General Provider Information Manual | Department of Health Care Policy and Financing

Privacy Statement
Introduction to the Manual
- Bulletins
Administration
Provider Participation/Provider Enrollment

Privacy Statement

The Colorado Department of Health Care Policy & Financing (the Department) is committed to ensuring the privacy and security of Health First Colorado (Colorado's Medicaid Program) members' protected health information. To support this commitment, the Department has implemented and will continue to maintain appropriate policies, procedures, and mechanisms to protect the privacy and security of Protected Health Information that is used or disclosed by the Department.

As the single state agency responsible for the administration of Health First Colorado pursuant to Title XIX of the Social Security Act, the Department is specifically considered a Health Plan under the Privacy Regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As such, the Department is a Covered Entity that must adhere to the HIPAA Privacy Regulations as promulgated by the U.S. Department of Health and Human Services.

As part of its HIPAA compliance efforts, the Department has enacted several policies and procedures detailing the rights of Health First Colorado members, the Department's permitted uses and disclosures of member protected health information, and the Department's administrative duties under HIPAA.

Introduction to the Manual

This manual provides general information about Health First Colorado to assist enrolled providers with submitting claims for services rendered to Health First Colorado members.

Providers and their staff should familiarize themselves with the manual and refer to it to answer program and billing questions. Using the information in manuals and bulletins helps eliminate program and billing misunderstandings that can result in payment delays, incorrect payments, and payment denials, regarding covered services, member eligibility, and billing procedures.

Rules

The manuals are instructional guides and are not Health First Colorado policy manuals.

The rules and regulations governing Health First Colorado policy may be found in Volume VIII, the Medical Assistance Manual of the Colorado Department of Health Care Policy and Financing (Program Rules and Regulations). These rules also are available in the Colorado Code of Regulations (10 CCR 2505-10) available at most libraries.

The Health First Colorado Provider Billing Manuals contain basic billing and benefit information about Health First Colorado. The Provider Billing Manuals are the only authorized billing procedure manuals for Health First Colorado. Providers may download copies of manuals as needed. The manuals are designed to help providers correctly file Health First Colorado claims.

Electronic Billing

The Billing Manuals are designed to be used by both electronic and paper claim billers as a Health First Colorado policy reference. Providers should file electronic claims whenever possible. For instructions on electronic billing, see below:

Batch billers may use the explanations of the paper claim fields located in individual manuals to clarify field descriptions on electronic claims. Batch billers should utilize electronic specifications in the TR3 and in the appropriate Companion Guides.
Electronic billers using the Provider Web Portal may use the Quick Guides.

The Health First Colorado Provider Manuals consist of:

The General Provider Information manual
- This manual contains Health First Colorado information common to all provider types, including eligibility, covered services, and provider enrollment and participation guidelines.
The Appendices
- These documents include contact addresses and phone numbers, prior authorization information, a glossary/acronym list, and additional reference information.
The Specialty Billing Information manuals
- This manual contains Health First Colorado information specific to provider types, including paper claims and electronic claims.
Pharmacy Billing Instructions
- This document provides a link to the Pharmacy billing instructions.
CMS 1500 Specialty Billing Information
- This document contains program-specific benefit, procedural, and billing information for providers billing on the CMS 1500 paper claim form.
Individual CMS 1500 Specialty Billing Manuals
- These manuals contain provider-specific benefit, procedural, and billing information for providers billing on the CMS 1500 paper claim form.
The Home and Community Based Services (HCBS) Specialty Billing Information manuals
- These manuals contain program-specific benefit, procedural, and billing information for Home and Community Based Services and should be used with the Billing Information section for detailed CMS 1500 claim field completion instructions.
Individual UB-04 Specialty Billing Manuals
- These manuals contain provider-specific benefit, procedural, and billing information for providers billing on the UB-04 paper claim form.
Refer to the DentaQuest Office Reference Manual for information on dental billing.

Bulletins

Updated Health First Colorado information is published in Provider Bulletins and Provider News. A link to the most recent bulletin is sent to the service location email address on file with the Department's fiscal agent. Update your contact information in the Provider Web Portal as needed and sign up here under Email List "00 - All Provider Emails" to ensure you receive notifications for each Provider Bulletin.

Keep the current Healthcare Common Procedure Coding System (HCPCS) procedure code bulletin for your program with your program-specific manual. Replace procedure code bulletins as new bulletins are published.

Administration

The Social Security Act provides entitlement to medical services for individuals who meet eligibility requirements. Title XVIII governs the Medicare Program, and Title XIX establishes the State Option Medical Assistance Program, also known as Health First Colorado. The Colorado Medical Assistance Act provides the legal authority for the Health First Colorado program.

The Health First Colorado program is a state and federal partnership funded by the State of Colorado and federal matching dollars. State funds are appropriated through the Colorado Legislature. Federal funding is dependent upon compliance with federal guidelines.

By statute, Health First Colorado pays for covered healthcare benefits for eligible members after all other healthcare resources have been exhausted. The Health First Colorado program is an entitlement program, which means that any person who meets the eligibility criteria is entitled to receive any medically necessary service covered by the program. Covered benefits include most medical services and limited related support services required in the diagnosis and treatment of disease, disability, infirmity, or impairment. In general, Health First Colorado benefits are comprehensive and provide care in most medical disciplines. Refer to the Benefits and Benefit Delivery Programs section for detailed benefit information.

Department Responsibilities

The Department:

Establishes the policies, rules, and regulations that govern Health First Colorado.
Administers Health First Colorado to assure compliance with state and federal rules, guidelines and regulations.
Administers a Modified Medical Program providing limited medical benefits for needy citizens age sixty and older who are not eligible for Health First Colorado coverage. Benefits for these individuals are similar but not identical to Health First Colorado coverage.
Administers other medical assistance programs such as Child Health Plan Plus (CHP+) and the Colorado Indigent Care Program (CICP).
Establishes Health First Colorado policy.
Determines benefit and reimbursement levels for all medical assistance programs according to state and federal legislative intent.
Directs and monitors the activities of the fiscal agent.
Reviews and monitors program utilization.

County Departments of Human/Social Services Responsibilities

The County Departments of Human/Social Services:

Determine Health First Colorado member eligibility.
Issue Medical Identification Cards (MIC Card) to eligible members.
Advise Health First Colorado members of Health First Colorado benefits.

Fiscal Agent (FA) Responsibilities

The Fiscal Agent (FA):

Enrolls Health First Colorado providers.
Provides education and billing assistance to enrolled providers.
Receives, controls, and processes Health First Colorado claims according to Department policy.
Responds to provider inquiries.
Prepares the Department's required financial and utilization reports.
Prepares and distributes Remittance Advice (RA).
Adjusts claims as required.
Accepts and processes Reconsideration requests.
Produces the Health First Colorado Provider Manuals in cooperation with the Department.

Provider Responsibilities

Providers are responsible for:

Maintaining their copies of the manual in a current, updated manner (provider manual updates and revisions are made to manuals posted to the Billing Manuals web page. Update notifications are published in the Provider Bulletins).
Keeping provider enrollment information current with the fiscal agent.
Submitting claims correctly to the fiscal agent.
Following the procedures and guidelines for program participation established by the Department.

Member Responsibilities

Members are responsible for:

Understanding their rights.
Following the Member Handbook.
Cooperating with and being respectful to other members, providers and their staff.
Choosing a provider from within their plan network or contacting the Department if they want to see another provider.
Paying for services that are not covered by Health First Colorado.
Telling their provider and Health First Colorado if they have other insurance or family or address changes.
Asking questions when they do not understand or want to learn more.
Telling their provider, the information needed to render care, such as their symptoms.
Taking medications as prescribed or telling their provider about side effects or if the medications are not helping.
Inviting people who will be helpful and supportive to be included in their treatment.

Provider Participation/Provider Enrollment

To perform Health First Colorado benefit services and to receive Health First Colorado payments, providers must enroll in Health First Colorado. Enrolled providers must have and maintain licensure and certification required by Health First Colorado regulations. Providers seeking to enroll can find information regarding enrollment on the Provider Enrollment web page.

Provider Numbers

All providers will be assigned a Health First Colorado provider number by the fiscal agent.
The National Provider Identification (NPI) must be used to submit claims.
Atypical providers that cannot obtain an NPI are an exception to this requirement. The Health First Colorado number must be used by Atypical providers to submit claims.
Unauthorized use of provider numbers is not allowed.

Special Participation Conditions

Limited Participation Providers

Providers enrolled solely for the purpose of receiving Health First Colorado payments for services provided to Health First Colorado members also enrolled in the Medicare Program (dually eligible members) must have and maintain Medicare enrollment. Services by these providers (e.g., chiropractors, free-standing physical therapy facilities) usually are not Health First Colorado benefits, or these services are provided under circumstances that do not meet Health First Colorado requirements. Payment is limited to consideration of Medicare deductibles and coinsurance.

Locum Tenens

Practitioners who provide services under a locum tenens agreement must enroll in Health First Colorado. Claims for services by a locum tenens practitioner must identify the enrolled locum tenens practitioner as the rendering provider.

Hospitals may enter the member's regular practitioner’s Medical Assistance Program provider ID in the Attending Physician ID field if the locum tenens practitioner is not enrolled in Health First Colorado. A member’s regular practitioner can hold an MD, DO, or NP provider license.

Out-of-State Providers

Out-of-State providers enroll in Health First Colorado under the same rules and regulations applied to Colorado providers. The following benefit services are provided outside Colorado:

Services to residents of Colorado border localities where the use of medical resources in the adjacent state is common. Refer to Appendix F located on the Billing Manuals web page under the Appendices drop-down for a listing of recognized Colorado border towns.
Services to Health First Colorado members who live in other states under special circumstances, such as foster care.
Emergency services provided to Health First Colorado members who are traveling or visiting outside Colorado (documentation of the emergency must be on file). Prior authorization is not needed for emergency services.
Services needed because the individual's health would be endangered if he or she were required to return to Colorado for medical care (services must be prior authorized).
Services that are unavailable in Colorado (services must be prior authorized).

Ordering, Prescribing and Referring (OPR) Providers

Health First Colorado complies with Federal Medicaid Regulations in 42 CFR 455.410(b) which provide that Medicaid must require all ordering or referring physicians or other professionals providing services be enrolled as providers, and 42 CFR 455.440, which provides that Medicaid must require all claims for the payment of items and services that were ordered, referred, and prescribed to include the National Provider Identifier (NPI) of the ordering, referring or prescribing physician or other professional. Refer to the Ordering, Prescribing or Referring section of the Provider Enrollment web page for more information.

Prescribing Controlled Substances

Effective October 1, 2021, Medicaid providers permitted to prescribe controlled substances must query the Colorado Drug Monitoring Program (PDMP) before prescribing controlled substances to Medicaid members, in accordance with Section 5042 of the "Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and the Communities Act (SUPPORT Act)".

The requirement to check the PDMP does not apply when a member:

Is receiving the controlled substance in a hospital, skilled nursing facility, residential facility, or correctional facility
Has been diagnosed with cancer and is experiencing cancer-related pain
Is undergoing palliative care or hospice care
Is experiencing post-surgical pain that, because of the nature of the procedure, is expected to last more than 14 days
Is receiving treatment during a natural disaster or during an incident where mass casualties have taken place
Has received only a single dose to relieve pain for a single test or procedure

In the case that a provider is not able to check the PDMP before prescribing a controlled substance, despite a good faith effort, the State shall require the provider to document the effort, including the reasons why the provider was not able to conduct the check. The State may require the provider to submit, upon request, such documentation to the State.

Visit the About the PDMP Program web page for more information about the PDMP Program.

Registered Nurses Enrolled as Non-Physician Practitioners

Except as listed, benefit services provided by registered nurses enrolled as non-physician practitioners must comply with the following requirements:

Services must be ordered by a licensed physician (MD or DO) or advanced practice nurse (APN).
Services must be performed under the general supervision of a Physician/APN who is available when services are provided.
Claims must be submitted through the enrolled Physician, APN, Non-physician practitioner group, or clinic.
The supervising Physician/APN's National Provider ID (NPI) must appear on the claim form.
Claims must be billed using procedure codes specifically designated for non-physician practitioner billing.
Claims must identify the non-physician practitioner or the supervising Physician/Advanced Practice Nurse with their NPI as the rendering provider.
The non-physician practitioner must look to the billing provider for reimbursement.

