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Home and Community Based Services (HCBS) Brain Injury (BI), Community Mental Health Supports (CMHS) and Elderly, Blind and Disabled (EBD)

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General Information

Waiver programs provide additional Health First Colorado (Colorado's Medicaid program) benefits to specific populations who meet special eligibility criteria.

Level of care determinations are made annually by the Case Management Agencies (CMA). Members must meet financial, medical, and program criteria to access services under a waiver. The applicant must be at risk of placement in a nursing facility or hospital. To access waiver benefits, Members must be willing to receive services in their homes or communities. A Member who receives services through a waiver is also eligible for all basic Health First Colorado covered services except nursing facility and long-term hospital care. When a Member chooses to receive services under a waiver, the services must be provided by certified Health First Colorado providers.

Applicants may apply for more than one waiver but may only receive services through one waiver at a time.

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Prior Authorization Requests (PARs)

Unless otherwise noted, all HCBS services require prior approval before they can be reimbursed by Health First Colorado. Case Management Agencies complete the Prior Approval and/or Cost Containment requests for their specific programs according to instructions published in the regulations for the Department of Health Care Policy & Financing (the Department).

Refer to Appendix A located on the Billing Manuals web page under the Appendices drop-down for telephone numbers.

The following services have additional state approval processes beyond the PAR:

  • Services above the daily cost containment limit
  • Home modifications
  • Mental health counseling (beyond 30 visits),
  • Substance Abuse Counseling (beyond 30 visits)

Assistive Technology (beyond medication reminders). Provider Agencies may contact the CMA for the status of the PAR or inquire electronically through the Health First Colorado Provider Web Portal.

The CMAs responsibilities include, but not limited to:

  • Informing Members and/or legal guardian of the eligibility process.
  • Submitting a copy of the approved Enrollment Form to the County Department of Human/Social Services for a Health First Colorado Member identification number.
  • Developing the appropriate Prior Approval and/or Cost Containment Record Form of services and projected costs for approval.
  • Submitting the Prior Authorization and/or Cost Containment information to the authorizing agent. Refer to Appendix D located on the Billing Manuals web page under the Appendices drop-down for a list of authorizing agents.
  • Assessing the Member's health and social needs.
  • Arranging for face-to-face contact with the Member within 10 calendar days of receipt of the referral.
  • Monitoring and evaluating services.
  • Reassessing each Member.
  • Demonstrating continued cost-effectiveness whenever services increase or decrease.

Approval of prior authorization does not guarantee Health First Colorado payment and does not serve as a timely filing waiver. Prior authorization only assures that the approved service is a medical necessity and is considered a benefit of the Health First Colorado. All claims, including those for prior authorized services, must meet eligibility and claim submission requirements (e.g., timely filing, Provider information completed appropriately, required attachments included, etc.) before payment can be made.

Prior approvals must be completed thoroughly and accurately. If an error is noted on an approved request, it should be brought to the attention of the Member's Case Manager for corrections. Procedure codes, quantities, etc., may be changed or entered by the Member's Case Manager.

The authorizing agent or Case Management Agency is responsible for timely submission and distribution of copies of approvals to agencies and Providers contracted to provide services.

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PAR Submission

The HCBS-BI, CMHS, and EBD forms are submitted electronically via the Bridge by CMA Case Managers. The Bridge directly interfaces with the Colorado interChange System. Access to the Bridge is accomplished via the Medicaid Enterprise User Provisioning System (MEUPS).

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Consumer Directed Attendant Support Services (CDASS)

For Members authorized to receive CDASS, Case Managers will need to enter the data into one of the web-based systems in addition to sending a PAR to the Department's fiscal agent. Members have the option to receive Financial Management Services (FMS) from one (1) of two (2) FMS vendors:

  • Palco
  • Public Partnerships, LLC (PPL)

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PAR Form Instructional Reference Table

Field LabelCompletion FormatInstructions
PA Number being revised Conditional
Complete if PAR is a revision. Indicate original PAR number assigned.
RevisionCheck box
Yes/No
Required
Check the appropriate box.
Client NameTextRequired
Enter the Member's last name, first name and middle initial.
Example: Adams, Mary A.
Client ID7 characters, a letter prefix followed by six numbersRequired
Enter the Member's state identification number. This number consists of a letter prefix followed by six numbers.
Example: A123456
SexCheck box
M F
Required
Check the appropriate box.
Birthdate6 numbers
(MM/DD/YY)
Required
Enter the Member's birth date using MM/DD/YY format.
Example: January 1, 2015 = 01/01/15.
Requesting Provider #8 numbersRequired
Enter the eight-digit Health First Colorado Provider Agency number of the requesting Provider Agency.
Client's CountyTextRequired
Enter the member's county of residence  
Case Number (Agency Use)TextOptional
Enter up to 12 characters, (numbers, letters, hyphens) which helps identify the claim or Member.
Dates Covered
(From/Through)
6 numbers for from date and 6 numbers for through date
(MM/DD/YY)
Required
Enter PAR start date and PAR end date.
Services DescriptionTextNot required
List of approved procedure codes for qualified and demonstration services.
ProviderTextOptional CMA use)
Enter up to 12 characters to identify Provider Agency.
Modifier2 LettersRequired
The alphanumeric values in this column are standard and static and cannot be changed.
Max # UnitsNumberRequired
Enter the number of units next to the services being requested for reimbursement.
Cost Per UnitDollar AmountRequired
Enter cost per unit of service.
Total $ AuthorizedDollar AmountRequired
The dollar amount authorized for this service automatically populates.
CommentsTextOptional
Enter any additional useful information. For example, if a service is authorized for different dates than in Dates Covered" field, please include the HCPCS procedure code and date span here.
Total Authorized HCBS ExpendituresDollar AmountRequired
Total automatically populates.
Plus Total Authorized Home Health Expenditures
(Sum of Authorized Home Health Services during the HCBS Care Plan Period)
Dollar AmountRequired
Enter the total Authorized Home Health expenditures.
Equals Client's Maximum Authorized CostDollar AmountRequired
The sum of HCBS Expenditures + Home Health Expenditures automatically populates.
Number of Days CoveredNumberRequired
The number of days covered automatically populates.
Average Cost Per DayDollar AmountRequired
The Member's maximum authorized cost divided by number of days in the care plan period automatically populates.
CDASS

