- General Information
- Prior Authorization Requests (PARs)
- PAR Submission
- Consumer Directed Attendant Support Services (CDASS)
- PAR Form Instructional Reference Table
- Claim Submission
- Persons with a Brain Injury (HCBS-BI)
- HCBS-BI Procedure Code Table
- HCBS-BI Paper Claim Reference Table
- Community Mental Health Supports (CMHS), and Persons who are Elderly, Blind and Disabled (EBD)
- HCBS-CMHS Procedure Code Table
- HCBS-EBD Procedure Code Table
- HCBS-CMHS and EBD Paper Claim Reference Table
- Timely Filing
- HCBS-BI, CMHS and EBD Specialty Manuals Revisions Log
Return to Billing Manuals Web Page
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 (aka Single Entry Points). 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.
Each waiver has an enrollment limit. Applicants may apply for more than one waiver, but may only receive services through one waiver at a time.
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/single entry points 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 and Financing (the Department).
The telephone numbers are listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.
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). Providers may contact the CMA/SEP for the status of the PAR or inquire electronically through the Health First Colorado Online Portal.
The CMAs/SEPs 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. A list of authorizing agents can be found by referring to Appendix D, listed under the Appendices drop-down section on the Billing Manuals web page.
- 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/single entry point is responsible for timely submission and distribution of copies of approvals to agencies and providers contracted to provide services.
PAR Submission
The HCBS-BI, CMHS, and EBD forms are submitted electronically via the Bridge by CMA/SEP 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).
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)
PAR Form Instructional Reference Table
| Field Label | Completion Format | Instructions |
| PA Number being revised | Conditional Complete if PAR is a revision. Indicate original PAR number assigned. |
|
| Revision | Check box Yes/No |
Required Check the appropriate box. |
| Client Name | Text | Required Enter the member's last name, first name and middle initial. Example: Adams, Mary A. |
| Client ID | 7 characters, a letter prefix followed by six numbers | Required Enter the member's state identification number. This number consists of a letter prefix followed by six numbers. Example: A123456 |
| Sex | Check box M F |
Required Check the appropriate box. |
| Birthdate | 6 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 numbers | Required Enter the eight-digit Health First Colorado provider number of the requesting provider. |
| Client's County | Text | Required |
| Enter the member's county of residence | ||
| Case Number (Agency Use) | Text | Optional 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 Description | Text | Not required List of approved procedure codes for qualified and demonstration services. |
| Provider | Text | Optional (SEP use) Enter up to 12 characters to identify provider. |
| Modifier | 2 Letters | Required The alphanumeric values in this column are standard and static and cannot be changed. |
| Max # Units | Number | Required Enter the number of units next to the services being requested for reimbursement. |
| Cost Per Unit | Dollar Amount | Required Enter cost per unit of service. |
| Total $ Authorized | Dollar Amount | Required The dollar amount authorized for this service automatically populates. |
| Comments | Text | Optional 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 Expenditures | Dollar Amount | Required Total automatically populates. |
| Plus Total Authorized Home Health Expenditures (Sum of Authorized Home Health Services during the HCBS Care Plan Period) |
Dollar Amount | Required Enter the total Authorized Home Health expenditures. |
| Equals Client's Maximum Authorized Cost | Dollar Amount | Required The sum of HCBS Expenditures + Home Health Expenditures automatically populates. |
| Number of Days Covered | Number | Required The number of days covered automatically populates. |
| Average Cost Per Day | Dollar Amount | Required 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 facility | Check box Yes/No |
Required Check the appropriate box. |
| Case Manager Name | Text | Required Enter the name of the Case Manager. |
| Agency | Text | Required Enter the name of the agency. |
| Phone # | 10 Numbers 123-456-7890 |
Required Enter the phone number of the Case Manager. |
| Text | Required Enter the email address of the Case Manager. |
|
| Date | 6 Numbers (MM/DD/YY) |
Required Enter the date completed. |
| Case Manager's Supervisor Name | Text | Required Enter the name of the Case Manager's Supervisor. |
| Agency | Text | Required Enter the name of the agency. |
| Phone # | 10 Numbers 123-456-7890 |
Required Enter the phone number of the Case Manager's Supervisor. |
| Text | Required Enter the email address of the Case Manager's Supervisor. |
|
| Date | 6 Numbers (MM/DD/YY) |
Required Enter the date of PAR completion. |
Claim Submission
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.