On-Premise Supervision and Non-Direct Reimbursement Exemptions

The following list on-premise supervision and non-direct reimbursement exemptions:

Dentists and Dental Hygienists
- Services do not require physician order or physician supervision
- Dentists receive direct reimbursement
Podiatrists
- Services do not require physician order or physician supervision
- Podiatrists receive direct reimbursement
Optometrists
- Services do not require physician order or physician supervision
- Optometrists receive direct reimbursement
Certified Nurse Midwives
- Within the definitions of the Nurse Practice Act, services do not require physician order or on-premise physician supervision
- Certified Nurse Midwives receive direct reimbursement
- For reimbursement purposes, nurse midwives may serve as supervisors of lesser licensed practitioners
Certified Registered Nurse Anesthetists
- Services defined in Health First Colorado regulations do not require physician order or on-premise physician supervision
- If special enrollment qualifications are met, they may receive direct reimbursement
Certified Pediatric Nurse Practitioners
- Services defined in Health First Colorado regulations do not require physician order or on-premise physician supervision
- If special enrollment qualifications are met, may receive direct reimbursement
Certified Family Nurse Practitioners
- Services defined in Health First Colorado regulations do not require physician order or on-premise physician supervision
- If special enrollment qualifications are met, may receive direct reimbursement
Audiologists and Speech Pathologists
- Services by an Audiologist or Speech Pathologist require a physician order
- If special enrollment requirements are met, qualified audiologists and speech pathologists do not require on-premise physician supervision and may receive direct reimbursement
Non-Physician Practitioners
- Non-Physician Practitioner must be enrolled
- On-premise physician supervision is not required
- Claims must be submitted by a billing provider and the ordering provider's NPI must appear on the claim
- Reimbursement is made directly to the billing provider
Physical and Occupational Therapists
- Services defined in Health First Colorado regulations require a physician order
- Physical and Occupational Therapists receive direct reimbursement
Non-enrolled providers
- Services by non-enrolled providers must be ordered by an enrolled provider that can order services
- Services by a non-enrolled provider require Direct Supervision by an on-site enrolled provider during the rendering of services who is immediately available to give assistance and direction throughout the performance of the service
- Services must identify the enrolled provider as the rendering provider.

Participation Agreements and Responsibilities

A copy of the current Provider Participation Agreement can be found on the Provider Revalidation & Enrollment web page. All Health First Colorado-enrolled providers must sign the agreement before being accepted as a participating provider, this is done via the Online Provider Enrollment tool during enrollment or revalidation.

Enrolled providers are required to comply with federal and state laws and regulations applicable to Health First Colorado.
Colorado rules and regulations applicable to Health First Colorado are published in the Code of Colorado Regulations, 10 C.C.R. 2505-10, Department of Health Care Policy and Financing, Staff Manual Volume VIII, Medical Assistance.
Billing instructions and references to applicable Health First Colorado laws and regulations are published in provider manuals and bulletins.
Providers must comply with instructions and policies described in Health First Colorado publications.

Change of Ownership (CHOW): Change in Tax Identification Number

A change of ownership means that a provider has been issued a new tax identification number. Within thirty-five (35) calendar days of a change in ownership, a provider must update the provider portal of the Department’s Medicaid Management Information System (MMIS).
A change of ownership requires the new owner(s) to submit an application, complete a new Medical Assistance Program Provider Participation Agreement, and be fully approved in order to participate in Health First Colorado.
Providers with a change in tax ID number must re-apply, complete a new Medical Assistance Program Provider Participation Agreement, and be fully approved in order to participate in Health First Colorado. The previous Health First Colorado number must be disenrolled.
Providers must choose a date to stop billing under the previous Tax ID and begin billing under the new Tax ID. The two numbers should not have overlapping dates.

Practice Capacity

Providers are not required to accept all Health First Colorado members. Providers may limit the number of Health First Colorado members associated with their practice agency or facility if the policies and methods of applying limitations are non-discriminatory.

Health First Colorado Member Billing

Providers agree to accept Health First Colorado payment as payment in full for benefit services. Colorado law (C.R.S. 25.5-4-301(II)) provides that no Health First Colorado member shall be liable for the cost, or the cost remaining after payment by Health First Colorado, Medicare, or a private insurer, of medical benefits authorized under Title XIX of the Social Security Act. This law applies whether or not Health First Colorado has reimbursed the provider, whether claims are denied by Health First Colorado due to provider error, and whether or not the provider is enrolled in Health First Colorado. This law applies even if a Health First Colorado member agrees to pay for part or all of a covered service. This law also prohibits providers from billing Health First Colorado members or the estates of deceased Health First Colorado members for Health First Colorado benefit services. Refer to the Policy Statement: Billing Health First Colorado Members for Services.

Member Billing Prohibited

Members may not be billed for the difference between the provider's charges and Health First Colorado program, Medicare, or commercial insurance payments (except for members requesting brand name pharmacy items).

Providers may not assert a lien - including a hospital lien - on any money, settlement, recovery, or judgment paid to the member or to the member's estate as the result of a personal injury lawsuit.

Constraints against billing Health First Colorado members for benefit services apply whether or not Health First Colorado makes or has made payment and whether or not the provider participates in the Health First Colorado program.

Providers may not bill Health First Colorado members for missed appointments, telephone calls, completion of claim submission forms, or medication refill approvals.

Members may not be billed if the failure to obtain Health First Colorado payment is caused by the provider's failure to comply with Health First Colorado billing procedures.

Collection agencies cannot submit Health First Colorado claims for payment and cannot collect payment from Health First Colorado-eligible members.

Member Billing Permitted

Before providing services that will not be covered by the Health First Colorado program, providers should have the member sign an acknowledgment of financial responsibility. Only if a written agreement is developed, members have the following responsibilities:

If the service is not a covered benefit of the Health First Colorado program, members may be billed for the service.
Some members are responsible for Health First Colorado co-pay. By federal law, providers may not refuse services if the member cannot pay a Co-pay when services are rendered. Members may be billed for unpaid Co-pays. Providers may apply standard collection policies if the member fails to satisfy Co-pay obligations.
Members in nursing facilities are responsible for member payment when under Medicare Part A (skilled nursing) coverage. If the member payment amount exceeds the Medicare Part A coinsurance due, the difference is refunded to the member.
Health First Colorado members enrolled in a Health First Colorado Managed Care Program must follow the rules of the Managed Care Organization (MCO). Members who insist upon obtaining care outside of the MCO network may be charged for non-covered services.

Health First Colorado members who have commercial insurance coverage that requires them to obtain services through a provider network must obtain all available services through the network. Members who insist upon obtaining managed care-covered services outside the network may be charged for such services.

Claim Certification Statements

All claims sent electronically must contain a certification field to indicate that the sender verifies that submitted information is true and correct. The enrolled provider is completely responsible for the claim information and the conditions under which claims are submitted.

Certification statements on Health First Colorado paper claim forms become effective when the provider signs the claim form or the certification form. If the form is signed by an authorized agent, the provider remains completely responsible for the information on the claim and the conditions under which the claim is submitted.

According to Title VI of the Civil Rights Act, providers who receive any federal funds through programs such as the Medical Assistance Program, Medicare, CHAMPUS, etc., must provide oral interpretation services (excluding a member's family members) to all limited English proficient members in their practice, including those for whom you do not receive federal funds. Limited English proficient members are members who do not speak English as their primary language. Examples of oral interpretation services include oral interpretation services, bilingual staff, telephone interpreter lines, written language services and community volunteers. Written materials must be translated and provided to limited English proficient members if the practice comprises of 10% or 3,000 limited English proficient members, whichever is less. If you have questions, contact the Office of Civil Rights at 888-848-5306.

Authorized Signatures

Claims must be signed by the enrolled billing provider or by an authorized agent or representative designated by the enrolled billing provider. Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

A holographic signature stamp may be used. Typed signatures and "Signature on File" are not acceptable.

An authorized agent or representative may sign the claim for the enrolled provider.

The enrolled provider is solely responsible for submitted claim information.

Reimbursement Policies

Payment for Services

All Health First Colorado payments are made in the name of the enrolled provider (i.e., an individual or organization that meets the licensure and/or certification requirements for program participation). Under no circumstance will payments be made to a collection agency, accounting firm, legal firm, business manager, billing service, or similar organization. Collection agencies, accounting firms, legal firms, and similar organizations cannot submit claims for direct reimbursement. Claims and claim inquiries must be submitted by the enrolled provider.

If rate increases are implemented, claims that were already billed with and paid at a rate lower than the new rate cannot be adjusted by the fiscal agent for the higher rate. The lower of pricing logic will always be used. Providers are advised to bill their usual and customary charges.

Electronic Funds Transfer

Enrolled providers are required to receive their Health First Colorado payments through Electronic Funds Transfer (EFT). The only exceptions to this rule are for out of state providers (of any type), case managers (Provider Type 11), and state entities.

EFT is efficient and cost effective.
EFT reduces payment turn-around time.
EFT authorizes the Health First Colorado program to deposit payments directly into the provider's designated bank account.
EFT authorization does not allow the Health First Colorado program to remove funds from the provider's bank account. Erroneous transactions (e.g., duplicate deposits) are electronically reversed.

Providers are responsible for furnishing accurate banking information. If EFT information (e.g., bank account numbers, institutional identification numbers, etc.) changes, EFT may be interrupted until the provider submits corrected information. When EFT is interrupted, payments are made by State warrant (paper check). Paper warrants and remittance advice may be sent separately.

Federal Income Reporting

Health First Colorado payment information is reported each January on the Federal 1099 Income Report. Income is reported under the billing provider's Tax Identification Number (TIN), which is the Social Security Number (SSN) or Employer Identification Number (EIN).

The name of the enrolled provider must match exactly the name associated with the TIN. The IRS requires that Health First Colorado payments made in the name of an individual practitioner be reported under the individual's SSN.

Payments for services by enrolled practitioners may be made in the name of an employer, professional corporation, healthcare organization, or health delivery agency if:

The healthcare employer or organization is a Health First Colorado-enrolled provider.
There is an agreement between the enrolled practitioner and the employer or organization that requires the practitioner to turn over payments to the employer or organization.
The individual who actually renders the services is identified on the claim (by NPI number) as the rendering provider.
The group NPI number appears on the claim as the billing provider.

Civil Rights Anti-Discrimination

Providers must comply with applicable civil rights laws and regulations including prohibitions against discrimination on the basis of race, color, sex, age, religion, national origin, political affiliation, sexual orientation, gender identity, or discrimination on the basis of disability under the Americans with Disabilities Act.

Enrollment Information Accuracy

Providers are responsible for:

Furnishing accurate enrollment information.
Confirming the accuracy of the fiscal agent's enrollment information.
Maintaining up-to-date enrollment information via the Provider Web Portal.
Responding to requests from the fiscal agent for updated enrollment information.

Providers who are also enrolled in the Medicare Program should update their enrollment information online immediately when Medicare billing information is changed. All enrollment changes must be made online through the Provider Web Portal. Telephone requests cannot be accepted.

Re-Certification

The fiscal agent periodically may require that enrolled providers update their enrollment information. Providers receive notification of re-certification. Failure to respond to requests for re-certification information may result in provider suspension.

Revalidation

Federal regulations established by the Centers for Medicare & Medicaid Services (CMS) require enhanced screening and revalidation for all existing (and newly enrolling) providers. These regulations are designed to increase compliance and quality of care, and to reduce fraud. Failure to respond to a revalidation request or requirement may result in provider suspension or termination.

Record Keeping and Retention

Providers are required by the Provider Participation Agreement with the Health First Colorado program and Colorado State Rule 8.130.2 (Program Rules and Regulations) to maintain records necessary to disclose the nature and extent of services provided to members.

