How to Fill Out and Submit the Denver Health Prior Authorization Form

To request prior authorization from Denver Health Medical Plan, complete the one-page Denver Health prior authorization form with the member’s details, both the ordering and servicing provider’s information, ICD-10 and CPT or HCPCS codes, and attached clinical records, then submit it through the HealthTrio Connect provider portal or by fax to the number that matches the service type.¹ DHMP has five business days to respond to standard requests and seventy-two hours for urgent ones, and if it misses those deadlines the request is deemed approved by law.²

Confirm the Service Needs Authorization

Not every service requires advance approval, but the list is broader than many providers assume. Any care delivered outside the Denver Health network needs authorization.¹ Within the network, categories that commonly trigger a request include acute rehabilitation and skilled nursing admissions, non-emergent air ambulance, experimental procedures, durable medical equipment priced at $500 or more plus all DME rentals, enteral and total parenteral nutrition, most genetic testing, transplants, specialty infusions, and specific surgeries such as bariatric, blepharoplasty, breast procedures, varicose vein, and penile implant procedures.³

Thresholds vary by tier. Home health through a Tier 1 provider needs authorization starting on day 31; Tier 2 and out-of-network providers need it from day one. Outpatient PT, OT, and speech therapy through Tier 1 need authorization after the first 30 visits per calendar year; Tier 2 and out-of-network need it from visit one. Behavioral health services such as applied behavioral analysis, electroconvulsive therapy, and neuropsychological testing require authorization except through Tier 1 providers.³

If you are not sure, check the full list on the DHMP site or call the plan before scheduling. Skipping authorization for a listed service can result in denial of the entire claim, leaving the member responsible for the bill.

Get the Form and Gather Information First

The fillable PDF lives in the DHMP resource library, and the electronic version is in the HealthTrio Connect provider portal.¹ If you do not have a portal account, ask your organization’s local administrator to add you, or register as a new local administrator through the portal. Portal registration questions go to dhmp_portal@dhha.org.

Before you open the form, pull together everything it will ask for. Every field must be completed and clinical records must be attached, or DHMP will not process the request.⁴

Member Details

You need the patient’s full legal name (last, first, middle initial), date of birth, member ID number, and gender assigned at birth. Pull the member ID from the front of the insurance card itself. One transposed digit will delay processing or trigger an ineligibility denial.

Provider and Facility Details

The form separates the ordering or requesting provider from the servicing facility or provider. The ordering section captures the requesting physician’s name, NPI, phone, fax, and an office contact. The servicing section covers the facility or specialist who will actually perform the service, including that provider’s NPI and federal tax identification number.⁴ When the ordering and servicing providers are different people — a primary care doctor referring to a surgeon, for instance — both sections must be filled out in full.

Diagnosis and Procedure Codes

The clinical section takes ICD-10 diagnosis codes for the patient’s condition and CPT or HCPCS codes for the requested service. The form instructs you not to leave any column blank.⁴ Each procedure code also needs a start date, end date, and number of units. Multiple procedures each get their own line.

Clinical Records

Attach recent documentation that supports medical necessity: lab results, imaging reports, progress notes, and records showing that less intensive options were tried or are inadequate. The medical director reviews these against evidence-based criteria, so the clearer the clinical story, the faster the determination.

Fill Out the Form Section by Section

Start at the top with provider identification. Fill in the ordering provider’s name, NPI, phone, fax, and office contact, then move to the servicing facility section. Enter the member’s demographic details exactly as they appear on the insurance card. A nickname instead of a legal name, or an outdated address, creates avoidable delays.

Move to the clinical section. Enter each ICD-10 code with a short written description of the diagnosis. Below that, enter the CPT or HCPCS code with the start date, end date, and number of units for each procedure. Where the form provides space for a clinical justification narrative, use it to explain why this specific service is necessary for this specific patient. Attach the supporting clinical records as separate uploads in the portal or as additional pages behind the fax.

Review the whole form before you submit. Each submission generates a new authorization number, and DHMP will not modify a request once a decision has been made. Changing dates or adding visits later means filing a brand-new form.¹

Submit by Portal or the Right Fax Number

You have two submission routes. Through HealthTrio Connect, log in, complete the electronic form, attach documentation, and submit. By fax, use the number that matches the type of service. Sending a request to the wrong number will delay processing.

Inpatient services, including acute hospital admissions, skilled nursing, and rehabilitation: fax 303-602-2127.
Outpatient services, including outpatient procedures, home health, office visits, and radiology: fax 303-602-2128.
Urgent or expedited requests: fax 303-602-2160.

Each submission needs its own new form and cover sheet. Do not fax duplicates of the same request; duplicates slow processing rather than speed it up.¹

When to Expect a Response

Colorado law sets firm deadlines. For a standard request, DHMP must notify the provider and member within five business days that the request is approved, denied, or incomplete. An incomplete notice must identify the specific additional information needed; once that information arrives, the plan has another five business days to issue a final determination.²

For urgent requests, where delay could seriously harm the patient, the plan must respond within two business days but no longer than seventy-two hours, whichever comes first. The same seventy-two-hour window applies when the plan requests additional information on an urgent case.²

If DHMP misses any of those deadlines, the request is automatically deemed approved.⁵ Both the provider and member receive written notice once the determination is final, including specific reasons for any denial and any covered alternatives. You can also track pending requests through the provider portal.

If the Request Is Denied

A denial is not final. The denial letter will state the reason and the appeal options available under the member’s plan, with different procedures for Elevate Medicare Advantage, Elevate Medicaid Choice, and commercial coverage. Members who exhaust internal appeals can request an independent external review through the Colorado Division of Insurance, which assigns a certified external review organization to decide the case in writing within 45 days; an overturned denial requires the plan to approve coverage.⁶ Urgent cases can be expedited at every level with a physician’s statement of medical urgency.

1
Denver Health Medical Plan. Prior Authorizations
2
Justia. Colorado Code 10-16-112.5 – Prior Authorization for Health-care Services
3
Denver Health Medical Plan. Services Requiring Prior Authorization
4
Denver Health Medical Plan. Prior Authorization Request Form
5
Colorado General Assembly. HB19-1211 – Prior Authorization Requirements Health Care Service
6
Colorado Division of Insurance. When Your Health Insurance Company Says No