Utilization Management (UM) | Denver Health Medical Plan

Utilization Management (UM)

UTILIZATION MANAGEMENT/CASE MANAGEMENT

The Utilization/Case Management (UM/CM) Department at Denver Health Medical Plan, Inc. (DHMP) is designed to ensure the delivery of high quality and cost efficient health care for our members.  Services are intended to evaluate, promote, and coordinate quality for the most cost-effective care for our insured members including Denver Health Commercial Plans, Medicare Select/Choice, Health Exchange products (Elevate), CHP+ and Medicaid Choice.  One of our main goals is to make sure our members receive the right care in the right setting by the right provider.

The purpose of the UM/CM Department is to achieve the following objectives for all members:

To assure effective and efficient utilization of facilities and services through an ongoing monitoring and education program. The program is designed to identify patterns of over or under-utilization patterns and inefficient use of resources.

To assure fair and consistent UM decision making by using evidence-based, decision support criteria from guidelines such as InterQual, Hayes and Denver Health Medical Plan, Inc. Medical Policies.

To focus resources on a timely resolution of identified problems.

AUTHORIZATION PROCESS

It’s important to understand the difference between a referral and an authorization – and how to obtain each one.

Referral is the process of one provider (usually the Primary Care Provider, PCP) sending a patient to another provider (usually a specialist) for consultation or services. If you need to see a specialist please ask your Denver Health PCP for a referral.*

Authorization is a process of reviewing requests for health services to make sure the service is both medically necessary and appropriate for the member. The review also determines whether or not the requested service is a covered benefit under the member’s benefit plan.

For most of our plans, we require the Primary Care Provider (PCP) to direct the member’s care. This means that if you need to see a specialist you should see your Denver Health PCP first. He or she will then refer you to the right specialist to meet your needs. Referrals to other Denver Health providers DO NOT require an authorization, but referrals to providers outside of Denver Health DO require an authorization. 

Please see our Medical Prior Authorization List for the services that require prior authorization.

Medical Prior Authorization List

**THE EXCEPTION TO THIS RULE APPLIES TO POINT OF SERVICE MEMBERS WHO CHOOSE TO USE THEIR COFINITY NETWORK OPTION – THEY DO NOT NEED AN AUTHORIZATION TO SEE PROVIDERS IN THE COFINITY NETWORK.

For most of our plans (please refer to your member handbook for details) Authorization is required for all services provided outside of Denver Health – including inpatient admissions, durable medical equipment, outpatient services, home health services, skilled nursing facility admissions, etc. Below are forms that your provider can use to request an authorization for certain services. Your provider should complete the forms and fax them to one of the vendors at the top of the form. **

Type of Notification COMM/Elevate (All) MEDICAID & CHP MEDICARE (ALL)
Decisions
Urgent Concurrent/Concurrent 24 Hrs. 24 Hrs. 24 Hrs.
Expedited/Urgent Preservice 72 Hrs. 72 Hrs. 72 Hrs.
Standard/Preservice/Nonurgent 15 Calendar Days 10 Calendar Days 14 Calendar Days
Retrospective/Postservice 30 Calendar Days 30 Calendar Days 60 Calendar Days
Extensions
Urgent Concurrent/Concurrent None None None
Expedited/Urgent Preservice 1. Notify within 24 Hrs.
2. 48 Hrs. to receive information
3. Decision within 48 Hrs. of receiving information
None 14 Days
Standard/Preservice/Nonurgent 1. Notify within 15 Calendar Days
2. 45 Calendar Days to receive information
3. Decision within 15 Calendar Days of receiving information
1. Notify within 15 Calendar Days
2. 45 Calendar Days to receive information
3. Decision within 15 Calendar Days of receiving information
14 Calendar Days at member or health plan request, if in member's best interest
Retrospective/Postservice 1. Notify within 30 Calendar Days
2. 30 Calendar Days to receive information
3. Decision within 15 Calendar Days of receiving information
14 Calendar Days at member or health plan request, if in member's best interest None

COMMUNICATION

Members

Members should contact their physician to initiate an authorization. DHMP Member Services is available for members who have questions about existing authorizations.

Contact by phone
Denver Health Medical Plan303-602-2100
CHP+ by DHMP303-602-2100
Medicare by DHMP303-602-2111
Medicaid Choice303-602-2100


Providers

DHMP staff is available during normal business hours Monday through Friday, 8:00 a.m. to 5:00 p.m., excluding holidays, for calls and faxes related to UM issues. Providers may contact Utilization Management by fax to send authorization requests or clinical information. Please use the DHMP Prior Authorization Forms available on our website: http://denverhealthmedicalplan.org/provider-forms-and-materials

Contact by fax
Outpatient fax303-602-2128
Inpatient fax303-602-2127
DME fax303-602-2160
Contact by phone303-602-2140


Calls will be returned as soon as possible, but no later than one business day.