Out-of-Network Prior Authorization Request Form - Behavioral and Physical Health Requests - Submit Clinical Notes

Sep 17, 2026

Uploaded by Dozel

Out-of-network prior authorization request form for Rocky Mountain Health Plan covering behavioral health (MH/SUD), physical health, and concurrent/inpatient requests. Includes submission contact emails and fax numbers, new vs revised approval indicator, and plan-specific processing timeframes. Collects member and provider details, service location and type, diagnosis information, transplant organ and requested date range, and CPT/HCPCS codes. Requires attachment of clinical notes to avoid delays and outlines eligibility, concurrent review, confidentiality, and billing/coding conditions.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Request Information

Submission Contacts and Request Type

Member and Provider Details

Requested Services

Service Type and Location

Diagnosis and Date Range

Codes and Descriptions

Eligibility, Review, and Billing Notes

Confidentiality Notice

Out-of-network prior authorization request form Rocky Mountain Health Plan Behavioral health requests (MH/SUD): [rmhpbhvm@uhc.com](rmhpbhvm@uhc.com) or fax to 888-240-2689 Physical health requests: [rmhpcmresearchteam@uhc.com](rmhpcmresearchteam@uhc.com) or fax to 800-262-2567 Concurrent/inpatient requests: [rmhpmedicalum@uhc.com](rmhpmedicalum@uhc.com) or fax to 833-787-9448 | New request | Revised request of approval number: | | --- | --- | | To ensure your prior authorization request is completed in a timely manner, please allow: | | Medicaid —7 days CHP+ — 7 days Commercial/IFP — 5 days | Patient name: | Member ID number: | | | | Date of birth: | | --- | --- | --- | --- | --- | --- | | Requesting provider (please use full name): | | TIN: | | | | | Attending provider (please use full name): | | TIN: | | | | | Provider phone number: | | | Provider fax number: | | | | Billing contact (if different than requesting provider): | | | TIN: | | | | Billing contact: | | | Contact fax number: | | | | Facility/office where service is to be performed: | | | TIN: | | | | Address: | | | | Phone number: | | | Contact for determination notification: | | | Contact phone number: | | | Services Inpatient Observation Outpatient Outpatient surgery Office Transplant evaluation Transplant listing | If transplant, what organ? | | --- | | Date range of services being requested (include anticipated start and end date): | | Diagnosis code: | | Diagnosis description: | PCA-1-26-01403-Clinical-FM_08112026 | Remember to attach clinical notes with this request to avoid processing delays. | | | --- | --- | | CPT® code(s)/HCPCS code(s): | Name and quantity: | | Description of services: | | | For medications or enteral nutrition formula/supplies only: Where will the member pick up the supplies/items? | | | Pharmacy name: | Store number: | | Address: | | | Phone number: | Fax number: | The prior authorization for services noted in this form is only for the time period during which the patient remains eligible on the patient’s current health benefit plan or for a shorter period as specified in this form. Rocky Mountain Health Plans is not financially responsible for the services that are preauthorized if the patient is not eligible on the date services are provided. Further, as permitted by applicable law, this preauthorization is subject to concurrent review as to medical necessity, appropriateness or efficacy, and coverage for services being provided and is subject to the terms and conditions in the Member’s Evidence of Coverage, including but not limited to, coordination of benefit provisions, preexisting conditions and limitations, and any agreements between Rocky Mountain Health Plans and the health care provider. Billing for the services preauthorized on this form is subject to nationally standardized rules for coding and paying health services as used by Rocky Mountain Health Plans. Confidentiality notice This facsimile transmission (and/or documents accompanying it) may contain confidential, proprietary and privileged information. This information is intended only for the use of the individual(s) named above. Any unauthorized review, use, disclosure or distribution is prohibited. If you have received this transmission in error or cannot identify the recipient for distribution purposes, please notify Rocky Mountain Health Plans immediately at 800-854-4558. CPT® is a registered trademark of the American Medical Association. PCA-1-26-01403-Clinical-FM_08112026 © 2026 United HealthCare Services, Inc. All Rights Reserved.

FAQs

Where should the out-of-network prior authorization request be submitted for behavioral health versus physical health?

Behavioral health requests should be sent to rmhpbhvm@uhc.com or fax 888-240-2689. Physical health requests should be sent to rmhpcmresearchteam@uhc.com or fax 800-262-2567.

What is required to avoid processing delays for this request?

Attach clinical notes with the request to avoid processing delays.

How long does Rocky Mountain Health Plan take to process prior authorization requests by plan type?

Processing times listed are: Medicaid 7 days, CHP+ 7 days, and Commercial/IFP 5 days.

Sep 17, 2026

Uploaded by Dozel