Providers must maintain records that fully disclose the nature and extent of services provided. Upon request, providers must furnish information about payments claimed for Health First Colorado services. Records must substantiate submitted claim information. Such records include but are not limited to:

Billing information
Treatment plans
Prior authorization requests
Medical records and service reports, and orders prescribing treatment plans
Records and original invoices for items, including drugs that are prescribed, ordered, or furnished
Claims, billings, and records of Health First Colorado payments and amounts received from other payers

Records of providers shall include employment records, including but not limited to shift schedules, payroll records, and time- cards of employees.

Providers who issue prescriptions shall keep in the patient's record, the date of each prescription and the name, strength, and quantity of the item prescribed.

Each provider shall retain any other records created in the regular operation of business that relate to the type and extent of goods and/or services provided (for example, superbills). All records must be legible, verifiable, and must comply with generally accepted accounting principles, auditing standards, and all applicable state and federal laws, rules, and regulations.

Each medical record entry must be signed and dated by the person ordering and providing the service. Computerized signatures and dates may be applied if the electronic record keeping system meets Health First Colorado security requirements.

These records must fully substantiate or verify claims submitted for payment and must be furnished on request to the authorizing agency. Records must be retained for at least seven years or longer if required by regulation or a specific contract between the provider and the Health First Colorado program.

At the request of the US Department of Health and Human Services, the Department, the Colorado Department of Human Services, or the Medicaid Fraud Control Unit, and at the request of any of their authorized designees, record verification may include, but will not be limited to, interviews with providers, employees of providers, billing services that bill on behalf of providers, and any member of a corporate structure that includes the provider as a member.

Ownership Disclosure

As part of enrollment, revalidation, or upon request providers must disclose information about ownership and control, persons convicted of crime, business transactions, and subcontractor ownership.

The Federal Omnibus Budget Reconciliation Act of 1993 (OBRA 1993) prohibits enrolled physicians from making referrals for certain health services to an entity where the physician or an immediate member of the physician's family has a financial relationship with the service entity. The health service entity may not submit a claim or bill to any individual, third-party payer, or other entity for services provided as the result of a prohibited referral.

Advance Directives

Hospitals, nursing facilities, hospice programs, and health maintenance organizations must maintain written advance directive policies that include:

A description of the procedures for giving Health First Colorado members written information about their legal right to accept or refuse medical treatment and the right to formulate advance directives.
The provider's policies respecting implementation of such rights.

Termination of Enrollment

Health First Colorado provider enrollment may be terminated under the following circumstances:

Demonstrated inability to perform under the terms of the provider agreement.
Breaches of the provider agreement.
Failure to abide by applicable Colorado and United States laws.
Failure to abide by the rules and regulations of the U.S. Department of Health and Human Services and the Health First Colorado program.
Ineligibility or suspension from participation in other Federal or State medical programs.

Inactivation of Enrollment

Health First Colorado provider enrollment may be inactivated under the following circumstances:

The Provider’s license, certification, or accreditation has expired or is subject to conditions or restrictions.
The Provider has failed to complete Provider revalidation.
The Provider is no longer eligible to participate as a Medical Assistance Program Provider or breaches the Provider agreement.
There is a Change of Ownership.
The Provider’s business closes, or the business is nonoperational.
The Provider is deceased or retired.
The Provider is inactive and has not submitted any claims activity for 24 months.

Providers will receive notice from the Department prior to inactivation and will be given the opportunity to dispute the inactivation, including appeal rights. Inactivation may be backdated to the date of the applicable inactivation circumstance listed above.

Co-Pay

The Health First Colorado program requires members who receive Fee-For-Service (FFS) benefits to pay a small portion of their medical care costs to the provide in specific circumstances.

Providers bill usual and customary charges for all FFS services and Co-pay is automatically deducted during claims processing.
FFS providers collect Co-pays from members when services are rendered.
If a member is unable to pay the Co-pay, providers may collect it later.
Federal regulations prohibit providers from refusing service because of a member's inability to pay.
If the Co-pay is collected but not deducted from the FFS payment, the provider must refund the Co-pay to the member.
There is no co-pay maximum per calendar year, but there is a monthly maximum Only Old Age Pension (OAP) members have a $300 Co-pay maximum per year.
Providers must check the Provider Web Portal eligibility response to view a member's Co-pay liability status.
The Provider Web Portal will display $0 values for the TXIX benefit plan when a member is (or becomes) exempt from Co-pays. This may change during the month depending on when a member reaches their monthly Co-pay maximum. It is critical for providers to always check the eligibility response at each visit.

Co-Pay Amounts

Service	Co-pay Amount
Outpatient Hospital Services	$0.00 per visit (effective 7/1/23)
Outpatient Hospital non-emergent Emergency Room visit	$8.00 per visit (effective 7/1/22)
Physician (MD or DO) Home or Office visit	$0.00 per visit (effective 7/1/23)
Rural Health Clinic Visit	$0.00 per visit (effective 7/1/23)
FQHC Visit	$0.00 per visit (effective 7/1/23)
Pharmacy Services (each prescription or refill) Generic drugs Brand name and single-source drugs	$0.00 (effective 7/1/23) $0.00 (effective 7/1/23)
Optometrist visit	$0.00 per visit (effective 7/1/23)
Podiatrist visit	$0.00 per visit (effective 7/1/23)
Inpatient Hospital Services	$0.00 per admission (effective 7/1/23)
DME/Disposable Supply Services	$0.00 per date of service (effective 7/1/23)
Laboratory Services	$0.00 per date of service (effective 7/1/23)
Radiology Services	$0.00 per date of service (effective 7/1/23)

Co-Pay Monthly Maximum

There is a monthly Co-pay maximum for Health First Colorado members. This means once a member has paid up to a certain amount in Co-pays in a month, they don't have to pay any more Co-pays for the rest of that month. This maximum is based on a formula: 5% of the member's monthly household income.

For example, a household with a monthly income of $900 would pay no more than $45 in co-pays for that month.

This maximum is shared by all members of a household. If one member's Co-pays reach the maximum, all members of the household will have no Co-pays for the rest of that month.
The monthly maximum amount is calculated based on income records Health First Colorado has on file for each household.

Due to the timing of when claims are submitted and paid, it is possible that a member's Co-pay maximum will be met in-between the time the member sees the provider and when the provider is reimbursed for the visit. Providers must be prepared to refund a member's Co-pay if the Co-pay amount is not deducted from the final reimbursement from the Department. Whether the Co-pay amount is deducted can be seen in the remittance advice that accompanies each payment.

This policy is in accordance with 42 C.F.R. 447.56(f)

Co-Pay-Exempt Members and Services

Some Co-pay exemptions are processed automatically, and others require the provider to complete specific information on the claim transaction or form.

Exemptions Shown on Eligibility Verification

Members who are ages 18 and younger are automatically exempt from co-pays.

Exemptions Claimed Through Claim Completion

The following Co-pay exemptions are not displayed through Health First Colorado eligibility verification. Co-pay exemption is claimed through the FFS claims submission process. In some instances, providers should question members about their circumstances to determine the appropriateness for the following exemptions:

Institutionalized Members are Exempt from Co-Pay

Members under the age of 21 or over the age of 65 who reside in Skilled Nursing Facilities (SNF) or Intermediate Care Facilities (ICF) or reside in institutions for mental diseases.

Claims require completion of the following claim fields:

Claim Form	Required field completion for institutionalized members
CMS 1500	Field 12 Nursing Facility
837P	Refer to TR3	Refer to TR3
UB-04/837I	Refer to TR3
Pharmacy - NCPDP 5.1 Point of Sale and Universal Claim Form (UCF)	Point of Sale: Use Member Location "03"	UCF: Use Person Code: "03"

Preventative Services Co-Pay Exempt

The Department recognizes Modifier 33 when appended to a preventive service(s), as mandated under the terms of the Patient Protection and Affordable Care Act (PPACA) comprehensive healthcare reform law, and defined in accordance with the U.S. Preventive Services Task Force (USPSTF) A and B rating in effect at the time of service.

Use of Modifier 33 will bypass co-pay requirements and is appropriate with a CPT or HCPCS Code(s) that is a diagnostic/therapeutic service that is being performed as a preventative health service that is not for the treatment of illness or injury. For separately reported services specifically identified as preventive, the modifier should not be used. Providers may append Modifier 33 to an Evaluation & Management (E&M) office visit only if the primary purpose of the E&M office visit is the delivery of a USPSTF grade A or B service, and not if it is simply a component part of a different billed service.

Preventive services falling within the following categories are to be provided without cost sharing by the member:

Services rated "A" or "B" by the USPSTF
Advisory Committee on Immunization Practices (ACIP) Immunizations and their administration for routine use in children, adolescents, and adults

Women in the Maternity Cycle Exempt from Co-Pay

All services to women in the maternity cycle (including prenatal, delivery, and immediate postpartum period not to exceed six weeks) are exempt from co-pay.

Services do not have to be pregnancy related.
The member must inform the provider of her condition at the time of service.
Physicians should note the condition on prescriptions.
Claims require completion of the following claim fields.

Claim Form	Required field completion for members in maternity cycle
CMS 1500	Field 12 Pregnancy
837P	Refer to TR3
UB-04/837I	Condition Code B3
Pharmacy - NCPDP 5.1 Point of Sale and Universal Claim Form (UCF)	Point of Sale: Use Pregnancy Indicator "2" and Prior Authorization Type Code "4"	UCF: Use Prior Authorization Type Code: "4"

Emergency Services Delivered in any Setting Require Indicated Claim Completion

Claim Form	Required field completion for members in maternity cycle
CMS 1500	Field 24C: Enter "X" for each billed line.
837P	Refer to TR3.
UB-04	Type of Admission 01 and 05 (Form Locator 19)
837I	Loop 2300 CL101 = 1

Co-Pay Exemptions Processed Automatically

Dental services
Home and community-based services (HCBS)
Home healthcare
Regional Accountable Entities (RAEs)
Transportation

Member Inquiries

The Department's Customer Contact Center serves Health First Colorado members. Representatives are available Monday through Friday between the hours of 7:30 a.m. and 5:30 p.m. through the following:

Toll free: 800-221-3943
Fax: 303-866-4411
Email: Customer.Service@state.co.us
TDD: 800-659-2656

Members who have questions about the Health First Colorado co-pays should contact the Department's Customer Contact Center.

Providers with questions about Co-pay deductions on processed claims should call the Provider Services Call Center.

Refer to Appendix A and Appendix B on the Billing Manuals web page under the Appendices drop-down for additional contact information for Health First Colorado member and provider services.

Health First Colorado Member Eligibility

Before rendering services, the provider should verify the member's eligibility to ensure that the member is eligible for benefits. Providers should retain documentation of the verified eligibility for billing purposes.

A Provider shall verify that payments received are for medically necessary goods and services that were actually rendered, and that claims and encounters submitted for payment are true and correct.

Member Eligibility

The member's County Department of Human/Social Services establishes member eligibility for Health First Colorado benefits. Case managers advise potential members of proper application procedures and Health First Colorado benefits. Refer to Appendix D and Appendix E on the Billing Manuals web page under the Appendices drop-down for address, phone and fax number information.

After member eligibility is established, the county issues a unique State Identification (State ID) number and a Medical Identification Card (MIC).

Medical Identification Cards (MIC)

medical identification card

In March of 2016, the Department began issuing Medical Identification Cards (MICs) with a new look. A sample of the front and back of the new card is shown above.

The new cards do not replace those issued before March of 2016. Please accept both versions.

Delayed/Retroactive Eligibility

A member's Health First Colorado eligibility may be made retroactive prior to the application date. Charges for services are the member's responsibility until eligibility is established. (Example: A member is "pending" Health First Colorado eligibility.) Claims are denied if the member's eligibility status is not available through eligibility verification methods. Refer to Timely Filing in the Claims Submission section for more information.

Newborn Eligibility

A Health First Colorado State ID number is assigned to a newborn when the case manager establishes and approves eligibility. The hospital or physician may initiate the assignment of a newborn's Health First Colorado State ID number by contacting the mother's case manager at the time of delivery and providing the following information:

Newborn’s name, sex, and date of birth
Mother’s State ID number to verify eligibility at the time of delivery

Special Eligibility Programs

Health First Colorado offers benefits through special programs. Members who qualify for special programs may not be eligible for regular Health First Colorado benefits. However, members may qualify for one of the following special programs:

Presumptive Eligibility (PE) Children
PE Pregnant Women
CHP+ Prenatal Program
Breast and Cervical Cancer Program (BCCP)
Modified Medical Program
Qualified Medicare Beneficiaries (QMBS)
Undocumented Non-Citizen

Presumptive Eligibility (PE) for Pregnant Women

Presumptive Eligibility (PE) is temporary coverage of medical benefits until eligibility for either Health First Colorado (Colorado's Medicaid Program) or the CHP+ Prenatal Program is determined.

