DHHA Employer Plan enrolled employees with out-of-area/out-of-state spouse or dependents
As soon as you enroll in a DHMP plan, you must notify Health Plan Services (HPS) if anyone on your plan (spouse or dependent) lives out-of-area/out-of-state (considered to be out-of-network). Only the subscriber (DHHA Employer Plan enrolled employee) is authorized to notify DHMP of out-of-area/out-of-state spouse or dependents. Subscribers must notify DHMP of out-of-area/out-of-state spouse/dependents each plan year. If a spouse or dependent moves during the plan year, such as a child going out-of-area for college, you must notify HPS. What defines ‘out-of-area/out-of-state’ will be determined by your employer, Denver Health and Hospital Authority.
Prior authorization is required
ANY and ALL services out-of-network will require prior authorization in order for the claim to be processed. If there is no prior authorization in place, the claim will be denied and the member could be charged. Prior authorization is required for out-of-network services including, but not limited to:
- Primary care provider (PCP) visits
- Annual preventive care visits
- OB/GYN visits
- Outpatient behavioral health visits
Exception: prior authorization is NOT required for urgent or emergency care – which are covered anywhere in the U.S.
Contact Health Plan Services (HPS)
Before your spouse/dependent goes to any out-of-area/out-of-state provider visit, contact HPS at 303-602-2100 to find out how to request prior authorization for the appointment. The health care provider will need to submit a Request for Prior Authorization to DHMP in advance of the visit.
Important to establish care
In addition, subscribers who have a covered spouse or dependent out-of-area/out-of-state should have them schedule an appointment to establish care. This is an important step to ensure your spouse or dependent has an established PCP in place. Establishing care is the process of beginning a care relationship with a single primary care provider that will be the source for all day-to-day medical needs, helping with access to specialty care when needed.
For more information about coverage for dependents residing outside of the service area and your plan’s provider network, please refer to your member handbook.