Effective Date Monthly Allocation Amt.
Date (MM/DD/YY)
Dollar Amount
Required for CIH (formerly SCI), BI, CMHS and EBD
Enter CDASS information (All CDASS information must be entered in the FMS web portal).
Immediately prior to HCBS enrollment, this client lived in a long-term care facilityCheck box
Yes/No
Required
Check the appropriate box.
Case Manager NameTextRequired
Enter the name of the Case Manager.
AgencyTextRequired
Enter the name of the Case Management Agency.
Phone #10 Numbers
123-456-7890
Required
Enter the phone number of the Case Manager.
EmailTextRequired
Enter the email address of the Case Manager.
Date6 Numbers
(MM/DD/YY)
Required
Enter the date completed.
Case Manager's Supervisor NameTextRequired
Enter the name of the Case Manager's Supervisor.
AgencyTextRequired
Enter the name of the Case Management Agency.
Phone #10 Numbers
123-456-7890
Required
Enter the phone number of the Case Manager's Supervisor.
EmailTextRequired
Enter the email address of the Case Manager's Supervisor.
Date6 Numbers
(MM/DD/YY)
Required
Enter the date of PAR completion.

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Claim Submission

Submission of claims for services rendered must not be duplicative. Provider Agencies cannot be reimbursed for delivering the same service to the same Member on the same day at the same time, whether such services are billed on the same claim or on multiple/different claims. Additionally, Provider Agencies are barred from billing services that share or have overlapping service definitions but are described by different procedure codes on the same day to the same Member. Collectively referred to as duplicate claims, reimbursement for such claims requires clear documentation of the necessity of the service and that there was not duplicative service delivery. 

Refer to the service definitions on the Colorado Code of Regulations website to identify if claims are duplicative based on services rendered. Refer to the Provider specialty code enrollment requirements on the HCBS Provider Specialty Code List web page to identify services that may be provided by an individual provider. Provider Agencies may only bill for services approved in Members’ service plans.

In any instance in which duplicate claim submission results in Medicaid reimbursement, the Department has the authority to recoup funds from Provider Agencies.

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information, including claims submission.

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Denver Regional Pricing

Certain HCBS delivered to members while they are within the City and County of Denver are eligible for higher rates.  Information relative to these services, and guidance on the applicability of these rates to certain services, can be found in the Denver Minimum Wage Pricing Appendix, on the Department’s billing manual page under “HCBS”.

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Persons with a Brain Injury (HCBS-BI)

The Home and Community Based Services Brain Injury (HCBS-BI) waiver program provides a variety of services to qualified Members with brain injury as an alternative to inpatient hospital and nursing facility placement. Members meeting program eligibility requirements are certified as medically eligible for HCBS-BI by the Case Manager.

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HCBS-BI Procedure Code Table

Provider Agencies may bill the following procedure codes for HCBS-BI services:

