Prior Authorization Form for Referrals

Please read all instructions below before completing this form. If all *(Required) fields are not complete DHMP may not be able to process auth thus possibly effecting patient care. Therefore please take the time to double check this form is filled out to your best ability.

Do not use this form to: 1)Request an appeal; 2) Confirm eligibility; 3) Verify coverage; 4)Request a guarantee of payment ask whether a service requires prior authorization; 5) Request prior authorization of a prescription drug; 6) Request a referral to an out of network physician, facility or other health care provider.

Additional Information and Instructions:

Section I: General Information Information on the requestor for the referral.

Section II: Request/Review Type:Urgent reviews: Request an urgent review for a patient with a life-threatening condition, or for a

patient who is currently hospitalized, or to authorize treatment following stabilization of an emergency condition. You may also request an urgent review to authorize treatment of an acute injury or illness, if the provider determines that the condition is severe or painful enough to warrant an expedited or urgent review to prevent a serious deterioration of the patient’s condition or health. Please note, DHMP UM will review the "urgency" based on the date of the procedure to verify the service/procedure is urgent. Section III: Patient Information

A) Enter all pertinent patient information on the form. Please ensure the required fields are completed.

Section V: A) Services Requested. Must include CPT/HCPCS code along with ICD-10 Diagonsis code.B) Give a brief narrative of medical necessity in this space, or in an attached statement.C) Attach supporting clinical documentation (medical records, progress notes, lab reports, etc.), if needed.

Note: Some issuers may require more information or additional forms to process your request. If you think anadditional form may be needed, please check the issuer’s website before faxing or mailing your request. If the requesting provider wants to be called directly about missing information needed to process this request, you may include the provider’s direct phone number in the space given at the bottom of the request form.

Section IV: Provider InformationA) If the Requesting Provider or Facility will also be the Service Provider or Facility, enter "Same."B) If the requesting provider’s signature is required, you may not use a signature stamp.C) If the issuer’s plan requires the patient to have a primary care provider (PCP), enter the PCP’s name and

phone number. If the requesting provider is the patient’s PCP, enter “Same.”

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UM Phone Line: 303-602-2140Fax Lines: 303-602-2160 Durable Medical Equipment (DME) 303-602-2128 Speciality Referrals, Home Health, SNF, LTAC, Acute Rehab, Part B Therapy, Outpatient Occupational Therapy, Physical Therapy, Speech Therapy, Radiation Therapy, Infusion Therapy

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*Issuer Name: *Phone: *Fax: *Date:

SECTION II — Request/Review Type

SECTION III — PATIENT INFORMATION

*Name: *Phone: *DOB: *Sex: Male UnknownFemale

Subscriber Name (if different): Group #:

SECTION IV ― PROVIDER INFORMATION

*Requesting Provider Service/Facility (If Applicable)

*Name: *Name:

*NPI #: *NPI #:

*Phone: *Fax: *Phone: *Fax:

*Contact Name: *Phone: *Primary Care Provider Name:

*Requesting Provider’s Signature and Date: *Phone: Fax:

SECTION V ― SERVICES REQUESTED (WITH CPT OR HCPCS CODE) AND SUPPORTING DIAGNOSES

*Planned Service Service Code *Start Date *End Date *Dx Code (ICD-10)

DME (MD Signed Order Attached?

SECTION I — GENERAL INFORMATION

*Member/Medicaid/Medicare #:

*Start Date of Procedure: 0-1 Day ≥10 Days

*Request Type: Initial Request Renewal of Authorization

2-3 Days 4-9 Days

Extension of Existing Authorization

*UM Decision Time:

*Review Status: Initial ConcurrentHome Health Yes No

*Start Date of Care:

*Referral Source: *Family Support/Able to Teach: Yes No

*Disciplines

PT

OT

SLP

Aide

*Prior Level of Function *Frequency*Visits Requested *Rehab Potential *Week # Update *Notes

Skilled RN Visit (may include wond care, PICC lines, TPN, IV Antibiotics, new tube feeds, medications etc.)

*Date *Teaching *Patient/Family *Return Demonstration *Notes (including patient compliance)

Prior Authorization Form for ReferralsAll required fields (*) must be completed or DHMP Inc. can't process

your request and may cause a delay in services to the member.

*

*Certification Period:

*Homebound Status

*Diagonsis Description (ICD-10)

*AnticipatedDate of Discharge:

*Medical History and Diagnosis:

Wound Vac - Current measurements and status of the wound(s) - medical necessity for the skilled visits

*Wound Location *Length (cm) *Width (cm) *Depth (cm) *Tunneling *Appearance *Comments

Wound Vac:

Skilled Nursing Facility Checklist/Data Collection*1) Does patient qualify daily skilled therapy? (MUST HAVE Medicare or Commerical Insurance benefit to qualify for SNF

PT OT ST

*2) Does Patient qualify for daily skilled nursing/medical treatment?Wound Care Other:IV-Meds

CHECK ALL THAT APPLY - For the items below a referral to the DHMP UM Department prior to 48hrs. of discharge is recommended to optimally coordinate care.

Ht

Behavioral Issues

CDiff MRSA

Special Diets:

Communication Barriers

PASRR Completed

Supplemental Oxygen

Suction Frequency:

BiPAP/CPAP: New Trach: New Old

Weight Bearing Limitations

Hemodialysis:

Special Equipment Needs

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If you are uncertain on the status of your referral and would like an update please contact the UM Department @303-602-2140

Bariatric

End Of Life IssuesETOH/Substance Abuse

Psych-Social Issues

Oxygen Liter Flow

Old

All required fields (*) must be completed or DHMP Inc. can't process your request and may cause a delay in services to the member.

Hx of Multiple SNF Admits

Pain Control

Reason/Duration for IV(s):

PICC In Place

Isolation (Document Details):

IV-Meds/Infusions

Needs LTC/ALF after SNFRestraints/Sitter

Schedule

TPN (cyclic >24hrs) Gastric Tubes Other

VRE

Location

Tabacco Patch

Wt

Note: Therapy evaluation within 48 hours of referral to confirm current level of function and rehabilitation potential