Children's Habilitation Residential Program (CHRP) Waiver Program Billing Manual

• Overview
• Prior Authorization Requests (PARs)
• PAR Submission
• Claim Submission
• Children's Habilitation Residential Program (CHRP)
• Denver Regional Pricing
• Children's Habilitation Residential Program (CHRP) Standard Procedure Code Table – Outside Denver
• Paper Claim Reference Table
• CMS 1500 CHRP Claim Example
• Timely Filing
• HCBS CHRP Manual Revisions Log

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Overview

Home and Community-Based Services (HCBS) are certain Health First Colorado (Colorado's Medicaid program) benefits available to Members in their homes and communities as an alternative to institutional care. HCBS programs for persons with developmental disabilities include the Children's Habilitation Residential Program (HCBS-CHRP).

Waiver programs provide additional Health First Colorado benefits to specific populations who meet special eligibility criteria.

Level of care determinations are made annually by the Case Management Agencies serving each of the 20 Designated Service Areas statewide. 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, hospital, or ICF/IID (intermediate care facility for Individuals with Intellectual Disabilities). To use 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.

Applicants may apply for more than one (1) waiver but may only receive services through one (1) waiver at a time.

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Prior Authorization Requests (PARs)

All HCBS services require prior authorization before they can be reimbursed by Health First Colorado. Case Managers at one (1) of the 20 CMAs complete the Prior Authorization Requests for their specific programs according to instructions published in the regulations for the Department of Health Care Policy & Financing (the Department).

The CMA's responsibilities include, but are not limited to:

• Informing Members and/or legal guardian of the eligibility process
• Submitting evidence of Member eligibility for the waiver to the county Department of Human/Social Services for a Health First Colorado Member identification number
• Developing the appropriate Prior Authorization Request of services and projected costs for approval
• As the authorizing agent, submitting the prior authorization information to the fiscal agent. Refer to Appendix D located on the Billing Manuals web page under the Appendices drop-down for a list of authorizing agents.
• Assessing the Member's health and social needs.
• Arranging for face-to-face contact with the Member within 30 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 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 Agency 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 CMA is responsible for timely submission and distribution of copies of approvals to Provider Agencies.

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PAR Submission

The HCBS-CHRP Pars are electronically submitted by Case Managers via the Bridge, which directly interfaces with the Colorado interChange. Case Managers can access the Bridge via the Medicaid Enterprise User Provisioning System (MEUPS). Provider Agencies are not afforded access to the Bridge, but may obtain PAR information from Case Managers, the Provider Services Call Center, or through the Provider Web Portal. 

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Claim Submission

Submission of claims for services rendered must not be duplicative. Duplicate claims are any claims paid across more than one (1) claim number for the same beneficiary, date, procedure code and service state by the same Provider Agency. Duplicate claims can include different procedure codes but with overlapping service definitions. Duplicate claims also include a single Provider Agency offering more than one (1) service simultaneously. All overlapping services rendered and subsequent billing claims must have supporting documentation that clearly identifies the necessity and non-duplication of overlapping services to verify these services were provided separately and independently of one another.

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 Agency.

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

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.

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Children's Habilitation Residential Program (CHRP)

• HCBS-CHRP is a residential service and support program for children and youth from birth through age 20. HCBS-CHRP provides services for children and youth who have an intellectual or developmental disability and extraordinary needs that put them in at risk of, or in need of, out-of-home placement in a nursing facility, hospital, or ICF/IID.

The waiver provides support for eligible children who:

• May require added support as they transition back to the family home from a foster care or residential setting.
• May require services to support their families in remaining in the family home.
• Have an intellectual or developmental disability or developmental delay if under age five (5) and have intensive behavioral and/or medical support needs that put them at risk or in need of out-of-home placement.
• Are willing to receive services in their homes or communities.

The waiver is designed to assist children/youth to acquire, retain, and/or improve self-help, socialization, and adaptive skills necessary to live in the community with a plan to include services. Enrollment into the HCBS-CHRP waiver occurs through area Case Management Agencies.

The following services are provided through CHRP when deemed appropriate and adequate by the child/youth's physician and they are to be provided in the community, as available:

• Community Connector
• Habilitation (Residential 24-hour support)
• Respite
• Hippotherapy
• Massage Therapy
• Movement Therapy
• Child and Youth Mentorship
• Wraparound Services

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Denver Regional Pricing

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

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Children's Habilitation Residential Program (CHRP) Standard Procedure Code Table – Outside Denver

Providers may bill the following procedure codes for CHRP services:

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Paper Claim Reference Table

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

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CMS 1500 CHRP Claim Example

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Timely Filing

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

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HCBS CHRP Manual Revisions Log