Utilization Management

The Utilization (UM) 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 and promote high quality and cost-effective care for our insured members, including our large group plans, Medicare Advantage plans, Exchange and CO Option plans, CHP+ and Medicaid Choice plans. One of our goals is to ensure that our members receive the right care, in the right setting, by the right provider. The UM Department aims 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 MCG, 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.

• A 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 a member needs to see a specialist, they should ask their Denver Health PCP for a referral. *
• An 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 PCP to direct patient care. This means that if a member needs to see a specialist, they should first see their Denver Health PCP. He or she will then refer them to the right specialist to meet their 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 Services Requiring Prior Authorization for the services that require prior authorization. The exception to this rule applies to commercial plan Point of Service (POS) members who choose to use their First Health Network option. They do not need an authorization to see providers in the First Health Network.

For most of our plans, authorization is required for all services provided outside of Denver Health. Please refer to the member handbooks on this website for details. The services needing authorization include inpatient admissions, durable medical equipment, outpatient specialist services, home health services, skilled nursing facility admissions, and other services. Providers will submit a Prior Authorization Request Form for these services.

Communication