Rocky Mountain Health Plans to Align with UnitedHealthcare's Clinical Policies and Standards
Effective March 1, 2025, Rocky Mountain Health Plans (RMHP) will implement new UnitedHealthcare
requirements and criteria, enhancing the efficiency of RMHP's clinical review processes and accelerating
clinical decision-making times.
The updates will affect RMHP Individual Exchange plans, Medicaid PRIME, Child Health Plan Plus (CHP+),
Medicare Advantage, and Dual Eligible Special Needs Plans (D-SNP) as follows:
Medical prior authorization and notification requirements will be aligned with UnitedHealthcare's
standards for numerous codes, details of which are available here:
- UnitedHealthcare Community Plan CHP+ prior authorization requirements
- UnitedHealthcare Community Plan PRIME prior authorization requirements
- UnitedHealthcare Individual Exchange plans prior authorization requirements
- UnitedHealthcare Medicare Advantage prior authorization requirements
Please note that behavioral health prior authorization and notification requirements will remain
unchanged.
Medical Policies
Plans will conform to UnitedHealthcare Medical & Drug Policies, accessible on the Policies and Protocols
for Providers page.
Utilization Management Criteria
Plans will transition from MCG to InterQual® criteria for utilization management. This change is designed
to integrate seamlessly into existing practices. For more details, please visit the Clinical Guidelines page
and select InterQual Clinical Criteria.
Specific Updates for RMHP Individual Exchange Plans
These updates apply only to Colorado Doctor’s Plan, Monument Health HMO, Monument ONE, and
Rocky Mountain Valley Plans.
Site of Service Medical Necessity Reviews
Prior authorization or notification is now required for the following services:
- Office-based procedures are scheduled to be performed in outpatient hospitals or ambulatory
surgery centers. - Surgical procedures intended for outpatient hospital settings.
It is recommended that authorization requests be submitted well in advance to verify medical necessity
and the appropriate site of service. For any surgical procedures or CPT® codes already under prior
authorization/notification mandates, the ongoing review process to confirm medical necessity will
continue as usual.
