Services Requiring Prior Authorization

Definitions

Participating Provider is identified and described as follows: 

• Tier 1 Providers* are contracted providers considered in-network, listed in the Provider Directory, and do not require authorization unless service is included in the Authorization Categories for specific Lines of Business. Services must meet Medical Necessity and be a covered benefit.
• Tier 1 Capitated Providers* receive reimbursement from Denver Health Medical Plan (DHMP) on a per member per month (PMPM) contract.
  • Prior Authorizations are not required for any services
  • Only applies to DHHA Medical Care HMO, Elevate and Elevate Medicaid Choice 
• Tier 2 Providers* are contracted Providers considered out-of-network, not listed in the Provider Directory, and require prior authorization for all Lines of Business. Services must meet Medical Necessity and be a covered benefit. 
• Tier 3 Providers* are Non-Participating Providers (Out of Network Provider) for all Lines of Business require Prior Authorization and a One Time Agreement.  Services must meet Medical Necessity and be a covered benefit.

*Tier level participation may be different, based on a specific line of business.  

General Rules

•  Urgent and Emergency Care DO NOT require Prior Authorization. 
• Excluded services are not covered. Excluded services will be denied as a non–covered benefit, per the member’s Evidence of Coverage (EOC). 
• Providers are responsible for verifying eligibility and benefits before providing services to all DHMP members. Prior Authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the member’s eligibility, benefit limitations/exclusions, evidence of medical necessity during the claim review and provider status with DHMP. 
• Failure to obtain Prior Authorization prior to giving care for the services listed below may result in a denial for reimbursement. 
• Services not requiring Prior Authorization will be subject to audit. If in an audit those services did not meet medical necessity, there will be a possibility of recoupment. 
• If a DHMP member is admitted to your facility, you must notify DHMP within (1) business day. If you fail to notify DHMP during this window of time, the member’s admission and continued stay could be denied for “not timely notification.” 
• Non-Participating (Out of Network Providers) require authorization for all services, except for Urgent and Emergency Services.

Resources 

Providers can submit Prior Authorization Requests by either submitting an ONLINE Prior Authorization Request form or by completing and faxing a PDF Prior Authorization Request form. If using a PDF form, it should be faxed to DHMP. If you have questions, please contact Health Plan Services at 303-602-2100.

• Inpatient Request Fax: 303-602-2127
• Outpatient Request Fax: 303-602-2128
• Urgent/Expedited Request Fax: 303-602-2160

UM PRIOR AUTHORIZATION REQUEST FORM

Denver Health Medical Plan Secondary Payer and Authorizations

Denver Health Medical Plan (DHMP) does not typically require authorization when the secondary payer.  However, if the requested service was denied by the primary insurance as not a covered benefit or benefits have been exhausted, an authorization may be requested. 

Please submit clinical information with the primary insurances denial letter or limitation/exhaustion letter with the authorization request to the Utilization Management (UM) Department. 

As a courtesy, UM will accept prior authorization requests for certain items for DHMP Medicare Choice members for services that are never covered by Medicare without a denial from primary insurance.  For example, excluded items that would not be covered by Medicare under any circumstances such as oral nutrition, personal hygiene items or group 4 wheelchairs. 

Note: Prior Authorization is not a guarantee of payment for services. Payment is made in accordance with a determination of the member’s eligibility, benefit limitations/exclusions, and evidence of medical necessity during the authorization review and provider status with DHMP at the time services are rendered.

Denver Health Medical Plan Secondary Payer and Claims

Submit claims to the secondary insurance once you have billed the primary insurance and received payment or Explanation of Remittance (EOR).  DHMP will need the bill total, how much the primary insurance paid and why primary didn’t pay the remainder of the balance. 

Please include the adjustments and categories for the remaining balance for a seamless secondary claim process.  

Secondary coverage may only cover part or all the remaining costs or not pay any of the remaining costs. There are steps in place to ensure that both plan/coverages do not pay more than 100% of the bill based on contractual and benefit plan arrangements. 

Provider Forms and Materials

Providers refer to the Provider Forms and Materials page for provider forms, as well as provider tips for outpatient guidance, information on select services and benefit limitations by each line of business. 

Authorization Categories

Specialty Rx/Infusions Requiring Prior Authorization

If you have questions, please contact Health Plan Services at 303-602-2100.