for payment. Authorization for procedures is based on medical necessity as determined by InterQual© criteria.

Women's Health / OB/GYN Services:

OB/GYN office-based services do not require referral or prior authorization for participating providers. Certain facility-based procedures may require prior authorization. Refer to the Colorado Access authorization list* to determine whether a procedure requires authorization. Family planning services do not require prior authorization or referral for any provider, both participating and non-participating.

Diagnostic Services:

Routine laboratory and imaging services do not require prior authorization. Specialized diagnostic procedures may require prior authorization. Refer to the Colorado Access authorization list* to determine whether a diagnostic procedure requires authorization.

Diagnostic Interpretation Services:

Interpretation of diagnostic services, usually indicated by modifier 26, does not require prior authorization for participating providers.

Routine Vision Care:

Routine vision services do not require prior authorization. Certain specialty procedures may require prior authorization. Refer to the Colorado Access authorization list* to determine whether a procedure requires authorization.

Observation Services:

Observation stays at any facility 48 hours or less do not require an authorization.

If the observation stay converts to an inpatient stay, the facility will need to contact the Coordinated Clinical Services department within 1 business day to notify of the inpatient stay and initiate the review process. You can contact Coordinated Clinical Services at (720) 744-5100, toll free 1-800-511-5010 or by fax at 1-877-232-5976. Note: The inpatient stay admission date will be the date the patient presented in the facility emergency room.

Home Health Care:

All home health care services require prior authorization.

Durable Medical Equipment (DME):

Durable medical equipment may require prior authorization. In general, basic equipment and supplies or equipment that is ancillary to other procedures do not require prior authorization. Enhanced or specialty equipment or supplies generally require prior authorization. Refer to the Colorado Access authorization list* to determine whether a supply item or piece of equipment requires authorization.

Therapy:

All physical, occupational and speech therapy require prior authorization. Refer to the Colorado Access authorization list* to determine whether a therapy requires authorization.

Pharmacy:

Certain injectable medications require prior authorization. Refer to the Colorado Access authorization list* to determine whether an injectable medication requires authorization.

Retail pharmacy drugs are managed by formulary. Certain formulary drugs may be preferred agents or may require prior authorization. Refer to the Colorado Access formulary located in the Pharmacy Services section of this website for more information.

* The Colorado Access authorization list opens in a new window and requires a provider logon ID. If you do not have a provider logon ID, click here for a PDF of the Provider Logon ID Request Form.

 

Y0111_00618_CMS Approved 02022015

Last Revised: 09302014

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