2017 Medicare Medical Prior Authorization List | Denver Health Medical Plan

2017 Medicare Medical Prior Authorization List

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Some medical services must be reviewed and approved (prior authorization) by DHMP to ensure payment. It is the sole responsibility of your doctor or other provider to send a request to DHMP for authorization. The Utilization Management staff is available to answer questions about prior authorizations Monday through Friday, from 8:00 AM to 5:00 PM, except on holidays. If you have questions or concerns about the authorization process, specific cases, or UM decisions, please call us at 303-602-2140. A TTY/TDD line is available for the hearing- or speech-impaired at 711. We also have bilingual staff and language assistance services available at no charge.

Services that must be authorized prior to service include, but are not limited to:

  • Acute Care Hospital admissions - including medical, surgical, mental health and substance abuse admissions (facility must notify DHMP within one business day of an unplanned admission)
  • Long Term Acute Care admissions
  • Skilled nursing facility admissions
  • Inpatient rehabilitation admissions
  • Outpatient Surgery
  • Plastic Reconstructive, and/or Cosmetic Procedures including, but not limited to:
    • Breast related procedures (reconstruction, reduction, augmentation, breast implant or removal, removal or replacement of tissue expander)
    • Abdominoplasty, lipectomy, panniculectomy
    • Septoplasty and Rhinoplasty with/without septal repair
    • Blepharoplasty
  • Home Health Care
  • PET Scans
  • Radiation Therapy
  • Durable Medical Equipment, Orthotics, Prosthetics, Oxygen equipment and contents, cochlear implants, insulin pumps
  • Enteral and Parenteral Nutrition
  • Transplant related services, including initial consult and evaluations
  • Potentially experimental or investigational services
    • Clinical trials/studies
    • Unlisted procedure codes
  • Genetic testing
  • Non-formulary medications
  • Any out-of-network care

Utilization Management (UM) Standards for Decision Making

Type of Notification MEDICARE (ALL)
Urgent Concurrent/Concurrent 24 Hrs.
Expedited/Urgent Preservice 72 Hrs.
Standard/Preservice/Nonurgent 14 Calendar Days
Retrospective/Postservice 30 Calendar Days
Urgent Concurrent/Concurrent 1. Notify within 24 Hrs.
2. Decision within 72 Hrs
Expedited/Urgent Preservice 1. Notify within 24 Hrs.
2. 48 Hrs. to receive information
3. Decision within 48 Hrs. of receiving information
Standard/Preservice/Nonurgent 14 Calendar Days at member or health plan request, if in member's best interest
Retrospective/Postservice 14 Calendar Days at member or health plan request, if in member's best interest