By Plan:

Medicaid Members

Medicaid members require prior authorization for all EIS care

Commercial, Elevate and CHP+ Members

Commercial, Elevate and CHP+ members are managed via the Trust Fund -- only HIA and IFSP forms are to be submitted

  • Prior authorization submissions must be completely and accurately filled out.

  • Requests must be legible and free from any scratch outs or use of white out.

  • Each submission must be on a new prior authorization form with a new cover sheet.
  • Request must contain an IFSP form which is less than 12 calendar months old.
  • Domains must be completed and show at least a 33% delay in 1 of the 5 domains if it is not a State approved auto qualifying diagnosis.
  • Approvals will be granted for either 90 days or maximum of 6 months for any PT/OT/ST request for Medicaid Members.
  • 1 year requests for authorizations will not be allowed.
  • If there is a change in servicing providers, DHMP must be notified immediately. A new prior authorization request must be submitted along with the Colorado Fee-for-Service Medicaid Change of Provider Form.

Initial Authorization Requests

  • 30-day retroactive reviews are allowed for initial evaluations ONLY for PT/ST/OT.

  • Current IFSP is required for initial start of services.

  • A denial will be issued if clinical is not received after day 7 of submission.

Continued Care or Extension of Services

  • Any modification (extended dates or additional visits) requires a new submission.
  • A current IFSP is required for continued or extension of services.
  • Summary document or current clinical with progression/regression and functional status from Therapist are needed for each new request.
  • A denial will be issued if clinical is not received after day 7 of submission.

Retrospective Requests (Post Service)

  • With the exception of initial service requests, all services submitted after the start of care will be considered retrospective requests and will be processed as denials.
  • UM is unable to process a Prior Authorization Request for services which have already been submitted for claims payment. Please see the Claims decision letter for denials.