Forms & Documents - Colorado Access

General Forms

Behavioral Health Prior Authorization Request
Physical Health Prior Authorization Request
Short-Term Behavioral Health Services in a Primary Care Setting
ACC Dismissal Form
Grievance Form
Quality of Care Notification Form
Essential Community Providers
Clinical Staff Update Form
Enrollment Backdate Form
Provider Address Change Form
Online Eligibility Verification for off-hours/weekends
Truven/DAP Access Request Form

CHP+ offered by Colorado Access

Retro-Eligibility Claims Guidelines

Claims

General Companion Guide – Healthcare Claim Submissions
Claim Appeal Form
Provider Payment Options

Utilization Management and Pharmacy

Prior Authorization Durable Medical Equipment Request
Master Authorization List
Prior Authorization for Home Health Care/Outpatient Therapy (may be used for Synagis at-home administration)
Prior Authorization Injectable Medication
Psychological Testing Authorization
Request for Prescription Drug Coverage
Compounded Medication Claim Form
Intensive In-Home Services Application
Navitus Announcement
Navitus Synagis

Click here for all pharmacy forms on the Navitus Provider Portal

Clinical Practice Guidelines

Provider Frequently Asked Questions

How do I get Synagis for my patients?

Complete prior authorization forms and fax them to Navitus at 855-668-8551. All approved Synagis requests will be dispensed by Avella Specialty Pharmacy. If you wish to have a home health agency administer Synagis to your patient, please indicate that the medication will be shipped to the patient’s home. Upon prior authorization approval, Navitus will notify Avella, who will fax a home health request to set up the services. Our utilization management team will work to set up a home health agency to visit the patient’s home and administer the medication.

Is Synagis covered by Colorado Access?

Synagis is covered for eligible patients through the Colorado Access pharmacy benefit. The specific criteria for approval can be found here. Prior authorization forms should be faxed to Navitus at 855-668-8551.