Pregnant women who are U.S. citizens or documented non-citizens and have self-declared incomes at or below 133% of the Federal Poverty Level may be eligible for Health First Colorado (PE. Pregnant women who are U.S. citizens or documented non-citizens and have self-declared incomes between 134% and 200% of the Federal Poverty Level may be eligible for CHP+ Prenatal PE. Undocumented women are not eligible for PE. However, PE sites shall assist all members in filling out a Colorado Health Care Application regardless of citizenship, as undocumented members may be eligible for Emergency Medicaid for the delivery. All PE sites shall determine PE eligibility for both Health First Colorado and CHP+ Prenatal. Sites must verify pregnancy before enrolling a member in PE.

PE Period for Pregnant Women

The start date of Health First Colorado PE and CHP+ Prenatal PE is the date on which the PE card is issued and extends for 60 days. If the member does not have required documents at the time of application, she is given a fourteen-day provisional PE span. If the member does not present the required documents within fourteen days, the PE period will terminate at the end of the provisional period. If the application has not been processed by the end of the PE period, the PE site may extend the PE period until the eligibility determination is made. If eligibility is denied, PE expires at the end of the 60 days. When a member presents a PE card after the expiration date, always verify eligibility.

A pregnant woman who is determined to be eligible for Health First Colorado or CHP+ Prenatal remains eligible through her pregnancy and until the end of the month in which her 60th day postpartum occurs. Income changes during pregnancy do not affect eligibility. The infant has continuous eligibility until his or her first birthday.

PE Benefits for Pregnant Women

A Health First Colorado presumptively eligible pregnant woman is entitled to all medically necessary outpatient services covered by the Health First Colorado program. Inpatient hospital services are not a benefit during the Health First Colorado PE period. Labor and delivery are not covered during the PE period.

If determined to be eligible for Health First Colorado, after the PE period, the pregnant woman is entitled to all medically necessary covered benefits. Pregnant women age 20 and under are also eligible for Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, including dental, vision care and EPSDT health checkups. All Health First Colorado eligible pregnant women may receive EPSDT outreach and case management services.

CHP+ Prenatal PE benefits include outpatient and inpatient services as well as labor and delivery. Providers must be designated a CHP+ site in order to offer services. Providers must verify CHP+ Prenatal PE member eligibility through Colorado Access. CHP+ PE billing is processed through Colorado Access. Individual providers submit claims on the CMS 1500. Federally Qualified Health Centers submit claims on the UB-04. Questions regarding this program should be directed to CHP+ Customer Service at 800-359-1991.

Women in the maternity cycle are exempt from co-pay. The provider must mark the pregnancy indicator on the paper claim form or on the electronic format.

PE Card for Pregnant Women

A presumptively eligible pregnant member will receive a PE card that identifies her as eligible for medical services under either Health First Colorado PE or CHP+ Prenatal PE. However, inpatient hospital services are not a Health First Colorado PE benefit. After the full eligibility determination process, Health First Colorado eligible members receive a Medical Identification Card (MIC) and CHP+ Prenatal Program eligible members will receive a program card from the CHP+ Prenatal Program.

Presumptive Eligibility for the Breast and Cervical Cancer Program (BCCP)

The Breast and Cervical Cancer Program (BCCP) provides full Health First Colorado benefits to women screened at a Colorado Women's Cancer Control Initiative (CWCCI) site, who meet the eligibility requirements, and who are found to have breast or cervical cancer treatment needs including pre-cancerous treatment needs.

This program provides immediate Health First Colorado coverage through the PE process initiated at the CWCCI sites throughout Colorado. For BCCP, the PE period begins on the date the diagnostic test is performed. The CWCCI site is responsible for calling the Colorado Benefits Management System (CBMS) Help Desk to enroll the member and obtain a State ID number. The PE form and Health First Colorado application are completed at the CWCCI site. A copy of the PE form and the original application are sent by the CWCCI site to the department of human/social services in the member's county of residence for processing. The PE form, the signature page of the application, and other CWCCI forms are faxed to the Colorado Department of Public Health and Environment at 303-691-7900.

PE Period for BCCP

PE for the BCCP begins on the date the diagnostic test is performed. The CWCCI site may not receive the results of the test for several days. A woman cannot be enrolled in PE until the results of the test are known.

When the results are received and the diagnosis confirms an eligible cancerous or pre-cancerous condition, the CWCCI site may then call the State CBMS Help Desk. It is important that the CWCCI site use the diagnostic test date as the PE start date. The PE period extends until the end of the month in which the 45th day from the PE start date occurs. The State CBMS Help Desk may extend PE for an additional month if the Health First Colorado application has not been processed by the PE end date.

After a Health First Colorado application has been processed and the member is determined to be eligible for BCCP, the member will receive a Medical Identification Card and will remain on this program until active treatment for breast or cervical cancer (or pre-cancerous condition) is complete, or until she no longer meets other eligibility criteria. If a BCCP member has not sought treatment within three months of the PE start date, the member's eligibility will end on the last day of the third month.

PE Benefits for BCCP

A presumptively eligible BCCP member is entitled to all Health First Colorado services determined to be medically necessary.

BCCP Presumptive Eligibility Card

The BCCP no longer requires that a CWCCI site complete a PE card application. The PE form, however, must always be completed and signed by the member.

Modified Medical Program

The Modified Medical Program provides care for Colorado old age pensioners with limited incomes who do not qualify for the Health First Colorado program. Members in this program are not eligible for Home and Community Based Services (HCBS), inpatient psychiatric care, or nursing facility care.

Dual Eligibility

Providers are reminded that Health First Colorado is always the payer of last resort, therefore, services for dual-eligible members - those with coverage from Medicare and Health First Colorado - must be billed first to Medicare. Providers must be able to show evidence that claims for dual eligible members, where appropriate, have been denied by Medicare prior to submission to the Health First Colorado program. Per the Provider Participation Agreement, this evidence must be retained for seven years following the Medicare denial.

Contact the Provider Services Call Center with questions.

Qualified Medicare Beneficiaries

Elderly and disabled Medicare beneficiaries with incomes below the Federal poverty level and resources at twice the Supplemental Security Income (SSI) level are eligible for Health First Colorado payment of Medicare deductibles and coinsurance. Individuals who qualify are called Qualified Medicare Beneficiaries (QMBs).

Benefits

Health First Colorado benefits for Medicare QMB-Only members are limited to the Medicare coinsurance and deductibles for all Medicare-covered services.

Benefits for Health First Colorado-Medicare/QMB Beneficiaries (dually eligible) are all Health First Colorado covered services and the coinsurance and deductibles for all Medicare-covered services.

Non-Citizens

Non-citizens are individuals who are in the United States for educational or visitation purposes, for employment purposes permitted with a visa, and for reasons unknown. Some examples of immigration statuses include Legal Permanent Residents, Refugees/Asylumees, those who are lawfully residing in the Unites States, and undocumented individuals.

Application Procedures

Non-citizens must apply for assistance through their local county office application assistance site, online through www.colorado.gov/PEAK, by mail, or by phone (1-800-221-3943 / State Relay: 711), to determine if they must meet the Health First Colorado eligibility requirements.

Because non-citizens may be reluctant to apply for governmental assistance, providers are encouraged to advise potentially eligible individuals to apply for assistance to cover medical services. Confidentiality prevents the Department and eligibility sites from reporting to the United States Citizenship and Immigration Services of an individual's application for/receipt of assistance. Individuals who are undocumented can submit an application for Emergency Medical Assistance, if there is a life or limb threatening emergency.

Benefits

Qualified non-citizens will receive coverage for all medical services covered by the Medical Assistance category for which they are eligible. Individuals who are not qualified non-citizens may be eligible for benefits to cover emergency medical services. A physician will need to declare the presence of an emergency medical condition on the claim form. Coverage is limited to care and services that are necessary to treat immediate emergency medical conditions. This includes labor and delivery but does not include prenatal or follow-up.

Important: Organ transplants are not a covered benefit for non-citizens.
Lab tests for non-citizens must be coded as "Emergency". Tests for non-citizens that are not marked as "Emergency" will not be paid.

Limitation Messages

The message "Good for emergency services only" appears on eligibility inquiries.

Accessing Eligibility Verification Information

After obtaining the birth date and State ID or SSN, providers are encouraged to conduct eligibility requests to determine eligibility.

Eligibility information is updated daily, except for weekends and State holidays, through the State's eligibility database known as the Colorado Benefits Management System (CBMS). Eligibility verification is available electronically 24 hours a day, 7 days a week.

Providers can verify eligibility through one of the following:

Provider Web Portal
Interactive Voice Response (IVR) system
Batch 270

HIPAA 270/271 Health Care Eligibility Benefit Inquiry and Response

The HIPAA 270/271 Health Care Eligibility Benefit Inquiry and Response transaction is designed to allow providers to obtain member eligibility information using electronic data transfer. To use this method of eligibility verification, providers must have:

The ability to send a HIPAA compliant 270/271 transaction from their office or through a clearinghouse or switch vendor.
A signed Trading Partner Agreement with the clearinghouse, if used, or with the Health First Colorado program if sending the transaction directly from an office.
Characteristics of the interactive eligibility verification system are:
- Date spans can be verified.
- Eligibility and benefit limitations are provided.
- Eligibility responses can be printed.

Specific directions on how to submit a 270 eligibility inquiry and what to expect in the 271 eligibility response is outlined in the 270/271 Companion Guide, available on the EDI Support web page.

Provider web portal (Batch or Interactive):
X12N 270 - Eligibility Inquiry

Health First Colorado Eligibility Response System (CMERS)/Virtual Agent

A virtual agent named GABBY™, designed to listen to the caller and respond, was implemented to assist providers contacting the Provider Services Call Center.

This system furnishes providers with:

Health First Colorado eligibility
Provider warrant information
Claim status information
Unlimited eligibility inquiries
Claim status check by Provider ID/National Provider Identifier (NPI) with Member ID and Date of Service, or by Internal Control Number (ICN).
A guarantee number (audit number) for member eligibility.
Verbalize eligible service types to the caller.

Response Information

Eligibility verification includes:

Eligibility dates
Co-pay status
Third-Party Liability
Managed Care enrollment

Important Eligibility Information

Always verify eligibility before rendering services.

Why verify eligibility? The provider who checks a member's eligibility on the day of service and finds the member eligible receives an eligibility guarantee number. If eligibility has changed when the claim is submitted, the guarantee number exempts those claims from eligibility edits for that date of service.

Medical Identification Card (MIC)

MICs include the member's name and State ID. The card by itself will not verify eligibility, providers must still verify eligibility before services are rendered.

Billing Information

National Provider Identifier (NPI)

The Health Insurance Portability and Accountability Act (HIPAA) requires that covered entities (i.e., health plans, healthcare clearinghouses, and those healthcare providers who transmit any health information electronically in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard) use NPIs in standard transactions. Certain Provider Types are not able to obtain an NPI. Those providers will be assigned a Health First Colorado provider number.

Paper Claims

Electronic claims format shall be required unless hard copy claims submittals are specifically prior authorized by the Department. Requests may be sent to Gainwell Technologies, P.O. Box 30, Denver, CO 80201-0030. The following claims can be submitted on paper and processed for payment:

Claims from providers who consistently submit five (5) claims or fewer per month (requires prior approval)

Paper claims require an NPI for those provider types that can obtain one. Providers that cannot obtain an NPI are required to use an assigned Health First Colorado provider number on their claims.

Electronic Claims

Instructions for completing and submitting electronic claims are available through the following:

The Health First Colorado program collects electronic claim information interactively through the Provider Web Portal or via batch submission through a host system.

