Federally Qualified Health Care and Rural Health Care Billing Manuals | Colorado Department of Health Care Policy & Financing

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
- Federally Qualified Health Centers (FQHCs)
- Rural Health Clinics (RHCs)
Billing Information
- Temporary Service Sites and Mobile Units
Federally Qualified Health Center (FQHC) Benefits
Rural Health Clinic (RHC) Services
- FQHC and RHC Coding
- FQHCs and RHCs
UB-04 Paper Claim Reference Table
Timely Filing
Sterilization, Hysterectomies and Abortions
Institutional Provider Certification
FQHC/RHC Revisions Log

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Providers must be enrolled as a Health First Colorado (Colorado's Medicaid Program) provider in order to:

Treat a Health First Colorado member
Submit claims for payment to the Health First Colorado

Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10), for specific information when providing FQHC and RHC services.

Federally Qualified Health Centers (FQHCs)

The U.S. Department of Health and Human Services certifies Federally Qualified Health Centers (FQHCs) that qualify as FQHCs. FQHCs may be either freestanding or federally defined as "provider based". Federally Qualified Health Center services must be medically necessary and provided in outpatient settings only. Inpatient hospital stays are not included.

Rural Health Clinics (RHCs)

Rural Health Clinics are clinics that are located in rural areas and that have been certified under Medicare. These clinics are either freestanding or hospital affiliated. Rural Health Clinics cannot be rehabilitation facilities or facilities primarily for the care and treatment of mental illness.

Billing Information

Refer to the General Provider Information Manual for general billing information.

For FQHCs participating in the Alternative Payment Methodology (APM) 2 reimbursement methodology refer to the Alternative Payment Methodology 2 Billing Guidance for more information.

Temporary Service Sites and Mobile Units

Mobile units and temporary service sites including temporary vaccination sites are not required to be separately enrolled with Health First Colorado. Temporary vaccination sites and mobile units can bill from the location where the staff or unit is based.

Per C.R.S. 25.5-4-420, which can be found on the Colorado Revised Statues web page on the Colorado General Assembly website, service sites that become permanent locations are required to obtain and use a unique National Provider Identifier (NPI) for each service location and enroll with Health First Colorado.
Health First Colorado policy requires that all Federally Qualified Healthcare Centers (FQHC) locations enroll in Health First

Colorado separately in order to obtain a separate Health First Colorado Provider ID. Hospital-based FQHCs are an exception to the policy and may use one Provider ID for all sites on the main campus of the hospital-based FQHC. Hospital-based FQHCs are encouraged to obtain separate provider IDs for different locations on their main campus but are not required to do so. Mobile units of an FQHC are not required to be separately enrolled in Health First Colorado but are treated as part of the FQHC. Services provided in a temporary location do not require enrollment of the temporary location.

Federally Qualified Health Center (FQHC) Benefits

Core services that are medically necessary are FQHC benefits. Core benefits include the following outpatient services:

Physician services
Physician assistant services
Nurse practitioner services
Nurse midwife services
Clinical psychologist services
Clinical social worker services
Pneumococcal and influenza vaccines and administration
Services and supplies incidental to professional services
Part-time or intermittent nursing care and related medical supplies for homebound individuals
Other reimbursable ambulatory services
Dental

Federally Qualified Health Centers that offer the Nurse Home Visitor Program (NHVP) and/or the Prenatal Plus Program are instructed to submit fee-for-service claims for services rendered under these programs. Claims for services should be submitted using the CMS 1500 and will be reimbursed based upon the supplemental fee schedule. All services provided under these two programs must be excluded from the cost report as they are not considered when determining the encounter rates paid to FQHCs.

The NHVP is a home visitation program available to first-time moms in Colorado. Health First Colorado reimburses NHVP for targeted case management services provided to Health First Colorado members. The Prenatal Plus Program provides women access to a multidisciplinary care team throughout their pregnancy. Both programs have unique payment models and reporting mechanisms that necessitate Health First Colorado reimbursement remain separate from the encounter rate.