HCBS-BI Procedure Code Table
DescriptionProcedure Code + ModifiersUnits
Specialty 601: Adult Day Services
Adult Day Services, Tier 1S5100U61 unit = 15 minutes, maximum of two (2) hours per day
Adult Day Services, Tier 2S5102U61 unit = 2+ hours
Specialty 603: Assistive Technology Purchase
Assistive DevicesT2029U6Negotiated by Case Manager through prior authorization.
Specialty 609: Behavioral Programming
Behavioral ServicesH0025U61 unit = 30 minutes
Specialty 682: Transitional Living Program
Brain Injury Transitional Living Program (BI TLP)T2016U61 unit = 1 day
Specialty 702: FMS/CDASS
Consumer Directed Attendant Support Services (CDASS)  - Homemaker/ Personal Care/Health MaintenanceT2025U61 unit = 15 minutes
CDASS Per Member/Per Month (PM/PM) - Public Partnerships, LLC- FEA & Palco- FEAT2040U61 unit = 1 month
Specialty 641: Day Treatment
Day TreatmentH2018U61 unit = 1 day
Specialty 752: Home Delivered Meals
Home Delivered MealsS5170U61 unit = 1 meal
Home Delivered Meals after 1st discharge from a 24hr hospitalizationS5170U6, TF1 unit = 1 meal
Home Delivered Meals after 2nd discharge from a 24hr hospitalizationS5170U6, TG1 unit = 1 meal
Specialty 651: Home Modifications
Home ModificationsS5165U61 unit = half of each modification
Specialty 654: Independent Living Skills Training
Independent Living Skills Training (ILST)T2013U61 unit = 15 minutes
Specialty 635: Community Mental Health Services
Mental Health Counseling, FamilyH0004U6, HR1 unit = 15 minutes
Mental Health Counseling, GroupH0004U6, HQ1 unit = 15 minutes
Mental Health Counseling, IndividualH0004U61 unit = 15 minutes
Specialty 660: Non-Medical Transportation
Non-Medical Transportation (NMT), TaxiA0100U61 unit = one-way trip
Non-Medical Transportation (Taxi) to and From Adult DayA0100U6, HB1 unit = one-way trip
NMT, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
U6
U6, TT
U6, TN
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Mobility Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
U6, HB
U6, TT, HB
U6, TN, HB
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
U6
U6, TT
U6, TN
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Wheelchair Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
U6, HB
U6, TT, HB
U6, TN, HB
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
Non-Medical Transportation (NMT), Local Public Transit
RTD Local - Monthly Pass
RTD Local - 10-ride book
RTD Local - Day Pass
RTD Local - 3-Hour Pass
RTD Local - Access-A-Ride Single
RTD Local - Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
U6, TT
U6, TK
U6, TF
U6, TN
U6, SE
U6, TG
1 unit = 1 Monthly Pass
1 unit = 1 10-Ride ticket book
1 unit = 1 Day Pass
1 unit = 1 3-Hour Pass
1 unit = 1 Single Ticket
1 unit = 1 6-Ride ticket book
Non-Medical Transportation (NMT), Local Public Transit Adult Day
RTD Local - Monthly Pass
RTD Local - 10-ride book
RTD Local - Day Pass
RTD Local - 3-Hour Pass
RTD Local - Access-A-Ride Single
RTD Local - Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
U6, TT, HB
U6, TK, HB
U6, TF, HB
U6, TN, HB
U6, SE, HB
U6, TG, HB
1 unit = 1 Monthly Pass
1 unit = 1 10-Ride ticket book
1 unit = 1 Day Pass
1 unit = 1 3-Hour Pass
1 unit = 1 Single Ticket
1 unit = 1 6-Ride ticket book
Non-Medical Transportation (NMT), Regional Public Transit
RTD Regional - Monthly Pass
RTD Regional - 10-ride book
RTD Regional - Day Pass
RTD Regional - 3-Hour Pass
RTD Regional - Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
U6, CG
U6, TJ
U6, TU
U6, EY
U6, HC
1 unit = 1 Monthly Pass
1 unit = 1 10-Ride ticket book
1 unit = 1 Day Pass
1 unit = 1 3-Hour Pass
1 unit = 1 Single Ticket
Non-Medical Transportation (NMT), Regional Public Transit, Adult Day
RTD Regional - Monthly Pass
RTD Regional - 10-ride book
RTD Regional - Day Pass
RTD Regional - 3-Hour Pass
RTD Regional - Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
U6, CG, HB
U6, TJ, HB
U6, TU, HB
U6, EY, HB
U6, HC, HB
1 unit = 1 Monthly Pass
1 unit = 1 10-Ride ticket book
1 unit = 1 Day Pass
1 unit = 1 3-Hour Pass
1 unit = 1 Single Ticket
Specialty 745: Peer Mentorship
Peer MentorshipH2015U61 unit = 15 minutes
Specialty 666: Personal Care
Personal CareT1019U61 unit = 15 minutes
Personal Care, RelativeT1019U6, HR1 unit = 15 minutes
Specialty 643: Electronic Monitoring
Personal Emergency Response System (PERs) Install/PurchaseS5160U6Negotiated by Case Manager through prior authorization.
PERs, MonitoringS5161U6Negotiated by Case Manager through prior authorization.
Medication Reminder, MonitoringS5185U61 unit per month
Medication Reminder, Install/PurchaseT2029U6, SE1 unit = Purchase
Specialty 675: Respite
Respite Care, In Home – Outside Denver CountyS5150U61 unit = 15 minutes
Respite Care, In Home – Denver CountyS5150U6, HX1 unit = 15 minutes
Respite Care, Nursing Facility (NF)H0045U61 unit = 1 day
Specialty 678: Substance Abuse Counseling
Substance Abuse Counseling, FamilyT1006U6, HR, HF1 unit = 1 hour
Substance Abuse Counseling, GroupH0047U6, HQ, HF1 unit = 1 hour
Substance Abuse Counseling, IndividualH0047U6, HF1 unit = 1 hour
Specialty 680: Supported Living Program
Supportive Living Program (SLP) Acuity Tier 1T2033U61 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 2T2033U6, HB1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 3T2033U6, HE1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 4T2033U6, HK1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 5T2033U6, HB, HE1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 6T2033U6, HB, HK1 unit = 1 day
Supportive Living Program (SLP) - Negotiated RateT2033U6, HB, HK, SC1 unit = 1 day
Specialty 636: Transition Setup
Transition Setup - CoordinatorT2038U61 unit = 15 minutes
Transition Setup - Setup ExpensesA9900U6One-time payment = purchase = $2000.00 available for up to 30 days following HCBS enrollment. An additional $500.00 available with Department approval
Specialty 756: Remote Supports
Remote Supports ServiceO593TU61 unit = 15 Minutes
Remote Supports Technology (Install/purchase)A9279U61 unit = Monthly Purchase

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Paper Claim Reference Table

The following paper form reference table gives required and/or conditional fields for the paper CMS 1500 claim form for BI claims:

CMS Field Number and LabelField is?Instructions
1. Insurance TypeRequiredPlace an "X" in the box marked as Medicaid.
1a. Insured's ID NumberRequiredEnter the Member's Health First Colorado seven-digit ID number as it appears on the Health First Colorado Identification card. Example: A123456.
2. Patient's NameRequiredEnter the Member's last name, first name, and middle initial.
3. Patient's Date of Birth/SexRequiredEnter the Member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the Member.
4. Insured's NameNot required 
5. Patient's AddressNot Required 
6. Client Relationship to InsuredNot Required 
7. Insured's AddressNot Required 
8. Reserved for NUCC UseNot Required 
9. Other Insured's NameNot Required 
9a. Other Insured's Policy or Group NumberNot Required 
9b. Reserved for NUCC Use  
9c. Reserved for NUCC Use  
9d. Insurance Plan or Program NameNot Required 
10a-c. Is patient's condition related to?Not Required 
10d. Reserved for Local Use  
11. Insured's Policy, Group or FECA NumberNot Required 
11a. Insured's Date of Birth, SexNot Required 
11b. Other Claim IDNot Required 
11c. Insurance Plan Name or Program NameNot Required 
11d. Is there another Health Benefit Plan?Not Required 
12. Patient's or Authorized Person's signatureRequiredEnter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's SignatureNot Required 
14. Date of Current Illness Injury or PregnancyNot Required 
15. Other DateNot Required 
16. Date Patient Unable to Work in Current OccupationNot Required 
17. Name of Referring PhysicianConditional 
18. Hospitalization Dates Related to Current ServiceNot Required 
19. Additional Claim InformationConditional 
20. Outside Lab?
$ Charges
Not Required 
21. Diagnosis or Nature of Illness or InjuryRequiredEnter at least one but no more than twelve diagnosis codes based on the Member's diagnosis/condition.

