About 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/CO Option plans, CHP+ and Medicaid plans. We work to ensure that our members receive the right care, in the right setting, by the right provider. 

Utilization Management Objectives:

UM Department aims to achieve the following 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.

The Authorization Process

It’s important to understand the difference between a referral and an authorization – and how to obtain each one.

  • 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.

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.

Authorization is required for all services provided outside of Denver Health networks Please refer to the member handbooks on this website for details. 

Regulatory Turnaround Time Requirements

Type of Notification COMMERCIAL AND
EXCHANGE/co oPTION
MEDICAID & CHP MEDICARE (ALL)
Decisions
Urgent/Concurrent 24 Hrs. 72 Hrs. 72 Hrs.
Expedited/Urgent Preservice 72 Hrs. 72 Hrs. 72 Hrs.
Expedited Specialty Rx Part B Drugs 72 Hrs. 72 Hrs. 24 Hrs.
Standard/Preservice 15 Calendar Days 10 Calendar Days 14 Calendar Days
Standard Specialty Rx Part B Drugs 15 Calendar Days 10 Calendar Days 72 Hrs.
Retrospective/Postservice 30 Calendar Days 30 Calendar Days 30 Calendar Days
Extensions
Urgent/Concurrent 48 Hrs. 14 Calendar Days 14 Calendar Days
Expedited/Urgent Preservice 48 Hrs. 14 Calendar Days 14 Calendar Days
Standard/Preservice 15 Calendar Days 14 Calendar Days 14 Calendar Days
Retrospective/Postservice 15 Calendar Days None None
Part B Drug None None None
 
 

Communication (Phone, Fax, Webform)

Members should contact their physician to initiate an authorization. 

DHMP Health Plan Services staff is available for UM issues during normal business hours, Monday through Friday, 8 a.m. to 5 p.m., excluding holidays. Providers may contact Utilization Management by fax to send authorization requests and clinical information. The DHMP Utilization Management Department can receive faxes seven days a week, including holidays. Please use the Prior Authorization Request Forms.

Contact by fax or phone:
  • Outpatient fax | 303-602-2128
  • Inpatient Admit and Discharge Notification fax | 303-602-2127
  • Inpatient Clinical Records fax | 303-602-2004
  • Urgent/Expedited fax | 303-602-2160
  • Contact Health Plan Services by phone* | 303-602-2100

Phone calls will be returned within one business day.