Utilization Management (UM)

UTILIZATION MANAGEMENT/CASE MANAGEMENT

The Utilization/Case Management (UM/CM) 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, promote, and coordinate quality for the most cost-effective care for our insured members including Denver Health Commercial Plans, Medicare Select/Choice, Health Exchange products (Elevate), CHP+ and Medicaid Choice.  One of our main goals is to make sure our members receive the right care in the right setting by the right provider.

The purpose of the UM/CM Department is 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 InterQual, Hayes, and Denver Health Medical Plan Inc. Durable Medical Equipment Formulary.

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.

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 you need to see a specialist please ask your Denver Health PCP for a referral.*

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 Primary Care Provider (PCP) to direct the member’s care. This means that if you need to see a specialist you should see your Denver Health PCP first. He or she will then refer you to the right specialist to meet your needs. Referrals to other Denver Health providers DO NOT require an authorization, but referrals to providers outside of Denver Health DO require an authorization. 

**The exception to this rule applies to Point of Service members who choose to use their Cofinity Network or Out of Network Benefit Option – they do not need an authorization to see non-Denver Health providers.

For most of our plans (please refer to your member handbook for details) Authorization is required for all services provided outside of Denver Health – including inpatient admissions, durable medical equipment, outpatient services, home health services, skilled nursing facility admissions, etc. Below are forms that your provider can use to request an authorization for certain services. Your provider should complete the forms and fax them to one of the vendors at the top of the form. **

Type of Notification COMM/Elevate (All) MEDICAID & CHP MEDICARE (ALL)
Decisions
Urgent Concurrent/Concurrent 24 Hrs. 3 Working Days 24 Hrs.
Expedited/Urgent Preservice 72 Hrs. 3 Working Days 72 Hrs.
Standard/Preservice/Nonurgent 15 Calendar Days 10 Calendar Days 14 Calendar Days
Retrospective/Postservice 30 Calendar Days 10 Calendar Days 30 Calendar Days
Extensions
Urgent Concurrent/Concurrent 1. Notify within 24 Hrs.
2. Decision within 72 Hrs.
14 Calendar Days at member or health plan request, if in member's best interest 1. Notify within 24 Hrs.
2. Decision within 72 Hrs.
Expedited/Urgent Preservice 1. Notify within 24 Hrs.
2. 48 Hrs. to receive information
3. Decision within 48 Hrs. of receiving information
14 Calendar Days at member or health plan request, if in member's best interest 1. Notify within 24 Hrs.
2. 48 Hrs. to receive information
3. Decision within 48 Hrs. of receiving information
Standard/Preservice/Nonurgent 1. Notify within 15 Calendar Days
2. 45 Calendar Days to receive information
3. Decision within 15 Calendar Days of receiving information
14 Calendar Days at member or health plan request, if in member's best interest 14 Calendar Days at member or health plan request, if in member's best interest
Retrospective/Postservice 1. Notify within 30 Calendar Days
2. 45 Calendar Days to receive information
3. Decision within 15 Calendar Days of receiving information
14 Calendar Days at member or health plan request, if in member's best interest 14 Calendar Days at member or health plan request, if in member's best interest

COMMUNICATION

DHMP staff is available during normal business hours Monday through Friday, 8:00 a.m. to 5:00 p.m., excluding holidays, for member and provider inbound collect and toll-free calls and faxes related to UM issues. To contact Utilization Management:

Call us at 303-602-2140 or toll-free at 800-700-8140.
Fax: 303-602-2128

Contact us also via our webform

UM staff have password protected, confidential voice mailboxes to receive inbound calls after normal business hours. Calls will be returned as soon as possible, but no later than one business day.

Language services are available free of charge, as needed. TTY/TDD users should call 303-602-2129 or toll free at 1-866-538-5288.