Interactive Claim Submission and Processing via the Provider Web Portal

Interactive claim submission through the Provider Web Portal is a real-time exchange of information between the provider and the Health First Colorado program. Health First Colorado providers may create and transmit HIPAA compliant 837P (Professional) and 837I (Institutional) claims electronically one at a time. These claims are transmitted through the Provider Web Portal). Beginning July 1, 2014, all claims for dental services and dentures must be submitted to DentaQuest, the Dental Administrative Service Organization (ASO), on the 2012 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.

The Provider Web Portal contains training, user guides and help that describe claim completion requirements, edits that verify the format and validity of the entered information, and edits that assure that required fields are completed.

The Provider Web Portal reviews the claim information for compliance with Health First Colorado billing policy and passes the claim to the Colorado interChange (iC) system for adjudication and reporting on the Health First Colorado Provider Remittance Advice (RA).

The Provider Web Portal immediately returns a response to the provider about that single transaction indicating whether the claim will be denied, suspended or paid. If the claim is suspended, then it needs additional manual review by the fiscal agent.

The Provider Web Portal provides immediate feedback directly to the submitter. All claims are processed to provide a weekly RA to providers. The Provider Web Portal also provides access to reports and transactions generated from claims submitted via paper and through electronic data submission methods other than the Provider Web Portal. The reports and transactions include:

X12N 999 Functional Acknowledgement
RAs
Health Care Claim Payment/Advice (ASC X12N 835)
Managed Care Reports such as Primary Care Physician Rosters
Eligibility Inquiry (interactive and batch)
Claim Status Inquiry

Claims may be adjusted, edited and resubmitted, and voided in real time through the Provider Web Portal. Refer to the Provider Web Portal Quick Guides for help with claim submission via the Provider Web Portal.

Refer to the appropriate Companion Guide for additional electronic billing information.

Provider Responsibility to Review Delegate Provider Web Portal Accounts

A delegate is a person who has been given access to perform certain Provider Web Portal functions on the provider’s behalf. Providers are responsible to review the status of delegate accounts and the functions delegates are authorized to access in the Provider Web Portal. A delegate’s status and functions should be kept up to date in accordance with current job duties and employment status. Only delegates with a valid, current business reason should have Provider Web Portal access. A delegate account that has an outdated status presents a security risk to program integrity.

Refer to the Delegates Quick Guide for more information on adding, linking and managing delegates. Refer to the Delegates Access - Definitions Quick Guide for more information on delegate functions.

Batch Electronic Claims Submission

Batch billing refers to the electronic creation and transmission of several claims in a group. Batch billing systems usually extract information from an automated accounting or patient billing system to create a group of claim transactions. Claims may be transmitted from the provider's office or sent through a billing vendor or clearinghouse.

All batch claim submission software must be tested and approved by the Department's fiscal agent. Any entity sending electronic transactions through the Health First Colorado file delivery and retrieval system secure website (SFTP) for processing or the Provider Web Portal where reports and responses will be delivered must complete an EDI Trading Partner enrollment. This provides EDI the information necessary to assign a Logon Name, Logon ID, and Trading Partner ID, which are required to submit electronic transactions, including claims.

The X12N 837P, 837I, or 837D transaction data may be submitted via SFTP or the Provider Web Portal, each which validates submission of American National Standards Institute (ANSI) X12N format(s). The TA1 interChange Acknowledgement reports the syntactical analysis of the interchange header and trailer. If the data is corrupt or the trading partner relationship does not exist within the Colorado interChange, the claims will not be sent for adjudication and a TA1 will be made available for research and correction. An X12N 999 Functional Acknowledgement is generated when a file that has passed the header and trailer check passes through X12 validation.

If the file contains syntactical error(s), the segment(s) and element(s) where the error(s) occurred will be reported.

Testing and Vendor Certification

Completion of the testing process must occur prior to submission of electronic batch claims to the Colorado interChange. The EDI testing packet and Companion Guides are available on the EDI Support web page.

Assistance from the EDI helpdesk is available throughout this process. Each test transmission is inspected thoroughly to ensure no formatting errors are present. Testing is conducted to verify the integrity of the format, not the integrity of the data, however, in order to simulate a production environment, EDI requests that providers send real transmission data.

The number of required test transmissions depends on the number of format errors on a transmission and the relative severity of these errors. Additional testing may be required in the future to verify any changes made to the Colorado interChange have not affected provider submissions. In addition, changes to the ANSI formats may require additional testing.

Provider Reimbursement

The Health First Colorado program only reimburses enrolled Health First Colorado providers. Claims for reimbursement must be submitted by the provider to the fiscal agent on the appropriate claim form or electronic claim format and properly completed according to Health First Colorado policy.

Health First Colorado reimbursement is based on Colorado legislative funding as well as Federal and State regulations. The Health First Colorado program offers benefits through two reimbursement methods: Fee-For-Service (FFS) and Capitation.

Fee-For-Service Reimbursement

Fee-For-Service (FFS) reimbursement provides payment to enrolled providers for each service rendered to Health First Colorado members.

The FFS reimbursement rates are determined through the Colorado legislative budgetary process.
FFS claims are processed by the Health First Colorado fiscal agent.
Providers are responsible for preparing and submitting FFS claims in compliance with Health First Colorado claim filing requirements.

Capitated Reimbursement

The Health First Colorado program enters into contractual agreements with organizations to furnish services to Health First Colorado members under capitated reimbursement arrangements. Under capitation, contracted organizations receive a monthly fee for each Health First Colorado member enrolled in their program.

Capitated contractors provide services through a network of service providers.
Service providers are paid by the contracted organization.
The contractor is financially responsible for all services described in the capitation contract.
The Health First Colorado fiscal agent denies fee-for-service claims for covered benefit services provided to a member enrolled in a capitated program.
Capitation reimbursement is common for Managed Care Organizations (MCOs).

Third-Party Liability

By regulation, the Health First Colorado program does not duplicate payments made by any other resource. With the exception of Victim Assistance Programs, for each of the reimbursement methods described in this manual, third-party payments by other insurance carriers must be reported on the claim and are deducted from any applicable Health First Colorado payments. If the third-party payment is equal to or greater than the Health First Colorado allowable benefit, the Health First Colorado program will make no additional payment.

Health First Colorado (Colorado's Medicaid Program) pays the difference between TPL payment and Program Allowable.

Example:
Charge = $500
Program allowable = $400
TPL payment = $300
Program allowable - TPL payment = Reimbursement
$400.00
- $300.00
= $100.00

Health First Colorado Co-Pay

Applicable Health First Colorado co-pay is automatically deducted from the provider's payment during claims processing. Providers can collect co-pay from the member at the time of service, but services cannot be withheld if the member is unable to pay the co-pay.

Benefits and Benefit Delivery Programs

Some of the programs and benefits are available through both the FFS and Capitation reimbursement methods. Providers should read information carefully to ensure that they apply appropriate policies to the correct services and programs. Refer to the Reimbursement Policies section in this manual.

General Benefits/Limitations/Exclusions

The Health First Colorado program pays enrolled providers for medically necessary healthcare benefits for eligible members after all other healthcare resources have been exhausted.

The Health First Colorado program is an entitlement program, meaning that any person meeting the eligibility criteria is entitled to receive necessary medical services covered by the program without cost.

The Health First Colorado members are responsible for Health First Colorado co-pay described later in this section.

All benefit services are subject to applicable reimbursement policies including:

Prior authorization requirements
Referral requirements
Utilization review
Special consent requirements

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

8.280.4.E Other EPSDT Benefits

Other healthcare services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined by 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
For the purposed of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth in Section 8.076.1.8.b-g.
The service provides a safe environment or situation for the child.
The service is not for the convenience of the caregiver.
The service is medically necessary.
The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
The service is the least costly.

Acute and Ambulatory Benefits

Acute and ambulatory benefit services may be provided under FFS reimbursement and through capitated Managed Care Programs. In some instances, managed care entities and FFS Health First Colorado share responsibility for service delivery.

FFS Prior Authorization Requirements

Under FFS reimbursement, the Health First Colorado program prior authorizes:

Expensive services such as transplantation and long-term care.
Procedures where inappropriate utilization has been reported in medical literature.
Procedures that may be performed both for medical reasons and for cosmetic reasons.

FFS prior authorization approval assures the provider that the service is medically necessary and a Health First Colorado benefit. Capitated MCOs may have different prior authorization requirements. If a member is enrolled in an MCO, providers must follow the MCO rules.

Approval of the Prior Authorization Request (PAR) does not guarantee Health First Colorado payment.
PAR approval does not serve as a timely filing waiver.
PAR approval does not override benefit eligibility requirements or benefit delivery requirements.

The member must meet all applicable eligibility requirements at the time services are rendered.

Example: If the service is approved under the EPSDT Program, the member must be age twenty or younger at the time services are rendered.

The member must be eligible for services under the FFS Reimbursement Program at the time services are rendered.

Example: If the member is enrolled in a Health First Colorado capitated prepaid health plan when services are delivered, the provider must look to the MCO for reimbursement.

All claims, including those for prior authorized services, must meet all claim submission requirements (e.g., timely filing, pursuit of Third-Party Liability, required attachments included, etc.) before payment can be made.

PARs are reviewed by the designated authorizing agency identified in Appendix B on the Billing Manuals web page under the Appendices drop-down. The authorizing agency approves or denies requested services and sends notification of prior authorization action to each of the following parties:

The requesting physician
The proposed rendering provider (if identified on the PAR)
The Health First Colorado member

The notification letter identifies the action taken on the PAR and, if services have been denied or modified, the member's appeal rights.

Instructions for submitting the PAR are described in the specialty sections specific to the service(s) being provided.

Out-of-State Benefits

The Health First Colorado program provides the out-of-state services noted below. The service provider must be enrolled as a participant in the Health First Colorado program.

Services to residents of Colorado border localities where the use of medical resources in the adjacent state is common. A listing of recognized Colorado border communities is in Appendix F on the Billing Manual web page under the Appendices drop-down.
Services to Health First Colorado members who live in other states under special circumstances, such as foster care placement.
Emergency services provided to Health First Colorado members who are traveling or visiting outside Colorado. Documentation of the emergency must be submitted with the claim.
Services needed because the individual's health would be endangered if he or she were required to return to Colorado for medical care. Services must be prior authorized.
Services that are unavailable in Colorado. Services must be prior authorized.

Long-Term Care Benefits

All long-term care services require prior authorization or pre-admission review by the Department's contractor. Long-term care benefits include a variety of home and community-based services as alternatives to institutional care.

Long-Term Care Single Entry Point System

Colorado's Long-Term Care Single Entry point system provides an efficient way for individuals to access long-term care services. The Single-Entry Point (SEP) System is administered by Options for Long-Term Care agencies (OLTCs) positioned geographically throughout Colorado. The OLTCs conduct evaluations and needs assessment, care planning with the member, and ongoing case management to monitor the care plan, as well as coordinate service delivery and perform periodic reassessment of member needs. OLTC agencies arrange services for Home and Community Based Services members and evaluate options for members at home who are seeking nursing facility care. OLTCs perform pre-admission review and continuing care assessments and submit Health First Colorado FFS PAR requests as needed.

General Benefit Limits and Exclusions

The program does not pay for personal comfort items and unnecessary services.
This exclusion does not apply to immunizations and inoculations.

Items and services (e.g., free chest x-rays) for which no one incurs a legal obligation to pay are not benefits.
Homeopathic therapy is not a benefit.
Chiropractic services are not covered. Reimbursement for deductible and coinsurance will be made on Medicare crossover claims for Qualified Medicare Beneficiaries (QMBs).
Acupuncture used for the medical management of acute or chronic pain, or as an anesthesia technique is not a benefit.
Cosmetic surgery, intended solely to improve physical appearance, is not a benefit. Reconstructive surgery intended to improve function and appearance is a benefit if prior authorized.
One adult annual physical examination is a benefit. Physical examinations for diagnostic disease evaluation, for nursing facility or Home and Community Based Services (HCBS) admission or placement, or under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Program for members ages 20 and younger are a benefit.
Non-prescription drugs and food supplements are not benefits.
Under unusual or life-threatening situations, over-the-counter drugs and food supplements may be a benefit if prior authorized.
Hearing aids are not a benefit.
Members ages 20 and younger may qualify for hearing aids under the EPSDT Program.
Vision eyewear is not a benefit except as allowed under the EPSDT Program for members ages 20 and younger. Eyeglasses and contact lenses for members ages 21 and older are covered following related eye surgery.
Oral surgery related to the jaw or any structure contiguous to the jaw or reduction of fractures of the jaw or facial bones including dental splints or other devices is a covered benefit. Except in emergency circumstances, oral surgery requires prior authorization.