Enter applicable ICD-10 indicator.

HCBS
HCBS may use R69.
22. Medicaid Resubmission CodeConditionalList the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior AuthorizationConditionalHCBS
Leave blank
24. Claim Line DetailInformationThe paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of ServiceRequired

The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.

FromTo
010119   

or

FromTo
010119010119

Span dates of service

FromTo
010119013119

Practitioner claims must be consecutive days.
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

24B. Place of ServiceRequired

Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.

11Office
12Home

Note: Use POS Code 12 (Home) for Alternative Care Facility, Adult Day Program or Respite in the Facility

24C. EMGNot Required 
24D. Procedures, Services, or SuppliesRequiredEnter the HCPCS procedure code that specifically describes the service for which payment is requested.

HCBS
Refer to the HCBS-BI Procedure Code Table.
24D. ModifierConditionalEnter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

HCBS
Refer to the HCBS-BI Procedure Code Table.
24E. Diagnosis PointerRequiredEnter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ ChargesRequiredEnter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or UnitsRequiredEnter the number of services provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.
24G. Days or UnitsGeneral InstructionsA unit represents the number of times the described procedure or service was rendered.

Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.

Home and Community Based Services
Combine units of services for a single procedure code for the billed time period on one detail line. Dates of service do not have to be reported separately. Example: If forty units of personal care services were provided on various days throughout the month of January, bill the personal care procedure code with a From Date of 01/03/XX and a To Date of 01/31/XX and 40 units.
24H. EPSDT/Family PlanNot Required 
24I. ID QualifierNot Required 
24J. Rendering Provider ID #RequiredIn the shaded portion of the field, enter the NPI of the Health First Colorado Provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID NumberNot Required 
26. Patient's Account NumberOptionalEnter information that identifies the Member or claim in the Provider Agency's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment?RequiredThe accept assignment indicates that the Provider Agency agrees to accept assignment under the terms of the payer's program.
28. Total ChargeRequiredEnter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount PaidNot Required 
30. Rsvd for NUCC Use  
31. Signature of Physician or Supplier Including Degrees or CredentialsRequiredEach claim must bear the signature of the enrolled Provider Agency or the signature of a registered authorized agent.

Each claim must have the date the enrolled Provider Agency or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #
ConditionalEnter the name, address and ZIP code of the individual or business where the Member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado Mrovider number of the individual or organization.
33. Billing Provider
Info & Ph #
RequiredEnter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI NumberRequired 
33b- Other ID # If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado Provider number of the individual or organization.

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Community Mental Health Supports (CMHS) and Persons Who are Elderly, Blind and Disabled (EBD)

The HCBS-CMHS and EBD waiver programs provide a variety of services to the Elderly, Blind and Disabled (EBD), and Community Mental Health Supports (HCBS-CMHS), formally known as Persons with Major Mental Illness (MI), as an alternative to nursing facility, and inpatient hospitals to qualified Members. Members meeting program eligibility requirements are certified by the Case Management Agency as medically eligible for these HCBS waiver programs. These three waivers offer all of the following services:

