Referrals and Authorizations

Specialists Referrals

Specialty office visits for participating specialty providers do not require a referral to be submitted to Colorado Access from the member’s Primary Care Provider. Colorado Access encourages PCPs to direct care for specialty office-based care through clinical referrals. Colorado Access considers a clinical referral to be communication between the PCP and the specialty provider for the purposes of care continuity and treatment planning. Office visits for non-participating specialists do require a prior authorization from Colorado Access and will be considered on a case-by-case basis for particular clinical needs.

Note: Certain services, such as visits with physical, occupational and speech therapists require authorization.  Please read the General Authorization Rules listed below for more information.

Submitting an Authorization Request

Certain services require authorization in order to obtain coverage (payment). In most instances, prior authorization is required. It is best to plan ahead and submit an authorization request well in advance of the service being rendered. It takes a minimum of two (2) full working days to process an authorization request, and longer if additional information or reconsideration is required.

Colorado Access cannot retrospectively deny benefits for treatments that have been pre-authorized except in cases of fraud, abuse, or if the member loses eligibility.

Steps for Requesting an Authorization

1) Prior to submitting an authorization, we ask that you verify the member’s eligibility either via our Web site (www.coaccess.com) or by calling our Customer Service Department. 

2) Once you have determined that the member is eligible, you may either fax the Service Authorization Form to our Coordinated Clinical Services (CCS) Department or ask a Colorado Access Customer Service Representative to transfer you to CCS.

3) Click here for a copy of the Service Authorization Form. Required fields are indicated by bold face type. The form will be returned to sender if the required fields are not completed.

4) We will contact you if additional information is needed, if the service is authorized, or if there is an adverse service determination.

General Authorization Rules

Participating vs. Non-Participating Providers:

In general, all services rendered by non-participating providers require prior authorization for payment by Colorado Access except where specifically noted in the rules below.

Primary Care:

Services provided by participating PCP’s do not require prior authorization. 

Inpatient Care:

All inpatient care (place of service 21) requires prior authorization at a facility level. Professional services and ancillary services rendered during an inpatient stay are considered downstream and do not require separate authorization for both participating and non-participating providers. Initial authorization and concurrent review determinations are based on medical necessity as determined by InterQual© criteria.

Emergency and Urgent Care:

Emergency services (place of service 23) and urgent care services (place of service 20) do not require prior authorization if the service would be considered urgent or emergent as determined by a prudent layperson.

Ambulance:

Emergency ground or air ambulance transport does not require prior authorization. Scheduled ambulance transport from facility to facility is covered, but does require prior authorization. 

Outpatient Hospital / Ambulatory Surgery:

Procedures that are performed in an outpatient hospital (place of service 22) or ambulatory surgery center (place of service 24) may require prior authorization for the professional services. Refer to the Colorado Access authorization list to determine whether a procedure requires authorization. Facility and ancillary services are considered downstream to the procedure and do not require separate authorization for payment. Authorization for procedures is based on medical necessity as determined by InterQual© criteria.

Women’s Health / OB/GYN Services:

OB/GYN office-based services do not require referral or prior authorization for participating providers. Certain facility-based procedures may require prior authorization. Refer to the Colorado Access authorization list to determine whether a procedure requires authorization. Family planning services do not require prior authorization or referral for any provider, both participating and non-participating.

Diagnostic Services:

Routine laboratory and imaging services do not require prior authorization. Specialized diagnostic procedures may require prior authorization. Refer to the Colorado Access authorization list to determine whether a diagnostic procedure requires authorization. 

Diagnostic Interpretation Services:

Interpretation of diagnostic services, usually indicated by modifier 26, does not require prior authorization for participating providers.

Routine Vision Care:

Routine vision services do not require prior authorization. Certain specialty procedures may require prior authorization. Refer to the Colorado Access authorization list to determine whether a procedure requires authorization. 

Observation Services:

Observation stays (place of service 22) do not require prior authorization. Observation may be allowed for up to 72 hours as defined by Medicare rules.

Home Health Care:

All home health care services require prior authorization.

Durable Medical Equipment (DME):

Durable medical equipment may require prior authorization. In general, basic equipment and supplies or equipment that is ancillary to other procedures do not require prior authorization. Enhanced or specialty equipment or supplies generally require prior authorization. Refer to the Colorado Access authorization list to determine whether a supply item or piece of equipment requires authorization.

Therapy:

All physical, occupational and speech therapy require prior authorization.  Refer to the Colorado Access authorization list to determine whether a therapy requires authorization.

Pharmacy:

Certain injectable medications require prior authorization. Refer to the Colorado Access authorization list to determine whether an injectable medication requires authorization.

Retail pharmacy drugs are managed by formulary. Certain formulary drugs may be preferred agents or may require prior authorization. Refer to the Colorado Access formulary located in the Pharmacy Services section of this Web site for more information.