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.
HCBS-BI Procedure Code Table
Providers may bill the following procedure codes for HCBS-BI services:
| HCBS-BI Procedure Code Table | |||
| Description | Procedure Code + Modifiers | Units | |
| Specialty 601: Adult Day Services | |||
| Adult Day Services, Tier 1 | S5100 | U6 | 1 unit = 15 minutes, maximum of two (2) hours per day |
| Adult Day Services, Tier 2 | S5102 | U6 | 1 unit = 2+ hours |
| Specialty 603: Assistive Technology | |||
| Assistive Technology | T2029 | U6 | Negotiated by case manager through prior authorization |
| Specialty 609: Behavioral Programming | |||
| Behavioral Programming | H0025 | U6 | 1 unit= 30 minutes |
| Specialty 682: Transitional Living Program | |||
| Brain Injury Transitional Living Program (BI TLP) | T2016 | U6 | 1 unit = 1 day |
| Specialty 702: FMS/CDASS | |||
| Consumer Directed Attendant Support Services (CDASS) (Cent/Unit) | T2025 | U6 | 1 unit = $0.01 |
| CDASS Per Member/Per Month (PM/PM) | T2040 | U6 | 1 unit = 1 month |
| Specialty 641: Day Treatment | |||
| Day Treatment | H2018 | U6 | 1 unit = 1 day |
| Specialty 752: Home Delivered Meals | |||
| Home Delivered Meals | S5170 | U6 | 1 unit = 1 meal |
| Home Delivered Meals after 1st discharge from a 24hr hospitalization | S5170 | U6, TF | 1 unit = 1 meal |
| Home Delivered Meals after 2nd discharge from a 24hr hospitalization | S5170 | U6, TG | 1 unit = 1 meal |
| Specialty 651: Home Modifications | |||
| Home Modifications | S5165 | U6 | 1 unit = half of each modification |
| Specialty 654: Independent Living Skills Training | |||
| Independent Living Skills Training (ILST) | T2013 | U6 | 1 unit = 15 minutes |
| Specialty 635: Community Mental Health Services | |||
| Mental Health Counseling, Family | H0004 | U6, HR | 1 unit = 15 minutes |
| Mental Health Counseling, Group | H0004 | U6, HQ | 1 unit = 15 minutes |
| Mental Health Counseling, Individual | H0004 | U6 | 1 unit = 15 minutes |
| Specialty 660: Non-Medical Transportation | |||
| Non-Medical Transportation (NMT), Taxi | A0100 | U6 | 1 unit=one way trip |
| Non-Medical Transportation (Taxi) to and From Adult Day | A0100 | U6, HB | 1 unit = (1) 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 |
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 |
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 Mentorship | H2015 | U1, SC | 1 unit = 15 minutes |
| Specialty 666: Personal Care | |||
| Personal Care | T1019 | U6 | 1 unit = 15 minutes |
| Personal Care, Relative | T1019 | U6, HR | 1 unit = 15 minutes |
| Specialty 643: Electronic Monitoring | |||
| Personal Emergency Response System (PERs) Install/Purchase | S5160 | U6 | Negotiated by case manager through prior authorization. |
| PERs, Monitoring | S5161 | U6 | Negotiated by case manager through prior authorization. |
| Specialty 675: Respite | |||
| Respite Care, In Home | S5150 | U6 | 1 unit = 15 minutes |
| Respite Care, Nursing Facility (NF) | H0045 | U6 | 1 unit = 1 day |
| Specialty 678: Substance Abuse Counseling | |||
| Substance Abuse Counseling, Family | T1006 | U6 | 1 unit = 1 hour |
| Substance Abuse Counseling, Group | H0047 | U6, HQ | 1 unit = 1 hour |
| Substance Abuse Counseling, Individual | H0047 | U6, HF | 1 unit = 1 hour |
| Specialty 680: Supported Living Program | |||
| Supportive Living Program (SLP) Acuity Tier 1 | T2033 | U6 | 1 unit = 1 day |
| Supportive Living Program (SLP) Acuity Tier 2 | T2033 | U6, HB | 1 unit = 1 day |
| Supportive Living Program (SLP) Acuity Tier 3 | T2033 | U6, HE | 1 unit = 1 day |
| Supportive Living Program (SLP) Acuity Tier 4 | T2033 | U6, HK | 1 unit = 1 day |
| Supportive Living Program (SLP) Acuity Tier 5 | T2033 | U6, HB, HE | 1 unit = 1 day |
| Supportive Living Program (SLP) Acuity Tier 6 | T2033 | U6, HB, HK | 1 unit = 1 day |
| Supportive Living Program (SLP) - Negotiated Rate | T2033 | U6, HB, HK, SC | 1 unit = 1 day |
| Specialty 636: Transition Setup | |||
| Transition Setup - Coordination | T2038 | U6 | 1 unit = 15 minutes |
| Transition Setup - Items Purchased | A9900 | U6 | One-time payment |
