[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283955-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283955-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","out-of-network-prior-authorization-request-form-behavioral-and-physical-health-requests-submit-clinical-notes","Out-of-Network Prior Authorization Request Form - Behavioral and Physical Health Requests - Submit Clinical Notes","","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.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/out-of-network-prior-authorization-request-form-behavioral-and-physical-health-requests-submit-clinical-notes/283955/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/out-of-network-prior-authorization-request-form-behavioral-and-physical-health-requests-submit-clinical-notes/283955.png","ImageObject",442,249,{"name":42,"@type":43},"Dozel","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Where should the out-of-network prior authorization request be submitted for behavioral health versus physical health?","Question",{"text":63,"@type":64},"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.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What is required to avoid processing delays for this request?",{"text":68,"@type":64},"Attach clinical notes with the request to avoid processing delays.",{"name":70,"@type":61,"acceptedAnswer":71},"How long does Rocky Mountain Health Plan take to process prior authorization requests by plan type?",{"text":72,"@type":64},"Processing times listed are: Medicaid 7 days, CHP+ 7 days, and Commercial/IFP 5 days.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283955,1790217623,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},962085662650,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Out-of-network prior authorization request form  \nRocky Mountain Health Plan  \nBehavioral health requests (MH/SUD): [rmhpbhvm@uhc.com](rmhpbhvm@uhc.com) or fax to 888-240-2689  \nPhysical health requests: [rmhpcmresearchteam@uhc.com](rmhpcmresearchteam@uhc.com) or fax to 800-262-2567  \nConcurrent/inpatient requests: [rmhpmedicalum@uhc.com](rmhpmedicalum@uhc.com) or fax to 833-787-9448  \n\n| New request | Revised request of approval number: |\n| --- | --- |\n| To ensure your prior authorization request is completed in a timely manner, please allow: |  |\n\nMedicaid —7 days CHP+ — 7 days Commercial/IFP — 5 days  \n\n| Patient name: | Member ID number: |  |  |  | Date of birth: |\n| --- | --- | --- | --- | --- | --- |\n| Requesting provider (please use full name): |  | TIN: |  |  |  |\n| Attending provider (please use full name): |  | TIN: |  |  |  |\n| Provider phone number: |  |  | Provider fax number: |  |  |\n| Billing contact (if different than requesting provider): |  |  | TIN: |  |  |\n| Billing contact: |  |  | Contact fax number: |  |  |\n| Facility/office where service is to be performed: |  |  | TIN: |  |  |\n| Address: |  |  |  | Phone number: |  |\n| Contact for determination notification: |  |  | Contact phone number: |  |  |\n\nServices  \nInpatient Observation Outpatient Outpatient surgery Office Transplant evaluation Transplant listing  \n\n| If transplant, what organ? |\n| --- |\n| Date range of services being requested (include anticipated start and end date): |\n| Diagnosis code: |\n| Diagnosis description: |\n\nPCA-1-26-01403-Clinical-FM_08112026  \n| Remember to attach clinical notes with this request to avoid processing delays. |  |\n| --- | --- |\n| CPT® code(s)/HCPCS code(s): | Name and quantity: |\n| Description of services: |  |\n| For medications or enteral nutrition formula/supplies only: Where will the member pick up the supplies/items? |  |\n| Pharmacy name: | Store number: |\n| Address: |  |\n| Phone number: | Fax number: |\n\nThe 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.  \nConfidentiality notice  \nThis 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.  \nCPT® is a registered trademark of the American Medical Association.  \nPCA-1-26-01403-Clinical-FM_08112026  \n© 2026 United HealthCare Services, Inc. All Rights Reserved.","cbCaiqpdIDstZZjF","https://ap.wps.com/l/cbCaiqpdIDstZZjF","pdf",376022,"English","# Request Information\n## Submission Contacts and Request Type\n# Member and Provider Details\n# Requested Services\n## Service Type and Location\n## Diagnosis and Date Range\n## Codes and Descriptions\n# Eligibility, Review, and Billing Notes\n# Confidentiality Notice","[{\"question\":\"Where should the out-of-network prior authorization request be submitted for behavioral health versus physical health?\",\"answer\":\"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.\"},{\"question\":\"What is required to avoid processing delays for this request?\",\"answer\":\"Attach clinical notes with the request to avoid processing delays.\"},{\"question\":\"How long does Rocky Mountain Health Plan take to process prior authorization requests by plan type?\",\"answer\":\"Processing times listed are: Medicaid 7 days, CHP+ 7 days, and Commercial/IFP 5 days.\"}]","Out-of-Network Prior Authorization Request Form - Behavioral and Physical Health Requests - Submit Clinical Notes | PDF",1789623453]