  • Alternative Care Facility - Alternative Care Services means, but is not limited to, a package of personal care and homemaker services provided in a state-certified alternative care facility including assistance with bathing, skin, hair, nail and mouth care, shaving, dressing, feeding, ambulation, transfers, and positioning, bladder and bowel care, medication reminding, accompanying, routine housecleaning, meal preparation, bed making, laundry and shopping. Reimbursement shall be per unit, with one unit equaling one day of care.
  • Adult Day Services (Basic) - Services delivered on a tiered basis.
    • Tier I - Services provided virtually or in-person in an outpatient setting to include parks or other community-based locations. Meal provision not required if services are not provided in person or over the lunch hour. Service can be provided up to three hours per day.
    • Tier II - Services provided between three (3) - five (5) hours per day as approved by the Case Manager and in the context of the Member's health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the Member's home.
  • Tier III - Services provided over a full day as approved by the Case Manager and in the context of the member's health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the Member's home. Tier I Adult Day Services cannot be provided in conjunction with this service.
  • Adult Day Services (Specialized) - Services provided between three (3) - five (5) or more hours per day on a regularly scheduled basis, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual's plan of care would be provided as component parts of this service if such services are not being provided in the Member's home. Tier I Adult Day Services cannot be provided in conjunction with this service.
  • Electronic Monitoring (Personal Emergency Response Systems) - An electronic device, which enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once a help" button is activated. Monitoring of the device is included in the PERS service. The response center is staffed by trained professionals.
  • Electronic Monitoring (Medication Reminders) - Medication reminders are devices, controls, or appliances which enable an individual at high risk of institutionalization to increase their abilities to perform activities of daily living, such as medication administration. Medication reminders shall include devices or items that remind or signal the member to take prescribed medications. Medication reminders may include other devices necessary for the proper functioning of such items and may also include durable and non-durable medical equipment not available as a State plan benefit. 
  • Homemaker - Services consisting of general household activities (meal preparation and routine household care) provided by a trained homemaker. Provided when the individual regularly responsible for these activities is temporarily absent or unable to manage the home and care for him or herself or others in the home.
  • Home Modifications - Specific modifications, adaptations or improvements in an eligible Member's existing home setting which, based on the Member's medical condition are necessary to ensure the health, welfare and safety of the Member, enable the Member to function with greater independence in the home, are required because of the Member's illness, impairment or disability, as documented on the ULTC-100.2 form and the care plan and prevents institutionalization of the Member. There shall be a lifetime cap of $14,000.00 per Member.
  • Personal Care - Assistance with eating, bathing, dressing, personal hygiene, activities of daily living. These services may include assistance with preparation of meals but does not include the cost of the meals themselves. When specified in the service plan, this service may also include such housekeeping chores as bed making, dusting and vacuuming. Services are incidental to the care provided or are essential to the health and welfare of the individual, rather than the individual's family. Payment will not be made for services provided to a minor by the child's parent (or stepparent), or to an individual by the person's spouse.
  • Relative Personal Care - Personal Care Providers may be members of the Member's family. The number of Health First Colorado personal care units provided by any single member of the Member's family shall not exceed the equivalent of 444 personal care units per annual certification. Payment will not be made for services provided to an individual by an individual's spouse employed by a Personal Care Agency.
  • Respite care - Services provided to an eligible Member on a short-term basis because of the absence or need for relief of those persons normally providing the care. The unit of reimbursement shall be a unit of one day for care provided in a Nursing Facility or Alternative Care Facility. Individual Respite Providers shall bill according to an hourly rate or daily institutional Nursing Facility rate, whichever is less.
  • Non-Medical Transportation - Service offered in order to enable individuals served on the waiver to gain access to waiver and other community services, activities and resources, specified by the service plan. This service is offered in addition to medical transportation required under 42 CFR 431.53 and transportation services under the State Plan, defined at 42 CFR 440.170 (a) (if applicable), and shall not replace them.
    Non-Medical Transportation will be limited to two (2) roundtrips per week. Trips to and from adult day programs are not subject to this cap.
  • Consumer Directed Attendant Support Services (CDASS) - CDASS is a service delivery option that offers HCBS-EBD, HCBS-CMHS, and HCBS-BI Members the opportunity to direct personal care, homemaker and health maintenance tasks. Members may also designate an authorized representative to direct these activities on their behalf.
  • Home Delivered Meals - Includes nutritional counseling, planning, preparation, and delivery of meals. Must demonstrate need for the service in Service Plan: demonstrated need for nutritional counseling, meal planning, and preparation, dietary restrictions or specific nutritional needs, unable to prepare their own meals, limited or no outside assistance, inability to access and prepare nutritious meals demonstrates a need-related risk to health, safety or institutionalization. Home Delivered Meals are limited to two (2) meals per day up to 14 meals per week, up to 365 days post-transition.
  • A new expansion effective April 1, 2023, allows for home delivered meals following a 24hr hospitalization providing up to 30 days of meals post discharge two times within a certification period. Members have up to 30 days post discharge to opt in to receive this benefit.
  • Life Skills Training - Individualized training, provided in a Member's residence, the community, or group living situations, that is designed and directed with the Member to develop and maintain the ability to independently sustain himself/herself in the community. Must demonstrate need for the service in Service Plan: need for training to sustain self in the community, skills for which training is needed and that without poses a risk to the health, safety, or ability to live in the community, without training individual could not develop the skills needed, with training ability to acquire these skills within 365 days. Life Skills Training is limited to up to 24 units per day with no more than 160 units per week, up to 365 days post-transition.
  • Peer Mentorship - Provided by peers to promote self-advocacy and encourage community living by instructing and advising on issues and topics related to community living, describing real-world experiences as examples, and modeling successful community living and problem-solving. Must demonstrate the need for the service in Service Plan: need for soft skills, insight, or guidance from a peer, without service may experience a health, safety, or institutional risk, no other services or resources available to meet the need. Peer Mentorship is limited to 24 units per day for 365 days post-transition.
  • Remote Supports - Remote Supports service provides live, two (2)-way virtual coaching, supervision and cues from a virtual attendant for everyday activities of daily living that do not require hands-on assistance to be completed safely. These supports can help a Member live more independently in their home and community. Services may include prompts and reminders for such needs as dressing, cooking support, overnight support and fall detection. Remote Supports Technology is included to purchase and install devices that support the delivery of Remote Supports.
  • Transition Setup - Coordination and coverage of one-time, non-recurring expenses to establish a basic household upon transition from nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or Regional Center to a community living arrangement not operated by the state. 
    Note: This is not available for transition to Provider-owned settings (e.g., ACF, Host Home, Group Home, or SLP. This is not available in a community-to-community transition.] Units limited to 40, up to 30 days post-transition.

The HCBS-EBD program offers the following additional services:

  • In-Home Support Services (IHSS) - IHSS includes health maintenance activities, support for activities of daily living or instrumental activities of daily living, personal care service and homemaker services. Additionally, IHSS Providers are required to provide the core independent living skills. This service is only available for EBD, CIH (formerly SCI) and CHCBS Members.

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HCBS-CMHS Procedure Code Table

Providers may bill the following procedure codes for HCBS-CMHS services:

