Frequently Asked Questions

• Members
• Providers
• Medicare
• Insurance Fraud
• Employers
• Producers

MEMBERS

RMHP offers a variety of plans, so the answers below may differ depending on the RMHP plan through which you receive your benefits. For additional information, see your plan materials or contact Customer Service.

Customer Service

How do I contact Customer Service?

You can contact RMHP Customer Service Monday through Friday from 8:00 a.m. to 5:00 p.m. at 970-243-7050 or 800-346-4643 or email customer_service@rmhp.org 

General Questions

How do I appeal a decision made by RMHP?

If a Member disagrees with a decision made by RMHP and wants to appeal the decision, the Member must use the Mandatory Complaint Procedures described in the Health Plan Guide. These procedures vary depending on your RMHP plan.

My Benefits

Where can I get a summary of my benefits?

After enrolling in an RMHP plan, the subscriber will receive a Health Plan Guide that includes a summary of benefits. If you need a replacement Health Plan Guide, you may contact Customer Service.

How do I add members of my family to my plan?

There are time limits for making changes to your coverage, such as adding your spouse or other dependents to your plan. See your Health Plan Guide for time limits. You can obtain a change form from your employer or by contacting RMHP Customer Service.

Can I move outside of Colorado and still keep my benefits?

Except for Members enrolled on an Indemnity or PHCS plan, eligible under any continued coverage through COBRA, or dependent children, Members who do not reside in the service area are not eligible to receive any benefits. These requirements vary depending on your RMHP plan.

What services require preauthorization?

Referrals are not required; however, certain health care procedures and services must be preauthorized by RMHP before you receive them, or you may not get the maximum level of coverage your plan allows. When you see a participating provider, your doctor gets the necessary preauthorization for you. For services provided by a nonparticipating provider, it is your responsibility to start the preauthorization process. Failure to have services preauthorized when required will result in a significant reduction in benefits, as described in your Health Plan Guide. Click here to see the list of services requiring preauthorization. Click here to see the list of durable medical equipment and medical supplies that require preauthorization.

Claims

What is Coordination of Benefits (COB)?

Coordination of Benefits (COB) is when a person has health care coverage under more than one health plan.  Refer to your Health Plan Guide for COB provisions and be sure to notify RMHP if you or a covered family Member has medical coverage with another health plan.

Copayments and Deductibles

How do I know how much I need to pay for health care services?

The subscriber receives a Coverage Schedule that shows how much you pay for the covered health care services listed in the Schedule of Benefits in the Health Plan Guide. It also shows benefits that are limited to a number of treatments, days, visits, or a specific dollar amount.  This information for most commonly used services is accessible in Access RMHP for Members, click here to register.

What is a Member Billing Statement (MBS)?

A Member Billing Statement  (MBS) will show the health care services you've received and any deductibles or copayments due to RMHP. You will receive a Member Billing Statement (MBS) only when you have received services for which RMHP has already paid the provider in full and for which you must pay your copayment directly to RMHP.

What is an Explanation of Benefits (EOB)?

You will receive an Explanation of Benefits (EOB) each time you receive services from a provider who is responsible for collecting your copayment. You will also receive one if you have medical coverage with another health plan. If you have questions about your copayments, coinsurance, or deductibles, the amounts can be found in the Coverage Schedule section of your Health Plan Guide.

Providers

How do I know if my physician or pharmacy participates with RMHP?

You may refer to the RMHP Provider Directory (printed version), the on-line RMHP Provider Directory, or contact Customer Service for this information.

Pharmacy

Will my physician know about the prescriptions on the RMHP formulary?

Yes, all participating providers have access to the RMHP formulary.

Why should I use a generic drug?

Generic drugs are therapeutically equivalent to brand name drugs, are approved by the Food and Drug Administration, and cost a lot less. Each time you purchase a prescription drug, ask your doctor or pharmacist if there is a generic offered.

Does RMHP have a mail order pharmacy program?

Yes, Express Scripts is our mail order pharmacy. Contact RMHP Customer Service, learn more, or download the Express Scripts Mail Order form. 

PROVIDERS

Are specialist referrals required?

RMHP does not require referrals for specialty care from participating physicians or providers. 

Is preauthorization required?