Rural Health Clinic (RHC) Services

Rural Health Clinic services include:

Services provided by a physician
Services provided by physician assistants, nurse practitioners, and nurse midwives under the supervision of a physician
Incidental related services and supplies, including visiting nurse care, and related medical supplies
Other ambulatory services which meet specific program requirements
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services which are not part of RHC services and meet EPSDT requirements
Clinical psychologist services
Clinical social worker services

FQHC and RHC Coding

Both FQHCs and RHCs use revenue codes to bill Health First Colorado.

FQHCs and RHCs

The valid revenue codes for reimbursement for services to the Health First Colorado are:

Facility	Revenue code	Service
FQHC	529	Physical Health
RHC	521	Physical Health
FQHC/RHC	900	Behavioral Health

Freestanding FQHC and RHC services are priced at an encounter rate. All routine services are included in the encounter rate.

In order to provide the Health First Colorado program with basic clinical information for use in evaluating services requested and received by Health First Colorado members, FQHCs are required to include all CPT codes and HCPCS codes for services provided during a visit on claims. In order to be reimbursed, an FQHC or RHC that submits a UB-04 or 837 Institutional (837I) electronic transaction must have at least one (1) claim line that identifies revenue code 0529 for FQHCs or revenue code 0521 for RHCs. All other lines on the claim should have the revenue code most appropriate for the service. The line item with revenue code 0529 or 0521 can appear at any line on the claim and with any procedure code.

CDT dental codes must be included on dental claims.

Beginning July 1, 2014, all FQHC claims for dental services and dentures must be submitted to DentaQuest, the Dental Administrative Service Organization (ASO), on the 2006 ADA Dental Claim form or by submitting the 837D electronic transaction via the DentaQuest Provider Web Portal. Information about claims submission for dental services can be found in the Office Reference Manual (ORM) under 'DentaQuest Resources' located on the Dentist page of DentaQuest's website.

Rates for FQHCs are determined using an alternative payment methodology.

Beginning on October 31, 2016, claims for encounters that have any Evaluation & Management (E&M) procedure on the claim must be billed to MMIS. The Regional Accountable Entities (RAEs) will not reimburse claims which include an E&M procedure even when the diagnosis code identifies the service as behavioral health.

For Health First Colorado a billable encounter at an FQHC is an in person or telemedicine face to face visit with a Health First Colorado member. Telemedicine services are limited to the procedure codes identified on the Telemedicine Provider Information web page. Services provided via telemedicine must use modifier GT on the claim. All other claim submission information is the same. Additionally, modifiers FQ and FR can be added to the claim:

FQ: The service was furnished using audio-only communication technology.
FR: The supervising practitioner was present through two-way, audio/video communication technology.

FQHCs, RHCs, and IHS providers can serve as an originating site allowing a member to connect with a distant provider that is not affiliated with the originating site. The service must be submitted on a professional service claim form (the 1500). Refer to the Telemedicine Billing Manual for the coverage of the originating site procedure code.

For FQHCs, Health First Colorado does not cover the professional component of an imaging service as a billable encounter. Health First Colorado only allows reimbursement for a visit, which is a face-to-face encounter between a Health First Colorado member and a provider listed at 10 CCR 2505-10 sections 8.700.6 and 8.700.1. A direct visualization by a physician without the member present is not billable as an encounter. For the technical component of an imaging service, when free standing FQHCs own the equipment, the costs are accounted for in the Prospective Payment System (PPS) rate and the technical component is not billable. When free standing FQHCs order imaging from another provider, the technical component services are billed by the rendering provider. For hospital based FQHCs, the costs of imaging and labs are removed from the cost report when determining the encounter rate. Since the costs are removed from the cost report, the technical component of imaging may be billed separately to Health First Colorado by the hospital.

Effective March 1, 2016, RHCs and their providers are able to bill for Long-Acting Reversible Contraceptive (LARC) devices on a fee-for-service (FFS) basis, outside of the normal RHC billable encounter rate. Long-acting reversible contraceptive devices can be billed on the CMS 1500 claim form using the appropriate Healthcare Common Procedure Coding System (HCPCS) codes for the devices.