Sterilization, Hysterectomy and Abortion Benefits

Refer to the Family Planning, Sterilizations, Hysterectomies and Abortions section in the Obstetrical Care Billing Manual located on the Billing Manuals web page.

Note: Abortion is only a benefit when due to rape, incest, or life endangerment.

Third-Party Liability (TPL) Coordination of Benefits

This manual describes policies for commercial health insurance coverage, Medicare coverage, and other liability programs such as accident coverage and victim compensation.

The term Third-Party Liability (TPL) describes circumstances when a Health First Colorado member has health insurance or other potential resources - in addition to the Health First Colorado program - that may pay for medical services.

An estimated 10% of Health First Colorado members have other health insurance resources available to pay for medical expenses.
Health First Colorado eligibility is not restricted by having other insurance coverage.

Providers should take special care to apply only the policies and procedures appropriate to the specific resource.

Payer of Last Resort

Health First Colorado is called the payer of last resort because Federal regulations require that all available health insurance benefits be used before Health First Colorado considers payment.

With few exceptions, claims for members with health insurance resources are denied when the claim does not show insurance payment or denial information.

Commercial health insurance coverage often offers greater benefits than Health First Colorado, so it is advantageous for providers to pursue commercial health insurance payments.

Health First Colorado does not automatically pay commercial health insurance co-pays, coinsurance, or deductibles. If the commercial health insurance benefit is the same or more than the Health First Colorado benefit allowance, no additional payment will be made.

Providers cannot bill members for the difference between commercial health insurance payments and their billed charges when Health First Colorado does not make additional payment. The provider also cannot bill members for co-pay/deductibles assessed by the TPL.

Common Types of Health-Related Coverage

The more common types of health insurance coverage and members who have other resources include the following:

Employed individuals who have commercial health insurance through employment or union membership.
Children covered under commercial health insurance carried by an absent parent.
Disabled individuals with coverage through employment or as a dependent through a family
Member's coverage.
Individuals eligible for Medicare coverage because of age or disability.
Individuals who have Medicare coverage and commercial Medicare supplemental plans.

Obtaining Information About Other Resources

Billing information for other resources should be obtained from the member. Providers should always ask the member about other insurance coverage. The Health First Colorado program maintains a reference file of known commercial health insurance and Medicare coverage information used to deny claims that do not show payment or denial by the commercial health insurer.

Eligibility Verification Information

Providers may access Health First Colorado's TPL reference information through electronic eligibility verification. Eligibility as well as information about commercial health insurance and Medicare may be verified electronically by utilizing the 270/271 Health Care Eligibility Inquiry and Response transaction, or manually by using a touch-tone telephone.

TPL information includes:

Name and address of the commercial health insurer.
Individualized commercial health insurance coverage information.
Commercial health insurance coverage information.
The individual's Medicare Health Insurance Claim (HIC) number.

TPL information reported through eligibility verification is furnished as a convenience to providers. Because TPL information is member-reported, the commercial health insurance portion of eligibility verification is not a guarantee that the information is accurate or timely. Providers should always question members about other insurance resources. TPL reference information is updated as new or revised coverage information is obtained.

Note: TPL information is not available from the State or from the County. Please do not contact these offices to request third-party billing information.

Inaccurate TPL Information

The Health First Colorado program collects information about members' TPLs from several sources.

Health First Colorado members and applicants are required to identify commercial health insurance coverage.
The Health First Colorado program exchanges information with other state agencies and some commercial health insurance companies.
Providers report commercial health insurance coverage on Health First Colorado claims.

The Health First Colorado program makes every attempt to maintain up to date TPL information. Providers may find, however, after submitting a commercial health insurance claim, Health First Colorado's records are inaccurate and that the commercial health insurance coverage is not in effect.

Unreported Health Insurance Coverage

Even if Health First Colorado records do not identify commercial health insurance coverage, providers who find that the member has such coverage should pursue those benefits before billing the Health First Colorado program.

Commercial health insurers often offer greater benefits than Health First Colorado.

When insurance benefits retroactively are identified, the Health First Colorado program retracts previous payments and requires the provider to submit claims to the commercial health insurers.

Providers may report insurance coverage by contacting the Department's fiscal agent or by completing the health insurance information required on the Health First Colorado claim.

Discontinued Health Insurance Coverage

Providers should report members' discontinued insurance coverage to the Department's fiscal agent by sending a copy of the insurance carrier's letter or denial notice and identifying the member by name and State ID number so records can be updated.

Health First Colorado claims are honored if the claim correctly indicates that the other insurance company has denied benefits.

Providers who notify the Department's fiscal agent that TPL coverage has been discontinued are not required to continue sending claims to the commercial health insurers. Until Health First Colorado records are updated and the TPL coverage notation no longer appears on the electronic eligibility verification response, subsequent Health First Colorado claims must continue to show that the commercial insurers have denied benefits.

Commercial Health Insurance Resources

The following resources are not considered commercial health insurance resources, and the policies discussed in this section do not apply to these resources. Subsequent sections describe these resources.

Medicare
Workers Compensation
No-fault automobile coverage
Victim Assistance Programs
Migrant Health Services
Indian Health Services coverage
Colorado Indigent Care Program
Colorado Health Care Programs (HCP) for Children

Pursuing Commercial Health Insurance Payments

When members accept Health First Colorado benefits, they assign their rights to health insurance payments to Health First Colorado. Most insurance companies make direct provider payments when the policyholder assigns benefits to the provider. Providers should take necessary steps to obtain consent to release information and benefit assignment for direct payment.

Insurance coverage information is considered part of treatment, payment and operations as defined in the privacy regulations. Pursuing information regarding other coverage therefore is not in violation of HIPAA privacy as specified at 45 C.F.R. § 164.501.

Commercial Managed Care Policies

Providers should not confuse Health First Colorado Managed Care enrollment with commercial managed care policies. Health First Colorado Managed Care enrollment refers to members who receive benefit services from a Health First Colorado-contracted Managed Care Organization (MCO). Commercial managed care policies are health coverage policies that exist in addition to the individual's Health First Colorado entitlement.

Members who have commercial managed care benefits must obtain MCO benefit services from the MCO. Health First Colorado claims for members who have commercial managed care coverage are denied.

Health First Colorado members are responsible for only co-pay amounts and may not be charged for any fees, including managed care co-pay.

Reporting Payments and Denials

If a member's eligibility response record shows commercial health insurance coverage and the Health First Colorado claims for that member do not show insurance payment or denial information, those claims are denied.

Providers must report TPL payment and denial information on the claim form.

Paper claim forms have designated fields for reporting TPL payments and denials.
Electronic claim formats have designated fields for reporting commercial health insurance coverage.
Indicate TPL EOB date on each claim.
EOB does not need to be attached for every claim submission.

Reporting commercial health insurance coverage on paper claim forms is slightly different from electronically reporting information. Directions for claim field completion to identify TPL payments and denials are available in the billing instructions for each claim form.

Audit Documentation

Providers must maintain records that support the accuracy of submitted claim information for a period of seven years, including copies of commercial health insurance denials and payments. Providers should document, date, and sign notes about reported member discussions regarding TPL. Upon request, records must be submitted for Health First Colorado audit and review. Failure to provide requested audit materials may result in sanctions and recovery of Health First Colorado payments.

Special Claim Submission Circumstances

Commercial Benefit Limits

Commercial health insurance coverage may limit some benefits for a specific time period, often yearly time periods. If a periodic benefit limitation is exhausted, claims for services in excess of the benefit limit must be submitted to the TPL before submitting to Health First Colorado.

Apportioned Payments

Under some circumstances, a commercial health insurance payment may be applied to more than one Health First Colorado claim submission. If the provider receives a third-party lump-sum payment for multiple services billed to the Health First Colorado program on separate claim records, the payment amount should be apportioned across the affected claims.

If payment cannot be divided and applied to each service, providers should apportion the payment on a percentage basis to the affected claims. Providers must maintain records to support submitted claim information including a detailed explanation of the apportionment method used.

Uncooperative Policyholders

Providers benefit from taking necessary steps to obtain required signatures and authorizations from members and policyholders. Some commercial health insurers refuse payment if the member or policyholder does not respond to requests for information.

Failure to Provide Information

If the member or policyholder refuses to provide required signatures or authorizations or does not respond to requests for information, Health First Colorado claims may be submitted through the reconsideration process. Claims must be received within 365 days of the date of service.

If the policyholder or member refuses to transfer payment to the provider or to cooperate it should be reported to the Department who may take further action.

Payments Made to Policyholders

Providers should always obtain an assignment of benefits for direct reimbursement by the commercial health insurers. If the commercial health insurance payment is sent to the member or policyholder, the provider should obtain payment and the payment voucher (e.g., Remittance Advice [RA] or Standard Paper Remit [SPR], etc.) from that member or policyholder for Health First Colorado billing purposes. If the member or policyholder refuses to transfer or make payment to the provider, Health First Colorado claims may be submitted through the reconsideration process. Claims must be received within 365 days of the date of service.

If the policyholder or member refuses to transfer payment to the provider or to cooperate, it should be reported to the Department, who may take further action.

Invalid TPL Denials

Some reasons given by TPL are invalid for submitting the claim for Health First Colorado payment. Providers should ensure that all TPLs are appropriately pursued before submitting Health First Colorado claims. The following are examples of invalid TPL reasons for submitting Health First Colorado claims:

No denial reason identified
Duplicate claim
Insufficient information for processing
Claim in process

Retroactive Identification of Commercial Health Insurance Resources

When commercial health insurance coverage is identified after claims are paid, providers receive notification of the intent to recover payment and instructions for submitting claims to the commercial health insurer. The notification letter contains billing information and a complete explanation about the retroactive Health First Colorado payment recovery process.

Medicare Resources

Health First Colorado members may qualify for Medicare benefits because of age or disability. Individuals who have Medicare coverage and Health First Colorado entitlement are called "dually eligible."

The Health First Colorado program administers very specific policies to coordinate benefits for Medicare-covered members. Information in this section applies only to Medicare benefit coordination. Do not apply these policies to other TPL.

Medicare-Only Provider Enrollment Types

Effective December 1, 2022, there will be a new enrollment option available for providers that serve Medicare-Medicaid members.

The new enrollment option is called Medicare Only Providers and will have several specialties available. Visit the Find Your Provider Type web page for more information on enrollment requirements.

This enrollment option is for providers who cannot enroll with Health First Colorado using any other available provider type, and who wish to receive secondary payment on their Medicare claims from Health First Colorado.

Medicare Only Providers will be limited to only receiving secondary reimbursement from Health First Colorado for claims that were primarily reimbursed by Medicare first.

Types of Medicare Coverage

Medicare pays benefits through the following two separate programs:

Part A Medicare pays for institutional care
Part B Medicare pays for professional services

Health First Colorado members may have the following coverage:

Part A Medicare coverage only
Part B Medicare coverage only
Both Part A and Part B coverage

Qualified Medicare Beneficiaries (QMBs)

In compliance with the 1988 Medicare Catastrophic Coverage Act, the Health First Colorado program pays Medicare deductibles and coinsurance for elderly and disabled individuals who have incomes below the Federal poverty level and resources at twice the Supplemental Security Income (SSI) level. Individuals who qualify for benefits under the Medicare Catastrophic Coverage Act are called Qualified Medicare Beneficiaries (QMBs). QMBs may or may not be entitled to regular Health First Colorado benefits.

Individuals may qualify for the following benefits:

Regular Medicare benefits with Health First Colorado benefits
QMB Medicare benefits with Health First Colorado benefits
QMB only benefits without Health First Colorado benefits

Health First Colorado Crossover Benefits

Regular Medicare + Health First Colorado: The Health First Colorado program processes Medicare crossover claims for Medicare benefits that are also Health First Colorado benefits and all regular Health First Colorado benefits. Calculation of the crossover payment is described below.