Preauthorization is required for certain services.  All preauthorization requests must be submitted on an RMHP form and faxed to our Utilization Management team. Click here for further details about preauthorization.

How do I check eligibility?

 

How do I check on the status of a claim?

 

How do I submit a claim?

Claims must be submitted on a CMS 1500 or UB-92.  Mail claims to Rocky Mountain Health Plans, PO Box 10600, Grand Junction, CO 81502.  To obtain information about electronic submission of claims, please click here or call the EDI Coordinator at 800-311-5260 or 970-244-7893.  If you are already a registered user, go to https://providers.rmhp.org.

How do I know when to bill Medicare first?

HMO Standard, Value, or Gold Plans. All Part A providers bill claims for RMHP Medicare Members to the Medicare intermediary, then cross the claims over to RMHP for consideration of coinsurance and deductible. All non-participating providers bill Medicare first for RMHP Medicare Members, regardless of whether they are Part A or Part B providers. Participating Part B providers bill RMHP directly. 

For Members with a Commercial RMHP plan, Medicare may or may not be primary.  Refer to the Provider Manual for complete details and exceptions or contact Customer Service at 800-854-4558 or 970-248-5036.

Do you use any subnetworks that I should know about?

All Members with a chiropractic benefit must use Landmark Healthcare Colorado, Inc., chiropractors.  Along the Front Range, Life Strategies is the exclusive provider for behavioral health services and Theraphysics is the exclusive provider network for outpatient therapy services. Vision Service Plan, or VSP, (vision) and American Specialty Health Networks (accupuncture) provide access to discounted services for our Medicare HMO Members.   Delta Dental offers a dental plan to complement some RMHP medical plans.

How do I contact Customer Service?

You can contact RMHP Customer Service Monday through Friday from 8:00 a.m. to 5:00 p.m. at 800-854-4558 or 970-248-5036.

MEDICARE

Aren't all Medicare plans the same?

No, there are different types of coverage available to Medicare beneficiaries, in addition to Original Medicare.

Supplemental Medigap Insurance

While Medicare is a government program, Medicare supplement policies (Medigap) are offered by private insurance companies. Some supplemental policies will pay most or all of the Medicare coinsurance amounts. Some plans may also cover Medicare's deductibles. Certain plans will also pay for outpatient prescription drugs, preventive care, and emergency medical care in a foreign country.

Medicare Advantage Plans

Another option is to choose a Medicare Advantage plan. These plans provide care under contract with CMS. They may offer such services as coordination of care or reducing out-of-pocket expenses. Some plans may offer additional benefits, such as prescription drugs. However, in many cases you must see only the plan’s contracted doctors, specialists, and hospitals for all your health care needs.  

A Cost-Saving Alternative

Another option to help you save money and still get the care you’re entitled to is through a Medicare plan like Rocky Mountain Health Plans, a health plan with a Medicare contract since 1977.

RMHP Medicare plans not only provide all services covered by Medicare Part A and Part B, but also offer additional coverage and benefits. For instance Rocky Mountain Health Plans have plan options that covers benefits such as preventive care, Part D prescription drug plan options, and more. (The coverage costs for these extra benefits vary among plans.) This can provide substantial savings as you may not need additional supplemental insurance coverage that comes with its own monthly premiums and copays.

A big advantage of Rocky Mountain Health Plans is that you can choose from an extensive network of doctors, specialists, and hospitals. You also have the option to see any doctor outside of our network for Medicare-covered services. These services may not be covered by Rocky Mountain Health Plans outside our network. However, Medicare will continue to pay for its share of charges it approves, and you would pay Original Medicare deductibles and coinsurance for Medicare covered services.

Call Rocky Mountain Health Plans now for more information about the benefits of choosing one of our Medicare HMO plans. No matter which region of the state you live in, you have a choice of three plans. You can reach a friendly Medicare Specialist by dialing:

Call to learn about any of our Medicare plans: 888-251-1330
8:00 a.m. to 5:00 p.m. Mountain Time, Monday through Friday. Part D benefit questions: 8:00 a.m. to 8:00 p.m., Mountain Time, seven days a week (except Thanksgiving & Christmas). If you are hearing impaired and use TTY equipment, call 800-704-6370, toll free.

Are you a new insurance company offering coverage to Medicare beneficiaries?