| Specialty 756: Remote Supports | |||
| Personal Care – Remote Supports | T1019 | U6, SE | 15 Minutes |
| Remote Supports Technology (Install/purchase) | S5160 | U6, SE | Dollar |
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 & Label | Field is? | Instructions | ||||||||||||||||||||||||||||||||||
| 1. Insurance Type | Required | Place an "X" in the box marked as Medicaid. | ||||||||||||||||||||||||||||||||||
| 1a. Insured's ID Number | Required | Enter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456. | ||||||||||||||||||||||||||||||||||
| 2. Patient's Name | Required | Enter the member's last name, first name, and middle initial. | ||||||||||||||||||||||||||||||||||
| 3. Patient's Date of Birth/Sex | Required | Enter 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. |
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| 4. Insured's Name | Not required | |||||||||||||||||||||||||||||||||||
| 5. Patient's Address | Not Required | |||||||||||||||||||||||||||||||||||
| 6. Client Relationship to Insured | Not Required | |||||||||||||||||||||||||||||||||||
| 7. Insured's Address | Not Required | |||||||||||||||||||||||||||||||||||
| 8. Reserved for NUCC Use | Not Required | |||||||||||||||||||||||||||||||||||
| 9. Other Insured's Name | Not Required | |||||||||||||||||||||||||||||||||||
| 9a. Other Insured's Policy or Group Number | Not Required | |||||||||||||||||||||||||||||||||||
| 9b. Reserved for NUCC Use | ||||||||||||||||||||||||||||||||||||
| 9c. Reserved for NUCC Use | ||||||||||||||||||||||||||||||||||||
| 9d. Insurance Plan or Program Name | Not Required | |||||||||||||||||||||||||||||||||||
| 10a-c. Is patient's condition related to? | Not Required | |||||||||||||||||||||||||||||||||||
| 10d. Reserved for Local Use | ||||||||||||||||||||||||||||||||||||
| 11. Insured's Policy, Group or FECA Number | Not Required | |||||||||||||||||||||||||||||||||||
| 11a. Insured's Date of Birth, Sex | Not Required | |||||||||||||||||||||||||||||||||||
| 11b. Other Claim ID | Not Required | |||||||||||||||||||||||||||||||||||
| 11c. Insurance Plan Name or Program Name | Not Required | |||||||||||||||||||||||||||||||||||
| 11d. Is there another Health Benefit Plan? | Not Required | |||||||||||||||||||||||||||||||||||
| 12. Patient's or Authorized Person's signature | Required | Enter "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. |
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| 13. Insured's or Authorized Person's Signature | Not Required | |||||||||||||||||||||||||||||||||||
| 14. Date of Current Illness Injury or Pregnancy | Not Required | |||||||||||||||||||||||||||||||||||
| 15. Other Date | Not Required | |||||||||||||||||||||||||||||||||||
| 16. Date Patient Unable to Work in Current Occupation | Not Required | |||||||||||||||||||||||||||||||||||
| 17. Name of Referring Physician | Conditional | |||||||||||||||||||||||||||||||||||
| 18. Hospitalization Dates Related to Current Service | Not Required | |||||||||||||||||||||||||||||||||||
| 19. Additional Claim Information | Conditional | |||||||||||||||||||||||||||||||||||
| 20. Outside Lab? $ Charges |
Not Required | |||||||||||||||||||||||||||||||||||
| 21. Diagnosis or Nature of Illness or Injury | Required | Enter 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 |
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| 22. Medicaid Resubmission Code | Conditional | List 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. |
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| 23. Prior Authorization | Conditional | HCBS Leave blank |
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| 24. Claim Line Detail | Information | The 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). |
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| 24A. Dates of Service | Required | 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.
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. |
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| 24B. Place of Service | Required | 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.
