CurrentColorado Rocky Mountain Health PlansPolicy N/A

Opioid attestation for high-dose and chronic opioid therapy

Form and attestation requirements for prescribers requesting authorization for chronic opioid therapy or opioid doses exceeding specified MME thresholds for members of Colorado Rocky Mountain Health Plans. Affects prescribers, pharmacies, and utilization review staff processing opioid prior authorizations.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOpioid attestation for high-dose and chronic opioid therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed opioid attestation form (signed, dated, with supporting documentation for >200 MME/day) to obtain authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120 MME/daymandatory consultation threshold

200 MME/daysupports required for high dose

42 dayschronic use definition

12 monthsauthorization interval

Coverage Criteria

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Chronic Opioid Attestation Criteria

Covered when ALL of the following are met for chronic non-cancer pain:

Chronic use criteria: 1) Documented ongoing clinical need for chronic opioid use at the prescribed dose (more than 42 days per 90 day calendar period) documented in the medical record; AND 2) Patient is using appropriate non-opioid medications and/or non-pharmacologic therapies; OR 3) Patient has tried and failed non-opioid medications and non-pharmacologic therapies for the treatment of this pain condition; AND 4) For long-acting opioids, patient has tried a short-acting opioid for at least 42 days or there is clinical justification why short-acting opioids were inappropriate or ineffective; AND 5) Baseline objective pain and function scores recorded with periodic assessments to demonstrate clinically meaningful improvement; AND 6) Screening for mental health disorders, substance use disorder, and naloxone use performed; AND 7) Periodic urine drug screening performed; AND 8) PDMP checked for other opioid therapy and concurrent benzodiazepine or sedative therapy; AND 9) Discussion with patient of realistic goals including discontinuation as an option; AND 10) Patient understands and signs a pain contract or informed consent document.>42 days in 90 days

From Chronic Opioid Attestation section

High Dose (>120 MME/day) Attestation Criteria

Covered when ONE of the listed clinical reasons and ONE of the prescriber qualifications/coordination elements apply:

Clinical reasons: i) Active cancer pain, palliative care, end of life care, or hospice requiring >120 MME/day; OR ii) Temporary medically necessary need requiring >120 MME/day for no more than 42 days (with care coordination if patient on chronic therapy from another prescriber OR if prescriber is the chronic opioid prescriber); OR iii) Discharge from hospital, surgery, or other trauma; OR iv) Patient following a tapering schedule with a starting dose >120 MME/day; OR v) Medically necessary need to exceed 120 MME/day documented in the medical record.>120 MME/day

From Opioid High Dose Attestation section

Prescriber qualifications or consultation: One of: 1) Prescriber is a pain management specialist as defined in WAC 246-919-945; OR 2) Minimum of twelve category I continuing education hours on chronic pain management within the previous four years (at least two hours on substance use disorders); OR 3) Pain management physician working in a multidisciplinary chronic pain treatment center or multidisciplinary academic research facility; OR 4) Minimum of three years clinical experience in a chronic pain management setting with at least 30% of current practice in direct pain management care; OR 5) Documented consultation with a pain management specialist via office visit, telephone/electronic consultation, or an audio-visual evaluation where the patient is present (documented in the medical record).applies for >120 MME/day

Prescriber qualifications and consultation options

For patients receiving opioids for pain related to active cancer treatment, hospice, palliative, or end-of-life care, a mandatory consultation with a pain management specialist is not required for authorization, although consultation is encouraged. Providers should still complete the attestation and include any relevant documentation to support the request. Failure to provide the completed attestation and supporting documentation may result in denial of the request; fax instructions and submission requirements are provided on the attestation form.

Provider Actions & Documentation Requirements

Prior Authorization

Opioid attestation required for PA

Completed opioid attestation required for prior authorization when patients begin chronic opioid use (defined as >42 days of opioid therapy within a 90‑day period) or when daily opioid doses exceed 120 MME. Chronic use or >120 MME/day may be authorized in 12‑month intervals when the prescriber signs the attestation; prescribers may request a shorter authorization by specifying an end date. For temporary high‑dose approvals (exceeding 120 MME/day) that are medically necessary for up to 42 days, the attestation will expire after 42 days. Exemptions/encouraged exceptions: active cancer treatment, hospice, palliative, or end‑of‑life care (consultation with a pain specialist is not required but is encouraged).

Fax completed attestation and supporting documentation to 1-866-940-7328.
Use the Prescription Monitoring Program (PMP) and calculate total MME per SUPPORT Act HCA MME Conversion Factor guidance.
Requests for non-preferred products must also include a completed Opioid Prior Authorization form.

Documentation Required

Conservative therapy documented

Document use of appropriate non-opioid medications and/or non-pharmacologic therapies, or document why such therapies were not appropriate or were tried and failed. For long‑acting opioids, document trial of a short‑acting opioid for at least 42 days or provide clinical justification why short‑acting formulations were inappropriate or ineffective. Record baseline objective pain and function scores, conduct periodic assessments, screen for mental health and substance use disorders, check PDMP for concurrent opioid/benzodiazepine therapy, discuss goals including discontinuation options, obtain patient informed consent or pain agreement, and perform periodic urine drug screening.

Documentation Required

Required supporting documentation and submission

Attach supporting medical records when requesting doses >200 MME/day. For any request involving >120 MME/day, include the Opioid High Dose Attestation documenting the clinical reason and either evidence of pain‑specialist involvement or the prescriber’s qualifications/consultation per the attestation criteria. Fax the signed attestation and all required supporting documentation to 1-866-940-7328. Failure to provide a completed attestation and required supporting documentation may result in denial of the request.

Supporting documentation required for requests exceeding 200 MME/day.
Signed attestation required for chronic opioid use or daily doses >120 MME.
Fax number for submission: 1-866-940-7328.

Background

Chronic opioid therapy is defined operationally as use of any opioid for more than 42 days within a 90‑day period. High‑dose opioid therapy is quantified using morphine milligram equivalents (MME): daily doses > 120 MME trigger elevated review requirements, and the attestation form is required when patients begin chronic use, when daily doses exceed 120 MME, or when both conditions apply.

When chronic opioid use or doses above 120 MME/day are present, the prescriber must complete and sign the attestation; completed attestations may authorize therapy in 12‑month intervals unless a shorter end date is specified. Doses above 120 MME/day generally require either that the prescriber be a pain management specialist or that a consultation with a pain management specialist be documented.

Frequency Limits and Authorization Interval

Temporary opioid doses >120 MME/day

Maximum durationTemporary opioid doses >120 MME/day are authorized for up to 42 days

PurposeIntended for acute medically necessary needs such as discharge, surgery, or trauma

DocumentationPrescriber must indicate coordination with chronic prescriber or that they are the chronic prescriber when applicable

Attestation authorization interval

Authorization intervalAttestation for chronic use or high-dose therapy may be authorized for up to 12 months when prescriber signs the attestation

Shorter interval optionPrescriber may request authorization for less than 12 months by specifying an earlier end date on the form

Temporary exceptionAttestation for temporary high-dose prescriptions expires in 42 days rather than 12 months

OpenPayer

Opioid attestation for high-dose and chronic opioid therapy

Coverage Criteria

Coding and Dose Thresholds

Provider Actions & Documentation Requirements

Background

Definitions

Conservative Treatment Requirements

Frequency Limits and Authorization Interval