No. Rocky Mountain Health Plans has had a Medicare contract since 1977 and provides coverage to Colorado Medicare beneficiaries in every county except Baca (Medicare Part D drug coverage is available in Baca county).

How do I decide which plan is right for me?

Consider your monthly premium budget, the prescription drugs you take, and how often you see your PCP and specialists. Our RMHP Medicare Sales Representatives are available to help you to understand the differences between the plans and which plan makes sense for you. We can also refer you to outside insurance counseling folks (through the Colorado Division of Insurance and the Medicare Ombudsman Office) who can help you free of charge.

How do I know if my doctors are covered on your plan?

You can check online by clicking the "Provider Directory" button above and typing in the name of your doctors to see if they are covered. Or you can reach a friendly Medicare Specialist by dialing:

Call to learn about any of our Medicare plans: 888-251-1330
8:00 a.m. to 5:00 p.m. Mountain Time, Monday through Friday. Part D benefit questions: 8:00 a.m. to 8:00 p.m., Mountain Time, seven days a week (except Thanksgiving & Christmas). If you are hearing impaired and use TTY equipment, call 800-704-6370, toll free.

How can I contact a live person to answer my questions?

You can reach a friendly Medicare Specialist by dialing:

Call to learn about any of our Medicare plans: 888-251-1330
8:00 a.m. to 5:00 p.m. Mountain Time, Monday through Friday. Part D benefit questions: 8:00 a.m. to 8:00 p.m., Mountain Time, seven days a week (except Thanksgiving & Christmas). If you are hearing impaired and use TTY equipment, call 800-704-6370, toll free.

You can also fill out our online information request form and a Medicare Specialist will contact you.

What is Medicare Part D?

Part D is a prescription drug benefit plan that will be available to all Medicare beneficiaries. Under Part D, you have Medicare drug coverage options and a wide range of new plan and benefit options. Your premiums, copays, and other out-of-pocket expenses will vary according to the plan you choose.

Does RMHP provide Part D benefits?

RMHP provides the Part D benefit in its plans with medical coverage. We also have two standalone plans.

Please click here to learn more about our Medicare plans that include Part D prescription drug coverage.

Please click here to learn more about our Medicare Part D prescription drug coverage standalone plans.

If I have Medicare, do I have to sign up for Part D?

Part D plans are open to all people eligible for Medicare and enrollment is voluntary. But you should be aware that the longer you wait to participate in Part D, the more expensive the premium will be. The monthly premium will increase by about 1 percent each month that you delay your enrollment in a Part D plan.

How can I make sure I am choosing the right Part D plans?

You can make a list of the drugs you take regularly.

• List the names of the drugs and their dosage (how many milligrams)
• List how much it costs to refill each prescription
• List how many times a year you refill each prescription
• Keep these lists so you can compare plans in November when you choose a plan

You can also call Medicare directly at 800-633-4227 to get more information 24 hours a day, 7 days a week. Hearing impaired persons who use TTY equipment can call 877-486-2048.

Is there anything else new for 2008?

RMHP will continue to offer Medicare coverage and will be here as always, as your trusted partner. We will continue to offer you a lot of flexibility in choosing coverage that works for you. Any changes to your existing plan benefits will be communicated to you well in advance so you will have plenty of time to understand and choose an option that works for you.

Information is current as of 12/20/07, please call to confirm that you have the most up-to-date information about our Medicare plans. CMS 122007 S5860 HO602 1037003 MC150WEB MEDIGAP-2007-AD-MC150WEB-0807

INSURANCE FRAUD

Reporting Health Care or Insurance Fraud and Abuse

What is health care/insurance fraud?

Fraud is the intentional misrepresentation of a material fact that is relied upon by the victim, which results in the loss of property, usually monetary. This can include payment for health care services induced by fraud.

What is health care abuse?

Health care abuse usually means any activity that unjustly robs the health care system – in our case, Rocky Mountain Health Plans (RMHP) – but does not constitute fraud. A provider may obtain payment for health care services to which he/she is not entitled, but there is not the intent to deceive as there is with fraud.