Use POS Code 12 (Home) for Alternative Care Facility, Adult Day Program, or Respite in the Facility |
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| 24C. EMG | Not Required | |||||||||||||||||||||||||||||||||||
| 24D. Procedures, Services, or Supplies | Required | Enter the HCPCS procedure code that specifically describes the service for which payment is requested. HCBS Refer to the HCBS-BI procedure code table.. |
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| 24D. Modifier | Conditional | Enter 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. |
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| 24E. Diagnosis Pointer | Required | Enter 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. |
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| 24F. $ Charges | Required | Enter 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. |
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| 24G. Days or Units | Required | Enter the number of services provided for each procedure code. Enter whole numbers only- do not enter fractions or decimals. |
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| 24G. Days or Units | General Instructions | A 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 & 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. |
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| 24H. EPSDT/Family Plan | Not Required | |||||||||||||||||||||||||||||||||||
| 24I. ID Qualifier | Not Required | |||||||||||||||||||||||||||||||||||
| 24J. Rendering Provider ID # | Required | In 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 Number | Not Required | |||||||||||||||||||||||||||||||||||
| 26. Patient's Account Number | Optional | Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA). | ||||||||||||||||||||||||||||||||||
| 27. Accept Assignment? | Required | The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program. | ||||||||||||||||||||||||||||||||||
| 28. Total Charge | Required | Enter 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 Paid | Not Required | |||||||||||||||||||||||||||||||||||
| 30. Rsvd for NUCC Use | ||||||||||||||||||||||||||||||||||||
| 31. Signature of Physician or Supplier Including Degrees or Credentials | Required | Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent. Each claim must have the date the enrolled provider 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. |
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| 32. 32- Service Facility Location Information 32a- NPI Number 32b- Other ID # |
Conditional | Enter 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. |
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| 33. Billing Provider Info & Ph # |
Required | Enter 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 |
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| 33a- NPI Number | Required | |||||||||||||||||||||||||||||||||||
| 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. | |||||||||||||||||||||||||||||||||||
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/single entry point 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 & 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 participant'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 participant'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 participant'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 are 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 step parent), or to an individual by the person's spouse.
- Relative Personal Care- Personal Care providers may be members of the individual's family. The number of Health First Colorado personal care units for 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 means 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) round-trips 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 member's residence, the community, or group living situations, that is designed and directed with 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.
- 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.
