CurrentColorado Rocky Mountain Health PlansPolicy N/A

HIV Diagnosis Verification / Prophylaxis Form

Form and verification process governing attestation of HIV diagnosis or authorization for HIV prophylaxis (including maternal-fetal and assault-related prophylaxis) for Colorado Medicaid members; affects prescribers submitting claims or prior authorizations to the payer.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHIV Diagnosis Verification / Prophylaxis Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the verification form in full and fax to 1-866-940-7328 (providers may verbally attest by calling listed numbers for a one-month override).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Retention (years)

1 monthVerbal attestation override

1-866-940-7328Fax

800-603-1714; 877-553-7481Phone

Coverage Criteria

Indications for HIV therapy or prophylaxis

Form indicates coverage consideration when one of the following indications is selected and verified

Indication selection: One of: maternal-fetal prophylaxis; sexual assault (non-occupational exposure prophylaxis); HIV (diagnosis) — specify diagnosis code when applicable; pre-exposure HIV prophylaxis; other (specified)

Provider must specify diagnosis code when applicable and sign/date the form.

This verification form is not the appropriate form for submissions involving Fuzeon, Selzentry, or Serostim. Do not use this form for those products; submissions for those drugs must follow the alternative processes required by the plan.

Coding

Form fields for diagnosis codeICD-10

No codes listed

Provider Actions & Submission Requirements

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHIV Diagnosis Verification / Prophylaxis Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the verification form in full and fax to 1-866-940-7328 (providers may verbally attest by calling listed numbers for a one-month override).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior Authorization

One-month override for verbal attestation

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 allow time for diagnosis codes to be updated in the billing process or for this verification form to be submitted with medical records to Medicaid.

Note

Drugs excluded from this form

This form is not the appropriate form for Fuzeon, Selzentry, or Serostim submissions.

Documentation Required

Record retention

Providers must retain copies of all documentation for five years.

Billing Rule

Submission requirements

Form must be completed in full and faxed to 1-866-940-7328. Include patient identifiers and prescriber information; incomplete forms may be returned.

Fax number: 1-866-940-7328
Include patient name, date of birth, and diagnosis code
Include prescriber name, signature, and prescriber fax number

Denial Risk

Incomplete form risk

An incomplete form may be returned.

Definitions

Indication for therapy

Indication options on the formMaternal-fetal prophylaxis; Sexual assault (non-occupational exposure prophylaxis); HIV (specify diagnosis code when applicable); Pre-exposure HIV prophylaxis; Other (specified)

Verbal-attestation overrideProviders who call 800-603-1714 or 877-553-7481 to verbally attest to an HIV diagnosis are allowed a one-month override for billing/verification

Submission methodFax the completed form to 1-866-940-7328

Documentation retentionProviders must retain copies of all documentation for five years

Form supports automatic claims processingTechnology allows claims to automatically process for maternal-fetal prophylaxis and assault victims

Background

This document is a verification form used to confirm an HIV diagnosis or an indication for HIV prophylaxis. Indications listed on the form include maternal-fetal prophylaxis, sexual assault / non-occupational post-exposure prophylaxis, pre-exposure prophylaxis, established HIV (diagnosis), or other (specified). The form supports claims processing and allows short-term verbal attestation in certain situations to avoid claim denials.