Home and Community-Based Services Billing Manual: Children's Home and Community-Based Services (CHCBS), Children with Life Limiting Illness (CLLI) | Department of Health Care Policy and Financing

Case Management Agency Responsibilities
Claim Submission
Prior Authorization Requests (PARs)
- PAR Submission
- PAR Form Instructional Reference Table
Children's Home and Community-Based Services (CHCBS)
Home and Community-Based Services for Children with Life Limiting Illness (CLLI)
- HCBS-CLLI Procedure Code Table
- Service Limitations
Paper Claim Reference Table
- CMS 1500 CHCBS Claim Example
- CMS 1500 HCBS-CLLI Claim Example
Timely Filing
HCBS-CHCBS and CLLI Specialty Manuals Revisions Log

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 case management agencies contracted by the Department to provide case management for eligible and enrolled Health First Colorado members. Eligible members must meet financial, medical and program criteria to access services under a waiver. The applicant must be at risk of transition to a Skilled Nursing Facility (SNF), hospital or Intermediate Care Facility for Individuals with an Intellectual Disability (ICF/IID). In order 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 or by a Health First Colorado contracting Managed Care Organization (MCO).

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

Effective June 30, 2024, the service “Case Management” was deactivated and removed from the waiver. From July 1, 2024, forward, eligible and enrolled CHCBS members will receive the Targeted Case Management benefit as provided by one of the Department’s contracted Case Management Agencies.

Case Management Agency Responsibilities

Contracted Case Management Agencies are delegated administrative authority over HCBS waivers.

Contracted Case Management Agencies responsibilities include, but are not limited to:

Informing members and/or legal guardians of the eligibility process.
Submitting required enrollment information 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 a copy of the Prior Authorization and/or Cost Containment document 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.
Monitoring and evaluating services.
Reassessing each member annually or upon a change in condition.

Claim Submission

Submission of claims for services rendered must not be duplicative. Providers 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, providers 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. Refer to the provider specialty code enrollment requirements on the HCBS Provider Specialty Code List web page to identify services that must be provided by an individual provider. Providers may only bill for services approved in the members’ service plans.

In any instance in which duplicate billings result in Medicaid reimbursement, a recovery shall be made by the Department against the provider.

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

Prior Authorization Requests (PARs)

Unless otherwise noted, all HCBS services require prior approval before they can be reimbursed by Health First Colorado. Contracted 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.

Providers may contact the Contracted Case Management Agency for the status of the PAR or inquire electronically through the Health First Colorado Provider Web Portal.

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 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. Providers are reminded to check member eligibility prior to rendering services.

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 Contracted Case Management Agency is responsible for timely submission and distribution of copies of approvals to agencies and providers contracted to provide services.

PAR Submission

The following PAR (CHCBS and CLLI) forms are filed via the "Bridge" by case managers employed by Contracted Case Management Agencies. The Bridge directly interfaces with the Colorado interChange. The Bridge is accessed by case manager agencies via the Medicaid Enterprise User Provisioning System (MEUPS). Providers are not authorized to access the Bridge but may view PARs in the Provider Portal.

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	Checkbox 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	Checkbox 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 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.
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.
Immediately prior to HCBS enrollment, this client lived in one of the following facility types	Check box Nursing facility Hospital	Required for CHCBS only. Check the appropriate box.
Case Manager Name	Text	Required Enter the name of the Case Manager.
Case Manager Signature	Text	Required Enter the name of the Case Manager's Supervisor.
Agency	Text	Required Enter the name of the case management agency.
Phone #	10 Numbers 123-456-7890	Required Enter the phone number of the Case Manager.
Email	Text	Required Enter the email address of the Case Manager.
Date	6 Numbers (MM/DD/YY)	Required Enter the date of PAR completion.

Children's Home and Community-Based Services (CHCBS)

The Children's Home and Community-Based Services (CHCBS) waiver program is for medically fragile children who are at risk of institutionalization in a hospital or skilled nursing facility and would not otherwise qualify for Health First Colorado services due to parental income and/or resources. All state plan Health First Colorado benefits are provided to children birth through age 17. The children must meet the established minimum criteria for hospital or skilled nursing facility level of care. Members that meet program eligibility requirements receive an annual long-term care certification by their Contracted Case Management Agency case manager.