HCBS-CMHS Procedure Code Table
Providers may bill the following procedure codes for HCBS-CMHS services:
| HCBS-CMHS Procedure Code Table | |||
| Description | Procedure Code + Modifiers | Units | |
| Specialty 601: Adult Day Services | |||
| Adult Day Services, Basic Tier 1 | S5100 | UA | 1 unit = 15 minutes, maximum of 3 hours per day |
| Adult Day Services, Basic Tier 2 | S5105 | UA | 1 unit = 3-5 hours |
| Adult Day Services, Basic Tier 3 | S5105 | UA | 1 unit = 3-5 hours |
| Adult Day Services, Specialized | S5105 | UA, TF | 1 unit = 3-5 hours |
| Specialty 602: Alternative Care Facility | |||
| Alternative Care Facility | T2031 | UA | 1 unit =1 day |
| Specialty 702: FMS/CDASS | |||
| Consumer Directed Attendant Support Services (CDASS) (Cent/Unit) | T2025 | UA | 1 unit = $0.01 |
| CDASS Per Member/Per Month (PM/PM) | T2040 | UA | 1 unit =1 month |
| Specialty 752: Home Delivered Meals | |||
| Home Delivered Meals | S5170 | UA | 1 unit = 1 meal |
| Home Delivered Meals after 1st discharge from a 24hr hospitalization | S5170 | UA, TF | 1 unit = 1 meal |
| Home Delivered Meals after 2nd discharge from a 24hr hospitalization | S5170 | UA, TG | 1 unit = 1 meal |
| Specialty 651: Home Modifications | |||
| Home Modifications | S5165 | UA | 1 unit =1 modification |
| Specialty 753: Life Skills Training | |||
| Life Skills Training | H2014 | UA | I unit = 15 minutes |
| Specialty 666: Non-Medical Transportation | |||
| Non-Medical Transportation (NMT), Taxi | A0100 | UA | 1 unit=one way trip |
| Non-Medical Transportation (Taxi), to and From Adult Day | A0100 | UA, HB | 1 unit = (1) 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 |
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 |
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 Mentorship | H2015 | UA | 1 unit = 15 minutes |
| Specialty 666: Personal Care/Homemaker | |||
| Homemaker | S5130 | UA | 1 unit = 15 minutes |
| Personal Care | T1019 | UA | 1 unit = 15 minutes |
| Personal Care, Relative | T1019 | UA, HR | 1 unit = 15 minutes |
| Specialty 643: Electronic Monitoring | |||
| Personal Emergency Response System (PERs) Install/Purchase | S5160 | UA | 1 unit = purchase and installation |
| PERs, Monitoring | S5161 | UA | 1 unit = 1 month of service |
| Medication Reminder, Install/Purchase | T2029 | UA | 1 unit = 1 purchase |
| Medication Reminder, Monitoring | S5185 | UA | 1 unit per month |
| Specialty 675: Respite | |||
| Respite Care, Alternative Care Facility (ACF) | S5151 | UA | 1 unit = 1 day |
| Respite Care, Nursing Facility (NF) | H0045 | UA | 1 unit =1 day |
| Specialty 636 Transition Setup | |||
| Transition Setup - Coordination | T2038 | UA | 1 unit = 15 minutes |
| Transition Setup - Items Purchased | A9900 | UA | One-time payment |
| Specialty 756: Remote Supports | |||
| Personal Care - Remote Supports | T1019 | UA, SE | 15 Minutes |
| Homemaker - Remote Supports | S5130 | UA, SE | 15 Minutes |
| Remote Supports Technology (Install/purchase) | S5160 | UA, SE | Dollar |
HCBS-EBD Procedure Code Table
Providers may bill the following procedure codes for HCBS-EBD services:
| HCBS-EBD Procedure Code Table | |||
| Description | Procedure Code + Modifiers | Units | |
| Specialty 601: Adult Day Services | |||
| Adult Day Services, Basic Tier 1 | S5100 | U1 | 1 unit = 15 minutes, maximum of 3 hours per day |
| Adult Day Services, Basic, Tier 2 | S5105 | U1 | 1 unit = 3-5 hours |
