Ensuring Appropriate Claims Payment

Upcoming Improvements to Claims Review

The Department of Health Care Policy & Financing (the Department) is committed to improving health and quality services to our members while ensuring appropriate claims payments to Health First Colorado (Colorado's Medicaid Program) providers.

In accordance with Senate Bill 18-266, the Department has implemented its Ensuring Appropriate Claims Payment project. The project is comprised of two components:

  • For outpatient hospital payments, the Department and its fiscal agent have mapped 3M EAPG return codes to edits in the Colorado interChange.
  • For other professional and outpatient claim types, the Department and its fiscal agent worked with Change Healthcare to implement the ClaimsXten™ tool to automatically review claims for appropriate billing practices. The first phase of ClaimsXten™ implementation excluded home and community-based services (HCBS) claims.

The Ensuring Appropriate Claims Payment project was implemented effective September 26, 2020, and is now live. Please contact the Provider Call Center with any questions.

ClaimsXten™ Provider Training Schedule

Colorado interChange Update - ClaimsXten™ Claims Editing Solution

Effective September 26, 2020, the Colorado interChange has been updated with a claims editing solution in accordance with Senate Bill (SB) 18-266, which requires the Department to implement new initiatives intended to help control Health First Colorado's costs and ensure appropriate claims payment. The Department and Gainwell Technologies (formerly DXC Technology) are working with Change Healthcare to implement the ClaimsXten™ tool.

Professional and Outpatient claims received in Colorado interChange will automatically process through ClaimsXten™ to apply additional editing based on State and Federal policies. This additional editing tool will help to identify inappropriate bill coding and reduce potential overpayments.

The following claims and providers services are excluded:

  • Claims that have Medicare information (Crossovers)
  • Home & Community-Based Services (HCBS Waiver)
  • Hospital (Outpatient) - General, Community Clinic with Type of Bill (TOB) 13X claims
  • Dental, Inpatient and Nursing Facility Claims

Refer to the Provider Claim Types Processed Through ClaimsXten™ chart for a complete list of included and excluded provider/claim types.

Hospitals

Effective October 1, 2020, the existing 3M Enhanced Ambulatory Patient Grouping (EAPG) was updated to improve payment accuracy.

Providers are encouraged to visit the Provider Training web page for the latest updates and information on the ClaimsXten™ training.

ClaimsXten™ Product Information

The ClaimsXten™ tool is a product of Change Healthcare. The tool automatically reviews claims to identify inappropriate bill coding and reduce overpayments. The goal is to increase billing transparency, so providers submit accurate claims for reimbursement on the first attempt.

The ClaimsXten™ tool is currently in use by many private insurance companies, so most providers will be somewhat familiar with the tool and basic functionality.

The first phase of ClaimsXten™ implementation will exclude home and community-based services (HCBS) claims.

3M EAPG solution improvements information

Outpatient hospital claims currently process through the 3M EAPG grouper. 3M has several return codes that edit on invalid or incorrect data on the claim and are mapped to interChange edits that either pay or deny.

This project will utilize technology that will automate and increase the accuracy of claims review and adjudication.

Mapping 3M's EAPG return codes to new edits within the interChange will improve the Department's ability to ensure appropriate payments for outpatient hospital claims.