CHCBS Procedure Code Table

Providers may bill the following procedure codes for HCBS-CHCBS services.

In-Home Support Services (IHSS)

IHSS within the CHCBS waiver is limited to health maintenance activities, which include support for activities of daily living. Additionally, IHSS providers must provide core independent living skills.

Specialty 656: HCBS-CHCBS Procedure Code Table
In-Home Support (HCBS-IHSS)
Description	Procedure Code + Modifiers		Units
Health Maintenance Activities – Outside Denver County	H0038	U5	1 unit = 15 minutes
Health Maintenance Activities – Denver County	H0038	U5, HX	1 unit = 15 minutes

Wellness Education Benefit (WEB)

The WEB is designed to reduce the need for a higher level of care by offering educational materials that provide members and their families with actionable tools that can be used to prevent the progression of a disability, increase community engagement, combat isolation and improve awareness of Health First Colorado services.

Specialty 683: HCBS-CHCBS Procedure Code Table
Wellness Education Benefit (WEB)
Description	Procedure Code + Modifiers		Units
Wellness Education Benefit	98960	U5	1 unit per month

Home and Community-Based Services for Children with Life Limiting Illness (CLLI)

The Home and Community-Based Services for Children with Life Limiting Illness (CLLI) Waiver is for children from birth through age 18 with a medical diagnosis of a life-limiting illness who meet the institutional level of care for inpatient hospitalization. Level of care determinations are conducted annually by Contracted Case Management Agencies. Services include Bereavement Counseling, Expressive Therapy (Art, Play and Music), Massage Therapy, Palliative/Supportive Care (Care Coordination and Pain and Symptom Management), Respite Care, and Therapeutic Life Limiting Illness Support Services. Members that are enrolled in the waiver also have access to all state plan Health First Colorado benefits, including curative care. There is no requirement for a nine-month terminal prognosis.

HCBS-CLLI Procedure Code Table

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

HCBS-CLLI Procedure Code Table
Description	Procedure Code + Modifiers		Place of Service	Units
Specialty 645: Expressive Therapy-Art/Play
Art and Play Therapy	H2032	UD, HA	11 - Office 12 - Home	1 unit = 15 minutes
Art and Play Therapy - Group	H2032	UD, HA, HQ	11 - Office 12 - Home	1 unit = 15 minutes
Specialty 646: Expressive Therapy- Music Therapy
Music Therapy	H2032	UD	11 - Office 12 - Home	1 unit = 15 minutes
Music Therapy - Group	H2032	UD, HQ	11 - Office 12 - Home	1 unit = 15 minutes
Specialty 613: Massage Therapy
Massage Therapy	97124	UD	11 - Office 12 - Home	1 unit = 15 minutes
Specialty 614: Palliative/Supportive Care
Care Coordination	G9012	UD	11 - Office 12 - Home	1 unit = 15 minutes
Pain and Symptom Management	S9123	UD	11 - Office 12 - Home 34 - Hospice	1 unit = 1 hour
Specialty 616: Respite (Unskilled)
Respite Care - Unskilled (4 hours or less) - Outside Denver County	S5150	UD	12 - Home	1 unit = 15 minutes
Respite Care - Unskilled (4 hours or less) - Denver County	S5150	UD, HX	12 - Home	1 unit = 15 minutes
Respite Care - Unskilled (4 hours or more) - Outside Denver County	S5151	UD	12 - Home	1 unit = 1 day
Respite Care - Unskilled (4 hours or more) - Denver County	S5151	UD, HX	12 - Home	1 unit = 1 day
Respite Care – Camp (Group, Overnight) - Outside Denver County	T2037	UD		1 unit = 1 day
Respite Care – Camp (Group, Overnight) - Denver County	T2037	UD, HX		1 unit = 1 day
Specialty 615: Respite (Skilled)
Respite Care - CNA (4 hours or less) - Outside Denver County	T1005	UD	12 - Home	1 unit = 15 minutes
Respite Care - CNA (4 hours or less) - Denver County	T1005	UD, HX	12 - Home	1 unit = 15 minutes
Respite Care - CNA (4 hours or more) - Outside Denver County	S9125	UD	12 - Home	1 unit = 1 day
Respite Care - CNA (4 hours or more) - Denver County	S9125	UD, HX	12 - Home	1 unit = 1 day
Respite Care - Skilled RN, LPN (4 hours or less) - Outside Denver County	T1005	UD, TD	12 - Home	1 unit = 15 minutes
Respite Care - Skilled RN, LPN (4 hours or less) - Denver County	T1005	UD, TD, HX	12 - Home	1 unit = 15 minutes
Respite Care - Skilled RN, LPN (4 hours or more) - Outside Denver County	S9125	UD, TD	12 - Home	1 unit = 1 day
Respite Care - Skilled RN, LPN (4 hours or more) - Denver County	S9125	UD, TD, HX	12 - Home	1 unit = 1 day
Specialty 617: Therapy and Counseling
Bereavement Counseling	S0257	UD, HK	11 - Office 12 - Home	1 unit = lump sum
Therapeutic Life Limiting Illness Support - Individual	S0257	UD	11 - Office 12 - Home	1 unit = 15 minutes
Therapeutic Life Limiting Illness Support - Family	S0257	UD, HR	11 - Office 12 - Home	1 unit = 15 minutes
Therapeutic Life Limiting Illness Support - Group	S0257	UD, HQ	11 - Office 12 - Home	1 unit = 15 minutes