QMB Medicare + Health First Colorado: The Health First Colorado program pays Medicare crossover coinsurance and deductible for all Medicare benefits including services that are not covered by regular Health First Colorado (e.g., chiropractic services) and all regular Health First Colorado benefits.

QMB-only benefits: The Health First Colorado program pays Medicare crossover coinsurance and deductible for Medicare covered benefits including services that are not covered by the regular Health First Colorado program.

There is no coverage for Health First Colorado-only benefits (e.g. pharmacy).
QMB-only members may not be billed for crossover balances.
QMB-only members are financially responsible for services that are not covered by Medicare.

Medicare Crossover Payments

Members are not responsible for remaining balances after Health First Colorado B crossover processing. For members under Medicare A (skilled nursing coverage) in nursing facilities, the member's member payment is applied to the Medicare A coinsurance. Medicare HMO co-pay should be treated like original Medicare Coinsurance.

Enter the total of Medicare Coinsurance + Medicare co-pay amount into the Medicare Coinsurance field.

Medicare Part A Crossover Payments

Hospital inpatient & outpatient charges: Provider payment is Health First Colorado's allowed benefit minus the Medicare payment or the Medicare determined deductible and coinsurance, whichever is less. If Medicare's payment equals or is greater than the Health First Colorado allowance, crossover claims are paid zero.

Nursing Facility services: Provider payment is the Health First Colorado facility per diem minus the Medicare payment or the Medicare determined coinsurance, whichever is less. If Medicare's payment is greater than the Health First Colorado-allowed facility per diem, crossover claims are paid zero.

For Part B services paid by Part A, the Health First Colorado program pays Medicare deductible and coinsurance.

Clinic and facility services (e.g. Dialysis, Rural Health, Home Health, Independent Rehabilitation): Health First Colorado pays Medicare deductible and coinsurance.

Medicare Part B Crossover Payments

The Health First Colorado program pays the Medicare deductible and coinsurance or the Health First Colorado-allowed benefit minus the Medicare payment, whichever is less. If Medicare's payment equals or is more than the Health First Colorado allowed benefit, crossover claims are paid zero.

Automatic Medicare Crossover Claims

Automatic crossover is an exchange of claim information between Medicare and the Health First Colorado program. When automatic crossover occurs, providers do not have to submit a crossover claim to the Health First Colorado program.

Medicare identifies claims selected for automatic crossover on a Medicare payment voucher (e.g., RA or SPR). The crossover message states that the claim has been forwarded to the Health First Colorado program for any additional benefits due. If the automatic crossover notice appears on the Medicare payment voucher, providers should allow 30 days for the Health First Colorado program to process the crossover claim.

Providers must submit a copy of the SPR with paper claims. Be sure to retain the original SPR for audit purposes.

If the Medicare crossover message does not appear, providers should assume that automatic crossover will not occur and should submit a crossover claim to the Health First Colorado program.

Automatic crossover is only available for claims processed by the Medicare Administrative Contactor (MAC) for Colorado. If the Medicare Administrative Contractor is not the designated MAC, providers must submit crossover information.

Automatic crossover is not available for railroad retiree claims processed by Palmetto GBA. Crossover messages that may appear on Palmetto GBA SPR are inaccurate. Providers must submit crossover information for railroad retirees.

Medicare must allow charges on the Medicare claim.

Medicare-denied claims do not cross over because there are no residuals (e.g., coinsurance or deductibles) to be considered for payment by the Health First Colorado program. If Medicare denies benefits, benefits are exhausted, or services are not covered by Medicare, providers may submit a claim directly to the Health First Colorado program for services. If the claim is partially allowed by Medicare, the Health First Colorado program will process denied billing lines. Providers should review their RAs carefully to determine the benefits allowed by Medicare and the Health First Colorado program.

If Medicare pays the entire claim at 100% of the allowed benefit, the claim does not cross over because there are no residuals (e.g., coinsurance or deductible) to be considered by the Health First Colorado program. If only a portion of the claim is paid at 100%, automatic crossover does occur, but no payment is made on the services paid at 100%.

Medicare adjustments do not cross over.

If Medicare adjusts a claim, the provider must submit a Health First Colorado adjustment. Adjustments may be submitted electronically or on paper. Paper adjustments must be accompanied by the Medicare SPR and adjustment documentation.

The member's HIC number must match Health First Colorado eligibility files.

If the member's Medicare ID number changes, automatic crossover is interrupted temporarily until the Health First Colorado eligibility file is corrected to reflect new information. If automatic crossover does not occur, providers must submit crossover claims.

The provider's Medicare provider number must be recorded in the Health First Colorado provider files.

Providers are responsible for furnishing Medicare provider information to Health First Colorado Provider Services. If the Medicare provider number is not recorded on Health First Colorado's provider enrollment file, automatic Medicare crossover is not possible.

The provider must accept Medicare assignment on claims for Health First Colorado members.

If the provider does not accept Medicare assignment, automatic crossover does not occur. Providers cannot bill Health First Colorado members for Health First Colorado-covered services, including Medicare benefit services.

If the provider does not accept Medicare assignment, the Health First Colorado program will not pay crossover benefits. If the provider has not accepted Medicare assignment in error or Medicare processes the claim as unassigned in error, the provider may obtain the Medicare payment and processing information from the member and submit a crossover claim to the Colorado Medical Assistance Program. By submitting a Health First Colorado crossover claim, the provider is deemed to have accepted Medicare assignment after-the-fact and must accept the combined Medicare and Health First Colorado payments as payment in full.

Automatic Crossover Denials

Claims may cross over automatically but appear on the Health First Colorado Remittance Advice (RA) as denied if the member is enrolled in a Health First Colorado MCO or has commercial health insurance coverage.

Providers should contact the Health First Colorado MCO for billing instructions if additional benefit is available for Health First Colorado Managed Care enrolled members.

Providers should submit claims to the commercial health insurer for individuals who have supplemental health insurance. If the supplemental health insurer denies benefits, the provider may submit a crossover claim with documentation of the commercial health insurance denial.

Provider-Submitted Crossover Claims

If automatic crossover does not appear on the Health First Colorado RA within 30 days of the Medicare processing date, regardless of the reason providers are responsible for submitting crossover claims within timely filing.

Provider-submitted crossover claims should be submitted electronically. Instructions for completing Medicare crossover information are included in the billing instructions for each claim format.

When crossover claims are submitted electronically, providers must maintain auditable Medicare processing documents that support the accuracy of submitted claim information. The Health First Colorado program must submit copies of audit information for audit and review upon request. Failure to provide requested audit materials may result in sanctions and recovery of Health First Colorado payments.

Crossover Timely Filing

Timely filing for Medicare crossover claims is within 120 days from the date of payment denial. When automatic crossover occurs, timely filing is met. If automatic crossover does not occur, providers are responsible for filing claims in compliance with timely filing regulations.

Health First Colorado claims for Medicare-denied, non-covered, or exhausted benefits are not crossover claims and, for timely filing purposes, must be filed within 365 days of the date of service or within 120 days of the Medicare denial date, whichever is longer.

Claims for Medicare-Exhausted Benefits

Medicare applies dollar-based benefit limits to some practitioner services. Because of the dollar limit, Medicare may make a partial payment when the dollar limit is reached. In those instances, providers should contact the Department's fiscal agent.

Crossover Billing Tips

The following billing tips will help providers correctly submit crossover claims:

Crossover claims must report the same information submitted to Medicare, including full charges (for Nursing Facility crossover submission, see the Nursing Facility Specialty Manual).
Crossover claim information (e.g., Medicare payment date, Medicare disallowed charge, Medicare deductible, Medicare coinsurance, Medicare payment, and related computations) on the claim form must be accurate and complete to reflect information on the Medicare payment voucher.
The net Health First Colorado billed amount must equal the sum of the reported Medicare coinsurance and deductible.

Other Third-Party Liability

There are a variety of circumstances, other than commercial health insurance coverage, where services provided to a member may be payable by a third-party. In some instances, liability is firmly established, such as with Workers Compensation. In others, however, there may be potential liability that has not been confirmed, such as with an automobile policy.

Established Third-Party Liability

Where TPL is established, providers should submit claims to the responsible third-party.

Workers Compensation

Services known to be billable to Workers Compensation should be billed to the Workers Compensation carrier. Health First Colorado claims instruct providers to identify services that are related to employment. The Health First Colorado program does not deny payment because of potential TPL resulting from employment accidents, but providers cannot receive payment from both programs.

Health Care Programs (HCP) for Children with Special Needs

Providers who render services to children covered by the Colorado Health Care Programs (HCP) for Children with Special Needs should follow HCP billing instructions. The Health First Colorado program does not deny claims for individuals who are enrolled in Colorado HCP, but providers cannot receive payment from both programs.

Potential Third-Party Liability

Providers should not delay Health First Colorado claims submission where there is potential TPL. The Health First Colorado program requires that claims be submitted within 365 days from the date of service. If providers subsequently receive payment from a third-party, the Health First Colorado payment must be refunded.

Accident Liability

Health First Colorado claims instruct providers to identify services that are related to accidents. The Health First Colorado program does not deny payment because of potential TPL resulting from accidents. Providers should not hesitate to indicate that services are related to an accident for fear that the claim will be denied.

The Health First Colorado program sends a questionnaire to members who have received services for a diagnosis that may be accident related. The questionnaire asks for information from the member about other liability or benefits available.

If providers receive payment from a third-party, they must return any Health First Colorado payment.

The Health First Colorado program appreciates providers' assistance in recovering payments from TPLs. Providers are asked to notify the Department's fiscal agent if the member or the member's representative (e.g., attorney) requests detailed copies of bills for medical services paid by the Health First Colorado program. Please copy and complete the Third-Party Liability Reporting Form in Appendix G on the Billing Manual web page under the Appendices drop-down.

Victim Assistance Programs

Victim Assistance Programs do not represent potential TPL. The Health First Colorado program does not deny claims for services to individuals who may be eligible for compensation from Victim Assistance Programs. Providers should submit claims to the Health First Colorado program when the member is Health First Colorado eligible.

Colorado Indigent Care Program (CICP)

Individuals who are covered under the Colorado Indigent Care Program (CICP) are not eligible for Health First Colorado benefits. If an individual has Health First Colorado benefits, claims should be submitted for Health First Colorado reimbursement.

Returning Health First Colorado Payments

With the exception of Victim Assistance Programs, the Health First Colorado program is the payer of last resort. Regardless of the payment source, when providers receive payment from a third-party for services that have previously been paid by the Health First Colorado program, the Health First Colorado payment must be refunded immediately.

Refunds must be made for the full amount of the Health First Colorado claim payment.
Providers may not retain a portion of the Health First Colorado payment to supplement a third-party payment.
If the third-party payment is the same or more than the Colorado Medical Assistance Program allowance for the billed service, the Health First Colorado program does not make additional payment.
If partial payment is due from Health First Colorado, the provider should submit the third-party payment information as part of an adjustment request. The Health First Colorado program will retract the original payment and reprocess the claim for any additional payment due.

Providers may refund Health First Colorado payments using any of the following procedures:

Submit an electronic adjustment transaction. The claim payment will be subtracted from the future payments for processed claims.
Submit a paper Refund to Medicaid or Returned Warrant Form accompanied by a business check for the full amount of the claim. The adjustment must identify the member, the Internal Control number of the claim to be recovered, and the date(s) of service.

Contact the Department's fiscal agent for instructions on specific circumstances.

General Claim Requirements

With few exceptions, Health First Colorado claims must be submitted electronically. Electronic claims may be submitted interactively (one transaction at a time) or in batch format. Batch may be submitted using batch submission software that must be developed by the provider or purchased from a certified software vendor, or by utilizing the HIPAA 837 transaction. Electronic filing reduces claim completion time, expenses, and claim processing time by eliminating paper handling, mailing time, and fiscal agent data entry.