Effective July 1, 2018, FQHCs and RHCs may be reimbursed by Health First Colorado for short term behavioral health services Fee-for-Service (FFS) for up to six (6) sessions per episode of care. An episode of care is currently defined as a 12-month period. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the Regional Accountable Entity (RAE) and will be reimbursed by the RAE under the capitated behavioral health benefit. These claims should be billed using the 900 revenue code. The following procedure codes may be billed under the short-term behavioral health services in the primary care setting policy:

90791
90832
90834
90837
90846
90847

If a member receives both an FFS short term behavioral health service and a medical service on the same day, a FQHC must submit two claims, one with the short-term behavioral service using revenue code 900 and one with the medical service using revenue code 529 for two encounter rate payments from Health First Colorado.

A visit that includes an FFS short term behavioral health service and other behavioral health services should include all behavioral health services in the visit on the claim billed to Health First Colorado.

Zero Pay Claims
If an FQHC submits claims that include two codes that are included in the National Correct Coding Initiative (NCCI) Procedure to Procedure edits, the claim may result in $0 pay. FQHCs are required to comply with NCCI coding. Complying with NCCI coding will prevent $0 pay claims. Failure to include the National Drug Code (NDC) on claims that include a procedure for a physician-administered drug may result in $0 pay.

National Drug Code (NDC)
FQHCs and RHCs must include all non-carved out physician-administered drugs on claims when they are part of the treatment. Claims and encounters for physician-administered drugs purchased through the 340B program should include the "UD" code modifier on the 837P, 837I and CMS 1500 claim formats. For any physician-administered drugs not purchased through the 340B program, no code modifier is required. A valid national drug code (NDC) number must be included on all claims and encounters for physician-administered drugs. To assist providers with billing, an HCPCS/NDC crosswalk can be found under Appendices at /billing-manuals.

UB-04 Paper Claim Reference Table

The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for the Health First Colorado as those indicated in the NUBCUB-04 Reference Manual.

All code values listed in the NUBCUB-04 Reference Manual for each form locator may not be used for submitting paper claims to the Health First Colorado. The appropriate code values listed in this manual must be used when billing the Health First Colorado.

The UB-04 Institutional Certification Form, located on the Provider Forms web page under the Claim Forms and Attachments drop-down menu, must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.

Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form. Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.

The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to the Health First Colorado for FQHC and RHC services.

Form Locator and Labels

Completion Format

Instructions

1. Billing Provider Name, Address, Telephone Number

Text

Abbreviate the state using standard post office abbreviations. Enter the telephone number.

Street
City
State
Zip Code

Abbreviate the state using standard post office abbreviations. Enter the telephone number.

2. Pay-to Name, Address, City, State

Text

Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:

Street/Post Office box City
State Zip Code
Abbreviate the state using standard post office abbreviations. Enter the telephone number.

3a. Patient Control Number

Up to 20 characters: Letters, numbers or hyphens

Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).

3b. Medical Record Number

17 digits

Optional
Enter the number assigned to the member to assist in retrieval of medical records.

4. Type of Bill

3 digits

Required
RHC: Use type of Bill 71X
FQHC: Use type of Bill 77X for outpatient

Digit 1	Frequency
0	Non-Payment/Zero Claim
1	Admit through discharge claim
2	Interim - First claim
3	Interim - Continuous claim
4	Interim - Last claim
7	Replacement of prior claim
8	Void of prior claim

5. Federal Tax Number

None

Submitted information is not entered into the claim processing system.

6. Statement covers period From/Through

From:6 digits MMDDYY
Through: 6 digits MMDDYY

Required
Each date of service must be billed on a separate line. Split an entire month into two claims. This FL must reflect the beginning and ending dates of service listed on the detail dates of service lines.

8a. Patient Identifier

Submitted information is not entered into the claim processing system.

8b. Patient Name

Up to 25 characters, letters and spaces

Required
Enter the member's last name, first name and middle initial.

9a. Patient Address - Street

Characters Letters and numbers

Required
Enter the member's street/post office box as determined at the time of admission.

9b. Patient Address - City

Text

Required
Enter the member's city as determined at the time of admission

9c. Patient Address - State

Text

Required
Enter the member's state as determined at the time of admission.

9d. Patient Address - ZIP

Digits

Required
Enter the member's zip code as determined at the time of admission.

9e. Patient Address - Country Code

Digits

Optional

10. Birthdate

8 digits (MMDDYYYY)

Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDYYYY format). Example: 01012010 for January 1, 2010.