| Adult Day Services, Basic, Tier 3 | S5105 | U1 | 1 unit = 3-5 hours |
| Specialty 602: Alternative Care Facility | |||
| Alternative Care Facility | T2031 | U1 | 1 unit =1 day |
| Specialty 636: Transition Setup | |||
| Community Transition Services, Coordinator | T2038 | U1 | 1 unit = 1 transition |
| Community Transition Services, Items Purchased | A9900 | U1 | 1 unit = purchase |
| Specialty 702: FMS/CDASS | |||
| Consumer Directed Attendant Support Services (CDASS) (Cent/Unit) | T2025 | U1 | 1 unit = $0.01 |
| CDASS Per Member/Per Month (PM/PM) | T2040 | U1 | 1 unit =1 month |
| Specialty 752: Home Delivered Meals | |||
| Home Delivered Meals | S5170 | U1 | 1 unit = 1 meal |
| Home Delivered Meals after 1st discharge from a 24hr hospitalization | S5170 | U1, TF | 1 unit = 1 meal |
| Home Delivered Meals after 2nd discharge from a 24hr hospitalization | S5170 | U1, TG | 1 unit = 1 meal |
| Specialty 651: Home Modifications | |||
| Home Modifications | S5165 | U1 | 1 unit =1 modification |
| Specialty 656: In-Home Support Services | |||
| IHSS Health Maintenance Activities | H0038 | U1 | 1 unit = 15 minutes |
| IHSS Personal Care Service | T1019 | U1, KX | 1 unit = 15 minutes |
| IHSS Relative Personal Care | T1019 | U1, HR, KX | 1 unit = 15 minutes |
| IHSS Homemaker Service | S5130 | U1, KX | 1 unit = 15 minutes |
| Specialty 753: Life Skills Training | |||
| Life Skills Training | H2014 | U1 | 1 unit = 15 minutes |
| Specialty 643: Electronic Monitoring | |||
| Medication Reminder, Install/Purchase | T2029 | U1 | 1 unit = 1 purchase |
| Medication Reminder, Monitoring | S5185 | U1 | 1 unit per month |
| Personal Emergency Response System (PERs) Install/Purchase | S5160 | U1 | 1 unit = purchase and installation |
| PERs, Monitoring | S5161 | U1 | 1 unit =1 month of services |
| Specialty 660: Non-Medical Transportation | |||
| Non-Medical Transportation (NMT), Taxi | A0100 | U1 | 1 unit=one way trip |
| Non-Medical Transportation (Taxi) , to and From Adult Day | A0100 | U1, HB | 1 unit = (1) 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 |
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 |
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 Mentorship | H2015 | U1 | 1 unit = 15 minutes |
| Specialty 666: Personal Care/Homemaker | |||
| Homemaker | H2015 | U1 | 1 unit = 15 minutes |
| Personal Care | T1019 | U1 | 1 unit = 15 minutes |
| Personal Care, Relative | T1019 | U1, HR | 1 unit = 15 minutes |
| Specialty 675: Respite | |||
| Respite Care, Alternative Care Facility (ACF) | S5151 | U1 | 1 unit = 1 day |
| Respite Care, In Home | S5150 | U1 | 1 unit = 15 minutes |
| Respite Care Nursing Facility (NF) | H0045 | U1 | 1 unit = 1 day |
| Specialty 756: Remote Services | |||
| Personal Care - Remote Supports | T1019 | U1, SE | 15 minutes |
| Homemaker - Remote Supports | S5130 | U1, SE | 15 minutes |
| Remote Supports Technology (Install/purchase) | S5160 | U1, SE | Dollar |
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 & Label | Field is? | Instructions | ||||||||||||||||||||||||||||||||||
| 1. Insurance Type | Required | Place an "X" in the box marked as Medicaid. | ||||||||||||||||||||||||||||||||||
| 1a. Insured's ID Number | Required | Enter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456. | ||||||||||||||||||||||||||||||||||
| 2. Patient's Name | Required | Enter the member's last name, first name, and middle initial. | ||||||||||||||||||||||||||||||||||