HCBS-CMHS Procedure Code Table
DescriptionProcedure Code + ModifiersUnits
Specialty 601: Adult Day Services
Adult Day Services, Basic Tier 1S5100UA1 unit = 15 minutes, maximum of 3 hours per day
Adult Day ServicesS5105UA1 unit = 3-5 hours
Adult Day Services, SpecializedS5105UA, TF1 unit = 3-5 hours
Specialty 602: Alternative Care Facility
Alternative Care FacilityT2031UA1 unit =1 day
Specialty 702: FMS/CDASS
Consumer Directed Attendant Support Services (CDASS) - HomemakerT2025UA1 unit = 15 minutes
CDASS Personal CareT2025UA15 minutes
CDASS Health MaintenanceT2025UA15 minutes
CDASS Per Member/Per Month (PM/PM) - Public Partnerships, LLC- FEAT2040UA1 unit = 1 month
Public Partnerships, LLC - FEAT2040UA1 unit = 1 month
Specialty 752: Home Delivered Meals
Home Delivered MealsS5170UA1 unit = 1 meal
Home Delivered Meals after 1st discharge from a 24-hr hospitalizationS5170UA, TF1 unit = 1 meal
Home Delivered Meals after 2nd discharge from a 24-hr hospitalizationS5170UA, TG1 unit = 1 meal
Specialty 651: Home Modifications
Home ModificationsS5165UA1 unit = 1 modification
Specialty 753: Life Skills Training
Life Skills TrainingH2014UA1 unit = 15 minutes
Specialty 666: Non-Medical Transportation
Non-Medical Transportation (NMT), TaxiA0100UA1 unit = one-way trip
Non-Medical Transportation (Taxi), to and From Adult DayA0100UA, HB1 unit = one-way trip
NMT, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
UA
UA, TT
UA, TN
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Mobility Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
UA, HB
UA, TT, HB
UA, TN, HB
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
UA
UA, TT
UA, TN
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Wheelchair Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
UA, HB
UA, TT, HB
UA, TN, HB
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
Non-Medical Transportation (NMT), Local Public Transit
RTD Local - Monthly Pass
RTD Local - 10-ride book
RTD Local - Day Pass
RTD Local - 3-Hour Pass
RTD Local - Access-A-Ride Single
RTD Local - Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
UA, TT
UA, TK
UA, TF
UA, TN
UA, SE
UA, TG
1 unit = 1 Monthly Pass
1 unit = 1 10-Ride ticket book
1 unit = 1 Day Pass
1 unit = 1 3-Hour Pass
1 unit = 1 Single Ticket
1 unit = 1 6-Ride ticket book
Non-Medical Transportation (NMT), Local Public Transit Adult Day
RTD Local - Monthly Pass
RTD Local - 10-ride book
RTD Local - Day Pass
RTD Local - 3-Hour Pass
RTD Local - Access-A-Ride Single
RTD Local - Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
UA, TT, HB
UA, TK, HB
UA, TF, HB
UA TN, HB
UA, SE, HB
UA, TG, HB
1 unit = 1 Monthly Pass
1 unit = 1 10-Ride ticket book
1 unit = 1 Day Pass
1 unit = 1 3-Hour Pass
1 unit = 1 Single Ticket
1 unit = 1 6-Ride ticket book
Non-Medical Transportation (NMT), Regional Public Transit
RTD Regional - Monthly Pass
RTD Regional - 10-ride book
RTD Regional - Day Pass
RTD Regional - 3-Hour Pass
RTD Regional - Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
UA, CG
UA, TJ
UA, TU
UA, EY
UA, HC
1 unit = 1 Monthly Pass
1 unit = 1 10-Ride ticket book
1 unit = 1 Day Pass
1 unit = 1 3-Hour Pass
1 unit = 1 Single Ticket
Non-Medical Transportation (NMT), Regional Public Transit, Adult Day
RTD Regional - Monthly Pass
RTD Regional - 10-ride book
RTD Regional - Day Pass
RTD Regional - 3-Hour Pass
RTD Regional - Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
UA, CG, HB
UA, TJ, HB
UA, TU, HB
UA, EY, HB
UA, HC, HB
1 unit = 1 Monthly Pass
1 unit = 1 10-Ride ticket book
1 unit = 1 Day Pass
1 unit = 1 3-Hour Pass
1 unit = 1 Single Ticket
Specialty 754: Peer Mentorship
Peer MentorshipH2015UA1 unit = 15 minutes
Specialty 666: Personal Care/Homemaker
Homemaker – Outside Denver CountyS5130UA1 unit = 15 minutes
Personal CareT1019UA1 unit = 15 minutes
Personal Care, RelativeT1019UA, HR1 unit = 15 minutes
Specialty 643: Electronic Monitoring
Personal Emergency Response System (PERs) Install/PurchaseS5160UA1 unit = purchase and installation
PERs, MonitoringS5161UA1 unit = 1 month of service
Medication Reminder, Install/PurchaseT2029UA1 unit = 1 purchase
Medication Reminder, MonitoringS5185UA1 unit per month
Specialty 675: Respite
Respite Care, Alternative Care Facility (ACF)S5151UA1 unit = 1 day
Respite Care, Nursing Facility (NF)H0045UA1 unit = 1 day
Specialty 636 Transition Setup
Transition Setup - CoordinatorT2038UA1 unit = 15 minutes
Transition Setup - Setup ExpensesA9900UAOne-time payment = $2000.00 available for up to 30 days following HCBS enrollment. An additional $500.00 available with Department approval.
Mental Health Transitional Living Homes - Level 1T2033UA, HB1 unit = 1 day
Specialty 756: Remote Supports
Remote Supports ServiceO593T  UA1 unit = 15 Minutes
Remote Supports Technology (Install/purchase)A9279UA1 unit = Monthly Purchase

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HCBS-EBD Procedure Code Table

Providers may bill the following procedure codes for HCBS-EBD services:

