CurrentColorado Rocky Mountain Health PlansPolicy N/A

HIV Diagnosis Verification / Prophylaxis Attestation Form

Form and attestation process used to verify HIV diagnosis or document indications for HIV prophylaxis (maternal-fetal, sexual assault/non-occupational exposure, pre-exposure prophylaxis) for Medicaid billing and prior authorization purposes; affects prescribers submitting claims or seeking overrides for Colorado Rocky Mountain Health Plans Medicaid members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHIV Diagnosis Verification / Prophylaxis Attestation Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the verification form in full or verbally attest by phone to receive a one-month override while documentation or diagnosis codes are updated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 yearsdocumentation retention requirement for providers

one-monthautomatic override period

1-866-940-7328fax to submit form

800-603-1714; 877-553-7481phone numbers for attestation

Coverage criteria and acceptable attestations

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHIV Diagnosis Verification / Prophylaxis Attestation Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the verification form in full or verbally attest by phone to receive a one-month override while documentation or diagnosis codes are updated.

SourceLink

On This Page

Provider actions, attestation, and documentation requirements

Prior Authorization

Attestation and one-month override

Form must be completed in full for submissions. Providers who call 800-603-1714 or 877-553-7481 to verbally attest to an HIV diagnosis will be allowed a one-month override to permit time for diagnosis codes to be updated in the billing process or for this verification form to be submitted with medical records. An incomplete form may be returned and may result in denial or delay of the request.

Providers may verbally attest to an HIV diagnosis by calling 800-603-1714 or 877-553-7481 — this grants a one-month override for claims processing or submission of the completed verification form.
Form must be completed in full; incomplete forms may be returned and can cause denial or delay.
Providers must retain copies of all documentation for five years.
Fax completed form to 1-866-940-7328.

Note

Provider impact

Provider-impact information: This form is not the appropriate form for Fuzeon, Selzentry, or Serostim submissions. Use the HIV Diagnosis Verification or Prophylaxis for HIV form and ensure all required fields (including diagnosis code and prescriber signature/date) are completed.

Documentation Required

Record retention and submission

Providers must retain copies of all documentation supporting the request for five years. Fax the completed verification form to 1-866-940-7328.

Record retention: retain documentation for five years.
Submission: fax completed form to 1-866-940-7328.

Denial Risk

Incomplete form

If the verification form is incomplete, it may be returned which can lead to denial or processing delays. Ensure all fields including diagnosis/indication, diagnosis code (if applicable), prescriber signature, and date are provided.

Incomplete form may be returned — risk of denial or delay if not completed in full.

Background and scope

This form documents the indication for HIV-related therapy or prophylaxis, including maternal-fetal prophylaxis, post-exposure prophylaxis for sexual assault/non-occupational exposure, confirmed HIV diagnosis, and pre-exposure prophylaxis. It is used to support Medicaid billing and prior authorization processes and to verify the clinical indication selected on the form.

Form fields and indication checkboxes

Indication checkboxes

Maternal-fetal prophylaxisForm includes a checkbox to indicate maternal-fetal prophylaxis as the indication for therapy.

Sexual assault (non-occupational exposure prophylaxis)Form includes a checkbox to indicate sexual assault (non-occupational exposure prophylaxis) as the indication for therapy.

Confirmed HIV diagnosisForm includes a checkbox to indicate HIV (diagnosis) as the indication for therapy.

Pre-exposure HIV prophylaxisForm includes a checkbox to indicate pre-exposure HIV prophylaxis as the indication for therapy.

Other indicationForm provides an 'Other' free-text line for additional indications to be specified.

OpenPayer

HIV Diagnosis Verification / Prophylaxis Attestation Form

Coverage criteria and acceptable attestations

Diagnosis and billing codes

Provider actions, attestation, and documentation requirements

Background and scope

Form fields and indication checkboxes