11. Patient Sex

1 letter

Required
Enter an M (male) or F (female) to indicate the member's sex.

12. Admission Date

6 digits

Not Required

13. Admission Hour

6 digits

Not Required

14. Admission Type

1 digit

Conditional
Complete for emergency visits.
1 - Emergency
Member requires immediate intervention as a result of severe, life threatening or potentially disabling conditions.
Exempts outpatient hospital claims from co-payment and PCP referral only if Revenue Code 0450 or 0459 is present. This is the only benefit service for an undocumented alien.
If span billing, emergency services cannot be included in the span bill and must be billed separately from other outpatient services.

15. Source of Admission

1 digit

Not Required

16. Discharge Hour

2 digits

Not Required

17. Patient Discharge Status

2 digits

Not Required

18-28. Conditions Codes

2 digits

Conditional Complete with as many codes necessary to identify conditions related to this bill that may affect payer processing.

Condition Codes

Military service related

Employment related

Information only bill

Lien has been filed

ESRD member - First 30 months entitlement

Treatment of non-terminal condition/hospice member

Member is homeless

Member is a non-US resident

Private room medically necessary

-DRG (Day outlier)

Renal dialysis settings

Full care unit

Self-care unit

Self-care training

Home care

Home care - 100 percent reimbursement

Back-up facility

Special Program Indicator Codes

EPSDT/CHAP

Physically Handicapped Children's Program

Family Planning

PPV/Medicare

Second Opinion Surgery

Pregnancy Indicator

PRO Approval Codes
C1	Approved as billed
C2	Automatic approval as billed - Based on focused review
C3	Partial approval
C4	Admission/Services denied
C5	Post payment review applicable
C6	Admission preauthorization
C7	Extended authorization

29. Accident State

2 digits

Not required

31 - 34. Occurrence Code/Date

2 digits and 6 digits

Conditional
Complete both the code and date of occurrence.
Enter the appropriate code and the date on which it occurred. Enter the date using MMDDYY format.
Occurrence Codes:

1	Accident/Medical Coverage
2	Auto Accident - No Fault Insurance Involved
3	Accident/Tort Liability
4	Accident/Employment Related
5	Other Accident/No Medical Coverage or Liability Coverage
6	Crime Victim
20	Date Guarantee of Payment Began
24*	Date Insurance Denied
25*	Date Benefits Terminated by Primary Payer
26	Date Skilled Nursing Facility Bed Available
27	Date of Hospice Certification or Re- certification
40	Scheduled Date of Admission (RTD)
50	Medicare Pay Date
51	Medicare Denial Date
55	Date of Death
A3	Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line A
B3	Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line B
C3	Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer indicated in FL 50, Line C

*Other Payer occurrence codes 24 and 25 must be used when applicable. The claim must be submitted with the third-party information.

35-36. Occurrence Span Code From/ Through

2 and 6 digits

Not required

38. Responsible Party Name/Address

None

Leave blank

39 - 41. Value Codes and Amounts

2 characters and up to 9 digits

Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.

Most common semiprivate rate (Accommodation Rate)

Medicare blood deductible

No fault including auto/other

Worker's Compensation

Member Liability Amount

Multiple Member Ambulance Transport

Pints of Blood Furnished

Blood Deductible Pints

New Coverage Not Implemented by HMO

Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).

Hematocrit Reading - EPO Related

Arterial Blood Gas (PO2/PA2)

EPO-Drug

Covered Days

Non-Covered Days

Enter the deductible amount applied by indicated payer:
Deductible Payer A
B1 Deductible Payer B
C1 Deductible Payer C

Enter the amount applied to member's co-insurance by indicated payer:
A2 Coinsurance Payer A
B2 Coinsurance Payer B
C2 Coinsurance Payer C

Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C

42. Revenue Code

3 digits

Required
FQHCs

FQHC Medical Claims
Use revenue code 0529 on at least one line of the claim regardless of the type of service identified in locator 44. All other lines should use the revenue code appropriate for the service.
FQHC Dental Claims
For claims with dates of service prior to July 1, 2014, use revenue code 529 on each line of the claim regardless of the type of services identified in locator 44. For claims with dates of service after July 1, 2014, refer to the Office Reference Manual (ORM) under 'DentaQuest Resources' located on the Dentist page of DentaQuest's website.