HCBS-EBD Procedure Code Table
DescriptionProcedure Code + ModifiersUnits
Specialty 601: Adult Day Services
Adult Day Services, Basic Tier 1 – Outside Denver CountyS5100U11 unit = 15 minutes, maximum of 3 hours per day
Adult Day Services, Basic, Tier 2 – Outside Denver CountyS5105U11 unit = 3-5 hours
Adult Day Services, Specialized – Outside Denver CountyS5105U1, TF1 unit = 3-5 hours
Specialty 602: Alternative Care Facility
Alternative Care FacilityT2031U11 unit = 1 day
Specialty 636: Transition Setup
Community Transition Services, CoordinatorT2038U11 unit = 1 transition
Community Transition Services, Setup ExpensesA9900U11 unit = purchase = $2000.00 available for up to 30 days following HCBS enrollment. An additional $500.00 available with Department approval.
Specialty 702: FMS/CDASS
Consumer Directed Attendant Support Services (CDASS) -HomemakerT2025U11 unit = 15 minutes
CDASS Personal CareT2025U115 minutes
CDASS Health MaintenanceT2025U115 minutes
CDASS Per Member/Per Month (PM/PM) - Public Partnerships, LLC- FEAT2040U11 unit = 1 month
Public Partnerships, LLC - FEAT2040U11 unit = 1 month
Specialty 752: Home Delivered Meals
Home Delivered MealsS5170U11 unit = 1 meal
Home Delivered Meals after 1st discharge from a 24hr hospitalizationS5170U1, TF1 unit = 1 meal
Home Delivered Meals after 2nd discharge from a 24hr hospitalizationS5170U1, TG1 unit = 1 meal
Specialty 651: Home Modifications
Home ModificationsS5165U11 unit = 1 modification
Specialty 656: In-Home Support Services
IHSS Health Maintenance Activities H0038U11 unit = 15 minutes
IHSS Personal Care ServiceT1019U1, KX1 unit = 15 minutes
IHSS Relative Personal CareT1019U1, HR, KX1 unit = 15 minutes
IHSS Homemaker Service S5130U1, KX1 unit = 15 minutes
Specialty 753: Life Skills Training
Life Skills TrainingH2014U11 unit = 15 minutes
Specialty 643: Electronic Monitoring
Medication Reminder, Install/PurchaseT2029U11 unit = 1 purchase
Medication Reminder, MonitoringS5185U11 unit per month
Personal Emergency Response System (PERs) Install/PurchaseS5160U11 unit = purchase and installation
PERs, MonitoringS5161U11 unit = 1 month of services
Specialty 660: Non-Medical Transportation
Non-Medical Transportation (NMT), TaxiA0100U11 unit = one-way trip
Non-Medical Transportation (Taxi), to and From Adult DayA0100U1, HB1 unit = one-way trip
NMT, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
U1
U1, TT
U1, TN
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Mobility Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
U1, HB
U1, TT, HB
U1, TN, HB
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
U1
U1, TT
U1, TN
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
NMT, Wheelchair Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
U1, HB
U1, TT, HB
U1, TN, HB
1 unit = one-way trip
1 unit = one-way trip
1 unit = one-way trip
Non-Medical Transportation (NMT), Local Public Transit
RTD Local - Monthly Pass
RTD Local - 10-ride book
RTD Local - Day Pass
RTD Local - 3-Hour Pass
RTD Local - Access-A-Ride Single
RTD Local - Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
U1, TT
U1, TK
U1, TF
U1, TN
U1, SE
U1, TG
1 unit = (1) Monthly Pass
1 unit = (1) 10-Ride ticket book
1 unit = (1) Day Pass
1 unit = (1) 3-Hour Pass
1 unit = (1) Single Ticket
1 unit = (1) 6-Ride ticket book
Non-Medical Transportation (NMT), Local Public Transit Adult Day
RTD Local - Monthly Pass
RTD Local - 10-ride book
RTD Local - Day Pass
RTD Local - 3-Hour Pass
RTD Local - Access-A-Ride Single
RTD Local - Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
U1, TT, HB
U1, TK, HB
U1, TF, HB
U1, TN, HB
U1, SE, HB
U1, TG, HB
1 unit = (1) Monthly Pass
1 unit = (1) 10-Ride ticket book
1 unit = (1) Day Pass
1 unit = (1) 3-Hour Pass
1 unit = (1) Single Ticket
1 unit = (1) 6-Ride ticket book
Non-Medical Transportation (NMT), Regional Public Transit
RTD Regional - Monthly Pass
RTD Regional - 10-ride book
RTD Regional - Day Pass
RTD Regional - 3-Hour Pass
RTD Regional - Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
U1, CG
U1, TJ
U1, TU
U1, EY
U1, HC
1 unit = (1) Monthly Pass
1 unit = (1) 10-Ride ticket book
1 unit = (1) Day Pass
1 unit = (1) 3-Hour Pass
1 unit = (1) Single Ticket
Non-Medical Transportation (NMT), Regional Public Transit, Adult Day
RTD Regional - Monthly Pass
RTD Regional - 10-ride book
RTD Regional - Day Pass
RTD Regional - 3-Hour Pass
RTD Regional - Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
U1, CG, HB
U1, TJ, HB
U1, TU, HB
U1, EY, HB
U1, HC, HB
1 unit = (1) Monthly Pass
1 unit = (1) 10-Ride ticket book
1 unit = (1) Day Pass
1 unit = (1) 3-Hour Pass
1 unit = (1) Single Ticket
Specialty 754: Peer Mentorship
Peer MentorshipH2015U11 unit = 15 minutes
Specialty 666: Personal Care/Homemaker
HomemakerS5130U11 unit = 15 minutes
Personal CareT1019U11 unit = 15 minutes
Personal Care, RelativeT1019U1, HR1 unit = 15 minutes
Specialty 675: Respite
Respite Care, Alternative Care Facility (ACF) S5151U11 unit = 1 day
Respite Care, In Home S5150U11 unit = 15 minutes
Respite Care Nursing Facility (NF)H0045U11 unit = 1 day
Specialty 756: Remote Services
Remote Supports ServiceO593TU11 unit = 15 minutes
Remote Supports Technology (Install/purchase)A9279U11 unit = Monthly Purchase

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HCBS-CMHS and EBD Paper Claim Reference Table

The following paper form reference table gives required and/or conditional fields for the paper CMS 1500 claim form for HCBS-CMHS and HCBS-EBD claims:

CMS Field Number and LabelField is?Instructions
1. Insurance TypeRequiredPlace an "X" in the box marked as Medicaid.
1a. Insured's ID NumberRequiredEnter the Member's Health First Colorado seven-digit ID number as it appears on the Health First Colorado Identification card. Example: A123456.
2. Patient's NameRequiredEnter the Member's last name, first name, and middle initial.
3. Patient's Date of Birth/SexRequiredEnter the Member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the Member.
4. Insured's NameNot required 
5. Patient's AddressNot Required 
6. Client Relationship to InsuredNot Required 
7. Insured's AddressNot Required 
8. Reserved for NUCC UseNot Required 
9. Other Insured's NameNot Required 
9a. Other Insured's Policy or Group NumberNot Required 
9b. Reserved for NUCC Use  
9c. Reserved for NUCC Use  
9d. Insurance Plan or Program NameNot Required 
10a-c. Is patient's condition related to?Not Required 
10d. Reserved for Local Use  
11. Insured's Policy, Group or FECA NumberNot Required 
11a. Insured's Date of Birth, SexNot Required 
11b. Other Claim IDNot Required 
11c. Insurance Plan Name or Program NameNot Required 
11d. Is there another Health Benefit Plan?Not Required 
12. Patient's or Authorized Person's signatureRequiredEnter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's SignatureNot Required 
14. Date of Current Illness Injury or PregnancyNot Required 
15. Other DateNot Required 
16. Date Patient Unable to Work in Current OccupationNot Required 
17. Name of Referring PhysicianConditional 
18. Hospitalization Dates Related to Current ServiceNot Required 
19. Additional Claim InformationConditional 
20. Outside Lab?
$ Charges
Not Required 
21. Diagnosis or Nature of Illness or InjuryRequiredEnter at least one but no more than twelve diagnosis codes based on the Member's diagnosis/condition.

Enter applicable ICD-10 indicator.

HCBS
HCBS may use R69.
22. Medicaid Resubmission CodeConditionalList the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior AuthorizationNot Required 
24. Claim Line DetailInformationThe paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of ServiceRequired

The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.

FromTo
010119   

or

FromTo
010119010119

Span dates of service

FromTo
010119013119

Practitioner claims must be consecutive days.
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

24B. Place of ServiceRequired

Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.

12Home

Note: Use POS Code 12 (Home) for Alternative Care Facility, Adult Day Program, or Respite in the Facility

24C. EMGNot Required 
24D. Procedures, Services, or SuppliesRequiredEnter the HCPCS procedure code that specifically describes the service for which payment is requested.

HCBS
Refer to the HCBS-EBD or HCBS-CMHS procedure code tables.
24D. ModifierConditionalEnter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

HCBS
Refer to the HCBS-EBD or HCBS-CMHS procedure code tables.
24E. Diagnosis PointerRequiredEnter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ ChargesRequiredEnter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or UnitsRequiredEnter the number of services provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.
24G. Days or UnitsGeneral InstructionsA unit represents the number of times the described procedure or service was rendered.

Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.

Home and Community Based Services
Combine units of services for a single procedure code for the billed time period on one detail line. Dates of service do not have to be reported separately. Example: If forty units of personal care services were provided on various days throughout the month of January, bill the personal care procedure code with a From Date of 01/03/XX and a To Date of 01/31/XX and 40 units.
24H. EPSDT/Family PlanNot Required 
24I. ID QualifierNot Required 
24J. Rendering Provider ID #RequiredIn the shaded portion of the field, enter the NPI of the Health First Colorado Provider Agency number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID NumberNot Required 
26. Patient's Account NumberOptionalEnter information that identifies the Member or claim in the Provider Agency's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment?RequiredThe accept assignment indicates that the Provider Agency agrees to accept assignment under the terms of the payer's program.
28. Total ChargeRequiredEnter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount PaidNot Required 
30. Rsvd for NUCC Use  
31. Signature of Physician or Supplier Including Degrees or CredentialsRequiredEach claim must bear the signature of the enrolled Provider Agency or the signature of a registered authorized agent.

Each claim must have the date the enrolled Provider Agency or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #
ConditionalEnter the name, address and ZIP code of the individual or business where the Member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado Provider number of the individual or organization.
33. Billing Provider
Info & Ph #
RequiredEnter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI NumberRequired 
33b- Other ID # If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado Provider Agency number of the individual or organization.

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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HCBS-BI, CMHS and EBD Specialty Manuals Revisions Log

Revision DateAddition/ChangesMade by
12/1/2016Manual revised for interChange implementation. For manual revisions prior to 12/01/2016 Please refer to Archive.HPE (now DXC)
12/27/2016Updates based on Colorado iC Stage II Provider Billing Manual v0_2.xlsxHPE (now DXC)
1/10/2017Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsxHPE (now DXC)
1/19/2017Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsxHPE (now DXC)
1/26/2017Updates based on Department 1/20/2017 approval emailHPE (now DXC)
5/22/2017Updates based on Fiscal Agent name change from HPE to DXCDXC
6/26/2018Updated billing and timely filing to point to general manualHCPF
6/28/2018Minor grammatical edit
Updated claims submission
HCPF
3/18/2019Clarification to signature requirementsHCPF
7/2/2019Updated Appendices' links and verbiageDXC
12/4/2019Updated modifiers for BI waiver serviceHCPF
1/10/2020Updated units for BI waiver serviceHCPF
3/3/2020Converted to web pageHCPF
3/4/2020Updates to NMT services to include public transportation, CDASS FMS providers, added transition servicesHCPF
8/28/2020General updates to language reflecting the use of the Bridge, added Adult Day changes.HCPF
9/14/2020Added Line to Box 32 under the Paper Claim Reference TableHCPF
11/24/2021Added Remote Supports Services effective 1/1/2022HCPF
1/27/2022Removed Remote Supports effective 1/1/2022HCPF
3/7/2022Added Remote Supports effective 3/11/2022HCPF
5/27/2022Consolidated TLP tier into one rate. Added a tier for SLP section for the new negotiated rate. HCPF
8/3/2022Updated Transportation description and moved to align with other similar services HCPF
10/31/2022Added Specialty numbers and arranged services as appropriateHCPF
4/3/2023Updated AWS URL LinksHCPF
4/13/2023Added Home Delivered Meal expansion codesHCPF
2/27/2024Added Denver County codes for TransportationHCPF
4/25/2024Added new Denver County codes, added Medication Reminder, and completed corrections.HCPF
7/19/2024Added duplicative claims language to submissions section. Updated Remote Supports codes.HCPF
12/19/2024Updated codes, added reference to Denver Regional Pricing Appendix, Updated references to agencies in accordance with Case Management Redesign.HCPF

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