The Utilization Management (UM) Department makes sure our members receive the right care in the right setting by the right provider.
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, 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, 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. **
- Durable Medical Equipment
- Oxygen/Oxygen equipment
- Incontinent Supplies
- Home Health Services
*Exceptions: You do not need a referrals to certain specialists, such as psychiatry, dermatology, OB/GYN, etc. For a full list of exceptions contact Member Services at 303-602-2100.
**Exception: most outpatient services for Point of Service (POS) members do not require an authorization.
Denver Health Medical Plan (DHMP) makes Utilization Management decisions only on existence of coverage and appropriateness of care and services. DHMP does not give rewards or financial incentives to our staff members who make decisions or providers or anyone else for denying, limiting or delaying health care coverage of services.
The Utilization Management Department is available Monday through Friday from 8:00 AM to 5:00 PM. Just call us at 303-602-2140 or toll-free at 800-700-8140.