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Utilization Management & Authorizations

Learn about our prior authorization requirements for physical and behavioral health.

Authorizations

 

We strive to make the prior authorization process as easy as possible for you. The following is a summary of our authorization rules and does not guarantee coverage.You can find additional information in the Provider Manual.

Certain services require prior authorization in order to obtain payment for services rendered. If you provide services without an authorization, your claim may be denied.

Steps for Requesting an Initial Authorization

  1. Prior to submitting an authorization, please verify the member’s eligibility here or the Colorado Department of Health Care Policy & Financing (HCPF) eligibility portal.
  2. Complete a Prior Authorization Form and fax, with appropriate clinical information, to the number listed on the form. Please complete all required fields – incomplete forms will not be accepted and will be returned to sender.
  3. You will be notified if additional information is needed, if the service is authorized, or if the service will not be authorized.
  4. If you have questions, please call us.

Behavioral Health Authorizations

We authorize behavioral health services under the Health First Colorado (Colorado’s Medicaid Program) Regional Accountable Entity contract and the Child Health Plan Plus contracts for our HMO plan. We are available 24 hours a day, seven days a week to take authorization requests.

Click here for information about the behavioral health services that require prior authorization. Please note that all services rendered by a non-participating provider require authorization for payment; the only exception to this is urgent and emergent situations as defined in the Provider Manual.

For those services that require authorization, failure to request authorization will result in an administrative denial. We cannot retrospectively deny benefits for treatment that received prior authorization except in cases of fraud, abuse, or if the member loses eligibility.

Physical Health Authorizations

We authorize some physical health services for the Child Health Plan Plus(CHP+) HMO. We are available from 8 a.m. to 5 p.m. Monday Through Friday to receive physical health authorization requests.

Click here for information about the CHP+ services that require prior authorization (navigation notes: you can use CTRL F and the filter functionality to search by procedure code). Please note that all services rendered by a non-participating provider require authorization for payment; the only exception to this is urgent and emergent situations as defined in the Provider Manual.

For those services that require authorization, failure to request authorization will result in an administrative denial. We cannot retrospectively deny benefits for treatment that received prior authorization except in cases of fraud, abuse, or if the member loses eligibility.

Please click here for information about the CHP+ pharmacy benefit, formularies, and the process by which to request authorization for medications.

Requesting Reauthorization for Continued Services

All requests for ongoing services beyond the initial authorization require reauthorization. Please complete and submit the appropriate prior authorization form and fax as indicated above at least one business day prior to the expiration of the previous authorization. Providers are responsible for tracking their authorization start dates, end dates, number of units used, and member eligibility. Providers must phone or fax clinical information supporting the medical necessity of the continued stay within one working day of the request for information from Colorado Access.

If a request for extended length of stay is denied by a medical director, the provider and attending practitioner will be notified and may request a peer-to-peer review within one business day. A request for a peer-to-peer review is not considered a complaint or an appeal.

Policies and Procedures

Please see the policies below for more information.
UM100 – Qualifications for Staff Engaged in Utilization Management Activities
UM101 – Criteria for Utilization Review
UM102 – Utilization Review Determinations
UM103 – Emergency and Post-Stabilization Care
UM104 – Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT)
UM105 – Peer Review Process
UM106 – Member Appeal Process