| 3. Patient's Date of Birth/Sex | Required | Enter 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. |
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| 4. Insured's Name | Not required | |||||||||||||||||||||||||||||||||||
| 5. Patient's Address | Not Required | |||||||||||||||||||||||||||||||||||
| 6. Client Relationship to Insured | Not Required | |||||||||||||||||||||||||||||||||||
| 7. Insured's Address | Not Required | |||||||||||||||||||||||||||||||||||
| 8. Reserved for NUCC Use | Not Required | |||||||||||||||||||||||||||||||||||
| 9. Other Insured's Name | Not Required | |||||||||||||||||||||||||||||||||||
| 9a. Other Insured's Policy or Group Number | Not Required | |||||||||||||||||||||||||||||||||||
| 9b. Reserved for NUCC Use | ||||||||||||||||||||||||||||||||||||
| 9c. Reserved for NUCC Use | ||||||||||||||||||||||||||||||||||||
| 9d. Insurance Plan or Program Name | Not Required | |||||||||||||||||||||||||||||||||||
| 10a-c. Is patient's condition related to? | Not Required | |||||||||||||||||||||||||||||||||||
| 10d. Reserved for Local Use | ||||||||||||||||||||||||||||||||||||
| 11. Insured's Policy, Group or FECA Number | Not Required | |||||||||||||||||||||||||||||||||||
| 11a. Insured's Date of Birth, Sex | Not Required | |||||||||||||||||||||||||||||||||||
| 11b. Other Claim ID | Not Required | |||||||||||||||||||||||||||||||||||
| 11c. Insurance Plan Name or Program Name | Not Required | |||||||||||||||||||||||||||||||||||
| 11d. Is there another Health Benefit Plan? | Not Required | |||||||||||||||||||||||||||||||||||
| 12. Patient's or Authorized Person's signature | Required | Enter "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. |
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| 13. Insured's or Authorized Person's Signature | Not Required | |||||||||||||||||||||||||||||||||||
| 14. Date of Current Illness Injury or Pregnancy | Not Required | |||||||||||||||||||||||||||||||||||
| 15. Other Date | Not Required | |||||||||||||||||||||||||||||||||||
| 16. Date Patient Unable to Work in Current Occupation | Not Required | |||||||||||||||||||||||||||||||||||
| 17. Name of Referring Physician | Conditional | |||||||||||||||||||||||||||||||||||
| 18. Hospitalization Dates Related to Current Service | Not Required | |||||||||||||||||||||||||||||||||||
| 19. Additional Claim Information | Conditional | |||||||||||||||||||||||||||||||||||
| 20. Outside Lab? $ Charges |
Not Required | |||||||||||||||||||||||||||||||||||
| 21. Diagnosis or Nature of Illness or Injury | Required | Enter 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 |
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| 22. Medicaid Resubmission Code | Conditional | List 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. |
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| 23. Prior Authorization | Not Required | |||||||||||||||||||||||||||||||||||
| 24. Claim Line Detail | Information | The 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). |
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| 24A. Dates of Service | Required | 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.
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. |
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| 24B. Place of Service | Required | 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.
