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Forms & Documents

Find the most recent forms below. If you can't find a form, or need help, please call us.

General Forms

Substance Use Disorder – Provider Application Form
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 Notification of Change Form
Provider Notification of Termination Form
Online Eligibility Verification for off-hours/weekends
Truven/DAP Access Request Form
Authorization to Disclose Protected Health Information
Autorización Para La Divulgación De La Información De Salud Protegida
Request for Access to PHI Form
SOLICITUD DE ACCESO A INFORMACIÓN DE SALUD PROTEGIDA

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
Clinical Appeal Form
Prior Authorization for Home Health Care/Outpatient Therapy (may be used for Synagis at-home administration)
Prior Authorization Injectable Medication
Psychological Testing Authorization
Compounded Medication Claim Form
Intensive In-Home Services Application
Navitus Announcement
Navitus Synagis
SUD Prior Authorization Request

Clinical Practice Guidelines

If you would like to provide feedback or have any questions regarding the Clinical Practice Guidelines, please email QualityManagement@coaccess.com.

Preventive Care

Pediatric Health Maintenance (American Academy of Pediatrics)
Pediatric Immunizations (Centers for Disease Control and Prevention)
Perinatal and Prenatal Care for Women and Infants (Epocrates)
Postpartum Care for Women (ACOG)

Physical Health
Down Syndrome (American Academy of Pediatrics)
Obesity Prevention – Child (Smoking Cessation (US Department of Health and Human Services)

Behavioral Health
Attention Deficit Hyperactivity Disorder (American Academy of Child and Adolescent Psychiatry)
Bipolar Disorder – Child (American Academy of Child and Adolescent Psychiatry)

Resources

Preventive Care
Adult Health Maintenance (Massachusetts Health Quality Partners)
Adult Immunizations (Centers for Disease Control and Prevention)
Influenza Vaccination (Centers for Disease Control and Prevention)
Postnatal Care to Reduce Infant Mortality (World Health Organization)

Physical Health
Appropriate Antibiotic Use (Centers for Disease Control and Prevention)
Asthma (National Institutes of Health)
COPD (Global Initiative for Chronic Obstructive Lung Disease)
Diabetes Care (American Diabetes Association)
Gastroesophageal Reflux Disease (Agency for Healthcare Research and Quality)
Obesity – Adult (Obesity Society, American Heart Association, American College of Cardiology)
Sexual Behaviors in <25 Years Olds (American Family Physician)
Smoking Cessation (US Preventative Services Task Force)

Behavioral Health
Alcohol and Substance Use Screening, Brief Intervention, and Referral to Treatment, SBIRT (Centers for Medicare and Medicaid)
Bipolar Disorder – Adult (American Psychiatric Association)
Intensive Outpatient Services (US Department of Health and Human Services)
General Anxiety Disorder (American Family Physician)
Major Depressive Disorder (Agency for Healthcare Research and Quality)
Substance Use Disorders (American Psychiatric Association)

Health Spotlight
COVID-19 (CDC)
COVID-19 (CDPHE)
Health Disparities (Article)

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.