Rocky Mountain Health Plans to align with UnitedHealthcare clinical requirements

Prior authorization, medical policy and protocol updates

Effective March 1, 2025, the following UnitedHealthcare requirements and criteria will apply to Rocky Mountain Health Plans (RMHP). This will help further streamline RMHP clinical review processes and reduce clinical decision turnaround times.

Updates that apply to RMHP Individual Exchange plans, Medicaid PRIME, Child Health Plan Plus (CHP+), Medicare Advantage and Dual Eligible Special Needs Plans (D-SNP)

Medical prior authorization and notification requirements
The plans will align with UnitedHealthcare medical prior authorization and notification requirements for many codes, 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

Note, there will be no changes to behavioral health prior authorization and notification requirements.

Medical policies
The plans will align with UnitedHealthcare Medical & Drug Policies on our Policies and Protocols for Providers page.

Utilization management criteria
The plans will transition from MCG to InterQual® for utilization management. This transition won’t disrupt your current practices. To learn more, visit our Clinical Guidelines page and select InterQual Clinical Criteria.

Updates that apply to RMHP Individual Exchange plans only

This includes Colorado Doctor’s Plan, Monument Health HMO, Monument ONE and Rocky Mountain Valley Plans.

Site of service medical necessity reviews
Prior authorization or notification will be required for the following services:

• Certain office-based procedures planned to be performed in outpatient hospitals or ambulatory surgery centers
• Certain surgical procedures planned to be performed in outpatient hospital settings

Please submit your request in advance of rendering these services to ensure medical necessity and appropriate site of service. For any surgical procedure or CPT® codes that are already subject to prior authorization/notification requirements, we’ll continue to review the procedures to determine medical necessity. Visit our Site of Service Medical Necessity Reviews guide for more information.

Questions?

If you have questions, please email rmhp_updates@uhc.com.

CPT® is a registered trademark of the American Medical Association.

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