Use POS Code 12 (Home) for Alternative Care Facility, Adult Day Program, or Respite in the Facility |
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| 24C. EMG | Not Required | |||||||||||||||||||||||||||||||||||
| 24D. Procedures, Services, or Supplies | Required | Enter 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. |
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| 24D. Modifier | Conditional | Enter 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. |
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| 24E. Diagnosis Pointer | Required | Enter 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. |
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| 24F. $ Charges | Required | Enter 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. |
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| 24G. Days or Units | Required | Enter the number of services provided for each procedure code. Enter whole numbers only- do not enter fractions or decimals. |
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| 24G. Days or Units | General Instructions | A 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 & 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. |
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| 24H. EPSDT/Family Plan | Not Required | |||||||||||||||||||||||||||||||||||
| 24I. ID Qualifier | Not Required | |||||||||||||||||||||||||||||||||||
| 24J. Rendering Provider ID # | Required | In 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 Number | Not Required | |||||||||||||||||||||||||||||||||||
| 26. Patient's Account Number | Optional | Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA). | ||||||||||||||||||||||||||||||||||
| 27. Accept Assignment? | Required | The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program. | ||||||||||||||||||||||||||||||||||
| 28. Total Charge | Required | Enter 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 Paid | Not Required | |||||||||||||||||||||||||||||||||||
| 30. Rsvd for NUCC Use | ||||||||||||||||||||||||||||||||||||
| 31. Signature of Physician or Supplier Including Degrees or Credentials | Required | Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent. Each claim must have the date the enrolled provider 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. |
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| 32. 32- Service Facility Location Information 32a- NPI Number 32b- Other ID # |
Conditional | Enter 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. |
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| 33. Billing Provider Info & Ph # |
Required | Enter 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 |
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| 33a- NPI Number | Required | |||||||||||||||||||||||||||||||||||
| 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. | |||||||||||||||||||||||||||||||||||
Timely Filing
For more information on timely filing policy, including the resubmission rules for denied claims, refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu.
HCBS-BI, CMHS and EBD Specialty Manuals Revisions Log
| Revision Date | Addition/Changes | Made by |
| 12/1/2016 | Manual revised for interChange implementation. For manual revisions prior to 12/01/2016 Please refer to Archive. | HPE (now DXC) |
| 12/27/2016 | Updates based on Colorado iC Stage II Provider Billing Manual v0_2.xlsx | HPE (now DXC) |
| 1/10/2017 | Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx | HPE (now DXC) |
| 1/19/2017 | Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx | HPE (now DXC) |
| 1/26/2017 | Updates based on Department 1/20/2017 approval email | HPE (now DXC) |
| 5/22/2017 | Updates based on Fiscal Agent name change from HPE to DXC | DXC |
| 6/26/2018 | Updated billing and timely filing to point to general manual | HCPF |
| 6/28/2018 | Minor grammatical edit Updated claims submission |
HCPF |
| 3/18/2019 | Clarification to signature requirements | HCPF |
| 7/2/2019 | Updated Appendices' links and verbiage | DXC |
| 12/4/2019 | Updated modifiers for BI waiver service | HCPF |
| 1/10/2020 | Updated units for BI waiver service | HCPF |
| 3/3/2020 | Converted to web page | HCPF |
| 3/4/2020 | Updates to NMT services to include public transportation, CDASS FMS providers, added transition services | HCPF |
| 8/28/2020 | General updates to language reflecting the use of the Bridge, added Adult Day changes. | HCPF |
| 9/14/2020 | Added Line to Box 32 under the Paper Claim Reference Table | HCPF |
| 11/24/2021 | Added Remote Supports Services effective 1/1/2022 | HCPF |
| 1/27/2022 | Removed Remote Supports effective 1/1/2022 | HCPF |
| 3/7/2022 | Added Remote Supports effective 3/11/2022 | HCPF |
| 5/27/2022 | Consolidated TLP tier into one rate. Added a tier for SLP section for the new negotiated rate. | HCPF |
| 8/3/2022 | Updated Transportation description and moved to align with other similar services | HCPF |
| 10/31/2022 | Added Specialty numbers and arranged services as appropriate | HCPF |
| 4/3/2023 | Updated AWS URL Links | HCPF |
| 4/13/2023 | Added Home Delivered Meal expansion codes | HCPF |