Examples of consumer fraud include:

• Fraudulent omission or misrepresentation of medical information or history on the application
• Fraudulent eligibility of dependents
• Fraudulent submission of claims
• Altering prescriptions
• Using another Member's card to obtain health care services

Examples of provider fraud include:

• Falsifying recipient identities
• Padding, or overstating health care charges
• Upcoding, or charging for similar but higher priced services
• Billing for services that were not provided
• Asking for, offering, or accepting kickbacks
• Performing noncovered services but billing for covered services

What is not health care/insurance fraud?

General complaints or unhappiness with a provider or RMHP are not examples of fraud. See how to handle these kinds of matters by reading your Health Benefits Contract.

What does RMHP do about health care or insurance fraud?

RMHP is committed to preventing, detecting, investigating, and prosecuting health care or insurance fraud. If you think someone is doing something wrong or illegal with regards to their Rocky Mountain Health Plans health care or insurance, please call:

Fraud Hotline
970-248-5101
888-237-1179

Or you may write:
Fraud Investigator
Rocky Mountain Health Plans
PO Box 10600
Grand Junction, CO 81502-5600

Or you may e-mail:
fraudauditor@rmhp.org

What information do we need from you?

Tell us what you know about the reported situation, either one that has happened or that is still happening.

• Who is involved?
• What are they doing?
• When is it happening?
• Where is it happening?
• Why is it happening?
• How is it happening?

The bottom line on fraud

Health care and insurance fraud and abuse costs each one of us – estimated at more than $100 billion annually in the United States alone.  The majority of frauds are discovered and stopped because someone got involved and reported the wrongdoing.

Use the Fraud Investigation Referral Form to send RMHP some of the information necessary to conduct a proper fraud investigation.  Thank you for your help. 

Employers

How do I contact Customer Service for assistance on questions relating to our employer group benefits?

You can contact RMHP Customer Service Monday through Friday from 8:00 a.m. to 5:00 p.m. at 877-784-9655 or 970-248-5000.

How do I order new-employee packets and additional forms?

New-employee packets and most forms can be ordered right here on our website. You can expect the new employee packets to be delivered within 3-4 business days; a minimum order of 5 new-employee packets is required. You can also click here for commonly used forms and documents.

How do I enroll a new employee?

Once the employee has met any waiting period, they need to complete the enrollment form from their new-employee packet. A waiver form must be completed for the employee and/or their dependents if they choose not to enroll. This enrollment documentation must be completed and received by RMHP within 30 days of the eligibility date.

How do I disenroll an employee or family member?

To disenroll an employee

You can click here to submit a disenrollment electronically. The Disenrollment Form must be received by our office by the end of the month in which coverage is to end.

If continuation rights are required for this employee and RMHP assists you with your continuation of coverage, COBRA/ Colorado Continuation of Coverage (CCOC) notification, please click here to submit an on-line Notice of Qualifying Event Form. 

To drop coverage for a dependent

Complete and submit a Change Form.  Click here to link to commonly used forms. If continuation rights are required for this dependent, please submit a Notice of Qualifying Event Form.

I am trying to help an employee who received a bill from a provider. How can we determine the reason for this?

Employers and producers can call the RMHP customer service specialty team to answer such questions regarding benefits, claims, eligibility, ID cards, etc. Call 877-784-9655 or 970-248-5000. Employees or their dependents can call our Customer Service directly at 800-843-0719 or 970-243-7050

For more information, please refer to the on-line Employer Group Manual or contact your broker or RMHP Group Service Representative.

Producers

How do I contact Customer Service?

You can contact RMHP Customer Service Monday through Friday from 8:00 a.m. to 5:00 p.m. at 877-784-9655 or 970-248-5000.

What are the service areas for commercial plans?

• HMO Service Area: All Colorado counties except Gunnison and Baca
• PPO and EPO Service Area: All Colorado counties.

Sales

How do I become an appointed broker?

Contact your local RMHP Sales Office for information on applying to become an appointed producer.  Click here to link to our sales office location contact information.

What products and services do you offer?

RMHP offers a full range of products for many different customers.  Click here to link to our health care plans.

How can I get marketing materials for my prospective groups?

New group submission material can be downloaded from commonly used forms. Marketing materials can be downloaded from the Why Choose RMHP section of our website.

How do I obtain a small group quote (less than 51 employees)?

RMHP gives you several ways to quote a group.  First, if you are an appointed producer, we provide you easy-to-use software so  you can produce your own pers