Service Limitations

Reimbursement for HCBS-CLLI Therapeutic Life Limiting Illness Support services (S0257 with any "UD" modifier) shall be limited to 98 hours per annual certification. Reimbursement for HCBS-CLLI respite care services (T1005, S9125, S5150 and S5151) shall be limited to 30 days (unique dates of service) per annual certification. Reimbursement for HCBS-CLLI respite care services (T1005, S9125, S5150 and S5151) shall not be duplicated at the same time of service as state plan Home Health or Palliative/Supportive Care services (S9123) and shall be denied. Expressive Therapy (H2032 - Art, Play and Music) is limited to 39 hours per annual certification. Massage Therapy (97124) is limited to 24 hours per annual certification.

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-CHCBS and CLLI claims:

CMS Field Number and 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 ID number as it appears on the Health First Colorado 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.

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.

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
CHCBS and CLLI may use R69

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.

23. Prior Authorization

Not Required

HCBS
Leave blank

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).

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.

From

Span dates of service

From

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 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.

School

Office

Home

Hospice

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 CHCBS or CLLI procedure code tables.

24D. Modifier

Required

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.
Refer to the CHCBS or CLLI procedure code tables.

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.

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-pay or commercial insurance payments from the usual and customary charges.

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.

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 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 Plan

Not Required

EPSDT shaded area)
Not Required
Family Planning (unshaded area)
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.

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.

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

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.

CMS 1500 CHCBS Claim Example

CMS 1500 HCBS-CHCBS Claim Example

CMS 1500 HCBS-CLLI Claim Example

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.

HCBS-CHCBS and CLLI 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 Manuals Comment Log v0_2.xlsx	HPE (now DXC)
1/10/2017	Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsx	HPE (now DXC)
1/19/2017	Updates based on Colorado iC Stage II 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)
2/10/2017	Removed all references to Special Program Codes	HCPF
3/13/2017	Changed Modifier code from UL to U2	HCPF
5/26/2017	Updates based on Fiscal Agent name change from HPE to DXC	DXC
6/15/2018	Updated timely filing information and removed references to LBOD, removed general billing information already available in the General Provider Information manual	DXC
6/27/2018	Updated ToC, minor edits, added link to general manual for claim submission info, updated Timely Filing	HCPF
12/20/2018	Clarification to signature requirements	HCPF
3/18/2019	Clarification to signature requirements	HCPF
7/2/2019	Updated Appendices' links and verbiage	DXC
3/9/2020	Converted to web page, removed CWA sections as waiver discontinued 7/2018	HCPF
3/24/2020	Removed CWA references other than stating when the program was discontinued, removed outdated images.	HCPF
9/14/2020	Added Line to Box 32 under the Paper Claim Reference Table	HCPF
10/31/2022	Added Specialty Number	HCPF
4/3/2023	Updated AWS URL Links	HCPF
4/25/2024	Added new Denver County codes, CHCBS WEB service, and completed corrections	HCPF
6/22/2024	Removed case management services pursuant to Case Management Redesign.	HCPF
7/19/2024	Added duplicative claim language to Claims Submission	HCPF