Prior Authorization in Colorado

Do You Know the Rule?

If you were looking to find basic information about prior authorization requests in Colorado, Simply Research would have you covered. But we break it down for you here, too.

Basics

Prior Authorization may be requested using the “Authorized Treating Provider’s Request for Prior Authorization” (Form WC 188) or in the alternative, shall be clearly labeled as a Prior Authorization request. Prior Authorization for payment shall only be requested when:

1. A prescribed treatment exceeds the recommended limitations set forth in the MTGs.

2. The MTGs require Prior Authorization for that specific service.

3. A prescribed treatment is not priced in the Medical Fee Schedule or is identified in Rule as requiring Prior Authorization for payment.

No Medical Review

Prior Authorization for prescribed treatment may be granted immediately and without a medical review. However, the Payer shall respond to all Prior Authorization requests in writing within 10 days from receipt of a completed request as defined per this Rule. The Payer, unless it has previously notified the Provider, shall give notice to the Provider of the procedures for obtaining Prior Authorization for payment upon receipt of the initial bill from that Provider.

Medical Necessity

When submitting a Prior Authorization request, a Provider shall concurrently explain the reasonableness and medical necessity of the treatment requested and shall provide relevant supporting documentation (documentation used in the Provider’s decision-making process to substantiate need for the requested treatment). A complete Prior Authorization request includes the following:

1. An adequate definition or description of the nature, extent and necessity for the treatment;

2. Identification of the appropriate MTG if applicable; and

3. Final diagnosis.

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