RHCs
Use revenue code 0521 on one line of the claim regardless of the type of service identified in locator 44. All other lines should use the revenue code appropriate for the service and list other revenue codes as informational.

43. Revenue code Description

Text

Required
Enter the revenue code description or abbreviated description.
When reporting an NDC:

Enter the NDC qualifier of "N4" in the first two positions on the left side of the field, immediately followed by the 11-digit NDC numeric code.
Enter one space for separation.
Enter the NDC unit of measure qualifier (examples include):
- F2 - International Unit
- GR - Gram
- ML - Milliliter
- UN - Units
Enter the NDC unit of measure quantity.

Example:

42 REV.CD.	43 DESCRIPTION
0636	N467066000501 ME.016

44. HCPCS/Rates/ HIPPS Rate Codes

5 digits

FQHC
Required
There may be multiple lines, each identified by revenue code 529 in locator 42. For each line enter a valid CPT code or HCPCS code that reflects the services rendered during the encounter. This includes any medical, laboratory, radiology, physical therapy, occupational therapy, pharmacy, supply or other service rendered during the encounter.

CPT and HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.

On dental claims the D-code must be put in locator 44 on each line for dates of services prior to July 1, 2014. For dates of services after July 1, 2014, refer to the Office Reference Manual (ORM) under 'DentaQuest Resources' located on the Dentist page of DentaQuest's website.

RHC
Conditional
Enter only the HCPCS code for each detail line.

Complete for laboratory, radiology, physical therapy, occupational therapy, and hospital-based transportation. When billing HCPCS codes, the appropriate revenue code must also be billed.

Services Requiring HCPCS
With the exception of outpatient lab and hospital-based transportation, outpatient radiology services can be billed with other outpatient services.

HCPCS codes must be identified for the following revenue codes:

32X Radiology - Diagnostic
33X Radiology - Therapeutic
34X Nuclear Medicine
35X CT Scan
40X Other Imaging Services
61X MRI

HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.

45. Service Date

6 digits

Required

FQHC
Enter the date of service using MMDDYY format for each detail line completed.

Each date of service must fall within the date span.

RHC
For span bills only.

Enter the date of service using MMDDYY format for each detail line completed.

Each date of service must fall within the date span.

46. Service Units

Up to 3 digits

Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit)

47. Total Charges

Up to 9 digits

Required
Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total in line 23 is required for all charges.

48. Non-covered Charges

Up to 9 digits

Required
Enter incurred charges that are not payable by the Health First Colorado.
Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges). Each column requires a grand total.
Non-covered charges cannot be billed for outpatient hospital laboratory or hospital-based transportation services.

50. Payer Name

1 letter and text

Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.

Source Payment Codes
B	Workmen's Compensation
C	Medicare
D	Health First Colorado
E	Other Federal Program
F	Insurance Company
G	Blue Cross, including Federal Employee Program
H	Other - Inpatient (Part B Only)
I	Other
Line A	Primary Payer
Line B	Secondary Payer
Line C	Tertiary Payer

51. Health Plan ID

8 digits

Required
Enter the provider's Health Plan ID for each payer name. Enter the eight-digit Health First Colorado
Program provider number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.

52. Release of Information

None

53. Assignment of Benefits

None

54. Prior Payments

Up to 9 digits

Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.

55. Estimated Amount Due

Up to 9 digits

Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.

56. National Provider Identifier (NPI)

10 digits

Required
Enter the billing provider's 10-digit National Provider Identifier (NPI).

57. Other Provider ID

Submitted information is not entered into the claim processing system.

58. Insured's Name

Up to 30 characters

Required
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.

60. Insured's Unique ID

Up to 20 characters

Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.

61. Insurance Group Name

14 letters

Conditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.

62. Insurance Group Number

17 digits

Conditional
Complete when there is third party coverage.

Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.

63. Treatment Authorization Code

Up to 18 characters

Conditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.

64. Document Control Number

Conditional

65. Employer Name

Text

Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).

66. Diagnosis Version Qualifier

Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0ICD-10-CM (DOS 10/1/15 and after)
9ICD-10-CM (DOS 9/30/15 and before)

67. Principal Diagnosis Code

Up to 6 digits

Required
Enter the exact diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
Use the following diagnosis codes for EPSDT screenings:

Z00.00-10
Z00.110-Z00.111
Z00.121-Z00.129
Z00.6-Z00.8
Z02.0-Z02.6
Z02.81-Z02.89
Z76.2

67A. - 67Q. - Other Diagnosis

6 digits

Optional
Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.

69. Admitting Diagnosis Code

6 digits

Not required

70. Patient Reason Diagnosis

Submitted information is not entered into the claim processing system.

71. PPS Code

Submitted information is not entered into the claim processing system.

72. External Cause of Injury code (E-Code)

6 digits

FQHC
Required if known

Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".

RHC
Optional

Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".

74. Principal Procedure Code/Date

7 characters and 6 digits

Required
Enter the procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Enter the date using MMDDYY format.
Apply the following criteria to determine the principle procedure:

The principal procedure is not performed for diagnostic or exploratory purposes. This code is related to definitive treatment.
The principal procedure is most related to the primary diagnosis.

74A. Other Procedure Code/Date

7 characters and 6 digits

Conditional

Complete when there are additional significant procedure codes.

Enter the procedure codes identifying all significant procedures other than the principle procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principle diagnosis. Enter the date using MMDDYY format.

76. Attending NPI - Required

Attending Last/First Name

NPI - 10 digits

Text

Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL - Enter "1D" for Health First Colorado
Enter the attending physician's last and first name.
This form locator must be completed for all services.

77. Operating NPI

Submitted information is not entered into the claim processing system.

78 - 79. Other ID

NPI - Conditional

NPI - 10 digits

Conditional
Complete when attending physician is not the PCP or to identify additional physicians.
NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility and PCP. The Health First Colorado does not require that the PCP number appear more than once on each claim submitted.
The attending physician's last and first name are optional.

80. Remarks

Text

Enter specific additional information necessary to process the claim or fulfill reporting requirements.

81. Code - QUAL/CODE/VALUE (a-d)

Qualifier: 2 digits
Taxonomy Code: 10 digits

Optional
Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.
Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system.

FQHC Claim Example

FQHC Crossover Claim Example

FQHC with RAE Diagnosis Code Claim Example

FQHC RAE Claim Example

RHC Claim Example

RHC Crossover 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 menu for more information on timely filing policy, including the resubmission rules for denied claims.

Sterilization, Hysterectomies and Abortions

Refer to the Obstetrical Care Billing Manual located on the Billing Manuals web page under the CMS 1500 drop-down menu for more information on sterilization, hysterectomies and abortions.

Institutional Provider Certification

The UB-04 Institutional Certification Form is located on the Provider Forms web page under the Claim Forms and Attachments drop-down menu.

FQHC/RHC Revisions Log

Revision Date	Addition/Changes	Made by
12/01/2016	Manual revised for interChange implementation. For manual revisions prior to 12/01/2016 Please refer to Archive.	HPE (now DXC)
1/19/2017	Updates based on the 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)
2/9/2017	Added RAE E&M policy and Type of Bill 77x	HCPF
2/9/2017	Made formatting changes to references of FQHCs and RHCs	HCPF
5/17/2017	Updated the Freestanding FQHCs and RHCs section	HCPF
5/17/2017	Updates based on Fiscal Agent name change from HPE to DXC	DXC
1/2/2018	Revenue Code Description - instructions for reporting an NDC	DXC
6/22/2018	Updated general billing and timely filing, changed BHO to RAE	HCPF
7/11/2019	Updated Appendices' links and verbiage	DXC
8/21/2019	Added language for valid revenue codes	HCPF
8/22/2019	Updated links, removed duplicated information	HCPF
11/20/2019	Added clarification to 0529	HCPF
8/7/2020	Updated item 81 of the Paper Claim reference Table for taxonomy code billing	DXC
12/2/2020	Updated billable encounter information, replaced instances of Colorado Medicaid with Health First Colorado	HCPF
2/18/2022	Enrollment of Temporary Service Sites and Mobile Unit Policy Clarification	HCPF
7/1/2022	Added APM 2 Billing Guidance link	HCPF
8/5/2022	Added FQ and FR modifier information	HCPF
3/7/2024	Updated link for C.R.S. 25.5-4-420	HCPF