Electronic claim submission is available for all claim types in the following electronic claim formats:

CMS 1500/ 837 Professional (837P)
UB-04/ 837 Institutional (837I)
Dental/ 837 Dental (837D)
Pharmacy/ NCPDP

Claim Submission

All claims, whether electronic or paper, are processed through the Colorado interChange. The fiscal agent processes claims and sends the Remittance Advice (RA) to the provider. RAs are available to the provider through the Provider Web Portal. Providers are responsible for reconciling each RA and resubmitting claims that do not appear on RA. Claims that are denied must be corrected and resubmitted by the provider in a timely manner.

Electronic Claims and Paper Claims

Electronic Claim Submission Exemptions

Electronic claims format shall be required unless hard copy claims submittals are specifically authorized by the Department. Requests may be sent to the Health First Colorado program, P.O. Box 30, Denver, CO 80202. The following claims can be submitted on paper and processed for payment:

Claims from providers who consistently submit 5 claims or fewer per month (requires prior approval). These providers are recommended to submit claims on the Provider Web Portal where payment status will be received immediately.

Service Bureaus, Billing Services and Claim Submission Software Vendors

Enrolled providers are responsible for the accuracy and timeliness of claim submission activities of agents, service bureaus, billing services, software vendors, and switch vendors.

Electronic Claims Submitted via Provider Web Portal

The Health First Colorado program allows providers to conduct the following transactions on the Provider Web Portal:

Create and transmit claims electronically
Transmit eligibility verification transactions
Transmit claim reversals
Transmit adjustment transactions
Transmit Nursing Facility PETI Prior Authorization Requests (PARs)

Refer to the Provider Web Portal Quick Guides and the EDI Support web page.

Re-Bills

Health First Colorado claim forms and provider agreements contain federally required certification statements that apply to Health First Colorado billings. The provider's signature acknowledges the provider's agreement to the terms and conditions of the certification statements. Dental or Institutional paper claims that do not include the certification statements cannot be accepted and are returned to the provider. Visit the Provider Forms web page for the Dental Certification form, located under the Dental Forms drop-down, and the Institutional Certification Form, located under the Claim Forms and Attachments drop-down.

If an electronic claim is denied, the claim should be re-billed electronically.

Timely Filing

Health First Colorado claims must be filed in a timely manner. A claim is considered to be filed when the fiscal agent documents receipt of the claim.

With few exceptions, electronic claims can be submitted 24 hours a day, seven days a week. Claim receipt is documented by the assignment of an Internal Control Number (ICN).

Paper claim receipt is documented by the fiscal agent's date stamp or the imprinted ICN.

Holidays, weekends, and dates of business closure do not extend the timely filing period.

Dated claim signatures, computerized or clerically prepared claim listings, and/or postmarks and certified mail receipts do not constitute proof of receipt for timely filing purposes.

The provider is responsible for assuring that each claim is received within the timely filing period. With the exceptions of paper claims that are returned to the provider because of missing information and, all claims filed with the fiscal agent appear on the RA as paid, denied, or "in process." If claim information does not appear on the RA within 30 days of an electronic transmission or paper claim mailing, the provider is responsible for contacting the fiscal agent to determine the status of the claim and resubmitting the claim if necessary.

Agent or software failure to transmit accurate and acceptable claims or failure to identify transmission errors in a timely manner needs to be resolved between the provider and the agent or software vendor. Failure to comply with filing requirements -including timely filing -because of software product failure or the action (or inaction) of a billing agent are not recognized as extenuating circumstances beyond the provider's control.

Original Timely Filing

Effective June 1, 2018, timely filing for Health First Colorado claim submission is 365 days from the date of service. Providers always have at least 365 days from the DOS to submit a claim. A timely filing waiver is needed if a claim is submitted beyond the 365-day timely filing period.

The timely filing for pharmacy claims is 120 days. This timely filing extension does not apply to pharmacy (point of sale) claims submitted through Prime Therapeutics.

Type of Service	Timely Filing Calculation
Nursing Facility, Home Health, Inpatient, Outpatient, all services filed on the UB-04	From the "through" date of service
Dental, EPSDT, Supply, Pharmacy, All services filed on the CMS 1500	From the date of each service (line item)
Home & Community Based Services	From the "through" date of service
Obstetrical services professional fees Global procedure codes: The service date must be the delivery date.	From the delivery date
Services billed separately, additional services	From date of service
Equipment rental - The service date must be the last day of the rental period	From the date of service

Medicare Crossover Claims

Timely filing for Medicare crossover claims is within 120 days from the date of payment or denial.

Complete the Medicare fields on electronic and hardcopy crossover claims using the Medicare processing information on the Medicare payment report.

Maintain the Medicare payment report and the page describing the payment or denial reasons in the member's file. A copy of the explanation of benefits (EOB) is not required with electronic submission, however the Medicare EOB date must be included on the claim.

When automatic crossover (the automated exchange of claims between Medicare and the Health First Colorado fiscal agent) occurs, timely filing requirements are met. If the automatic Medicare crossover claim does not appear on the Health First Colorado RA within 60 days from the Medicare processing date, the provider is responsible for submitting the crossover claim to the Health First Colorado program.

Claim Action

Any claim-specific action that does not result in Health First Colorado-authorized reimbursement for services rendered. The following are examples of action:

A claim denial on the Health First Colorado RA or 835
A claim payment on the Health First Colorado RA or 835
Claims that have been date-stamped by the fiscal agent or the Department and returned to the provider.

Correspondence, reports, or forms that do not identify the member, service date(s), types of service, and billing provider are not recognized as proof of timely filing compliance. Prior authorization is not a timely filing waiver. Waiting for prior authorization or correspondence from the Department or the fiscal agent is not an acceptable reason for late filing. Phone calls and other correspondence are not proof of timely filing. The claim must be submitted, even if the result is a denial.

Checking Claim Status

Providers may follow up with the fiscal agent regarding claim status by contacting the Provider Services Call Center. Providers can also utilize the HIPAA 276/277 Claim Status Request and Response transaction to inquire about claims. To use this method of determining claim status, the provider must be able to transmit compliant HIPAA transactions, or use a clearinghouse or switch vendor to transmit the data for them. Specific details for submitting and receiving this transaction are outlined in the 276/277 Companion Guide, located on the EDI Support web page.

Re-Bills and Adjustments and the 60-Day Rule

Electronic re-bills (resubmissions of previously denied or paid claims) and adjustment requests must be filed with the fiscal agent and received within the timely filing period.

If the timely filing period expires, a re-bill or adjustment request must be received within 60 days of the last action. Providers are required to resubmit claims every 60 days after the initial timely filing period to keep the claim within the timely filing period, even if the claim denies.
The previous ICN must be entered in the appropriate field of the electronic format, even if the claim is over 365 days. If the provider submits a paper claim, the ICN of the last action must be entered as follows:
- UB-04: Enter Previous ICN in Field 64A.
- CMS 1500: Enter Previous ICN is reported in Field 22-Original Ref and Field 22-Resubmission code of 9F.
- 2006 ADA Dental: Enter Previous ICN in Field 16 and enter 9F in Field 19.
Proof of compliance with all timely filing and 60-day rule requirements must be maintained in the provider's files. Compliance with the 60-day rule is calculated by using one of the following dates:
- The correspondence date of a load letter for member eligibility backdate.
- The date-stamp on returned paper claims.
- The date of the last remittance advice.

Claims that are not submitted within the 365-day guideline but have one of the above documents attached to the submission, will be put into "suspended" status and reviewed by the fiscal agent. Attachments should be submitted with the claim via the Provider Web Portal. The fiscal agent does not accept attachments via batch submissions.

Waiting for prior authorization or correspondence from the Department or the fiscal agent is not an acceptable reason for late filing. Phone calls and other correspondence are not proof of timely filing. The claim must be submitted, even if the result is a denial.

Timely Filing Continuity

Providers may continue to re-bill or adjust claims after the original timely filing period has expired if every submission meets applicable 60-day rule requirements.

If the original timely filing period expires, the next submission must be received within 60 days of the last action.

Copies of all RAs, and/or correspondence documenting compliance with timely filing and 60-day rule requirements must be maintained in the provider's files. A copy of the Remittance Advice (RA) should not be included with the claim.

Timely Filing Resubmission Instructions

Providers can keep claims within timely filing by resubmitting every 60 days after the initial timely filing period of 365 days from the date of service (DOS). Providers may resubmit within 60 days if an adjustment or recoupment is initiated by the fiscal agent, Gainwell Technologies, or Health Management Systems, Inc. (HMS).

The previous Internal Control Number (ICN) must be referenced on the claim if the claim is over 365 days.

Providers must submit all claims within 365 days. The next submission must be received within 60 days of the last action if the original timely filing period (365 days) has expired.

Referring to the Previous ICN on a Claim Provider Web Portal:
Claims outside of timely filing must be resubmitted by entering the previous ICN in the “Previous Claim ICN” field in the Claim Information section. Refer to the Submitting an Institutional Claim Quick Guide and the Submitting a Professional Claim Quick Guide for more information.

Delayed Processing by Third-Party

Providers should not submit or resubmit claims which will be received by the fiscal agent later than 365 days from the date of service.

Providers must complete third-party information on the electronic claim format and retain a copy of the third-party payment or denial notice in their files. A copy of the EOB should not be attached to the electronic claim. If a paper claim is sent, the provider must complete the third-party payment/denial fields and retain a copy of the third-party payment or denial notice. A copy of the third-party payment or denial notice also must be attached to the paper claim. The provider is responsible for pursuing available third-party resources in a timely manner.

Delayed/Retroactive Member Eligibility

If the timely filing period expires because eligibility determination is delayed or backdated, the fiscal agent is authorized to consider the claim to be filed timely if it is received within 60 days of the date that the member's eligibility is approved. Each claim must have an attached, Department-authorized, load letter.

Do not submit claims without member state identification numbers. If eligibility determination is pending, file the claim with the required documentation described above as soon as an assigned number is available.

All Load Letter requests should be faxed to the Department at 303-866-2082 or via encrypted email to HCPF_LoadLetterRequests@state.co.us. Use Load Letter Request as the subject. Do not use the member's State ID in the subject line.

Delayed Notification of Health First Colorado Eligibility

Providers are expected to take appropriate and reasonable action to identify Health First Colorado eligibility within 365 days (timely filing guidelines). Some examples of appropriate action include:

Reviewing past medical and accounting records for eligibility and billing information for services provided
Requesting eligibility information from the referring provider or facility where the member was seen
Contacting the member by phone and by email and by mail
Verify eligibility via the Provider Web Portal or via batch

It is not effective to rely solely on billing statements, collection notices, or collection agencies as the only means of obtaining eligibility and billing information. If the timely filing period expires because the provider is not aware that the member is Health First Colorado eligible, the fiscal agent is not authorized to override timely filing.

Timely Filing Extensions for Circumstances Beyond the Provider's Control

Occasionally, the timely filing period may expire because of delays in obtaining eligibility or Medicare processing information. The Department authorizes the fiscal agent to extend the timely filing period under the following circumstances:

Delayed/Retroactive Member Eligibility
Other Circumstances beyond the Provider's Control

Other Circumstances Beyond the Provider's Control

Requests for timely filing waivers must contain a detailed description of the extenuating circumstances beyond the provider's control resulting in failure to meet timely filing requirements.

Exceptions are granted only where the provider is able to document that appropriate action to meet filing requirements was taken and that the provider was prevented from filing as the result of exceptional circumstances that could not have been foreseen or controlled.

Employee negligence, employer failure to provide sufficient, well-trained employees, or failure to properly monitor the activities of employees and agents (e.g., billing services) are not extenuating circumstances beyond the provider's control. Waiting for prior authorization or correspondence from the Department or the fiscal agent is not an acceptable reason for late filing. Phone calls and other correspondence are not proof of timely filing. The claim must be submitted, even if the result is a denial.

Issues resulting in failure to transmit accurate and acceptable claims or failure to identify transmission errors in a timely manner must be addressed. If the issue is between the provider and the software vendor, billing agent or clearinghouse, this does not constitute an acceptable reason to be outside the timely filing period.

General Claim Completion Instructions

The following general instructions help assure prompt, accurate claim processing:

Always read the instructions for the specific claim format being completed. The instructions describe each data field and the information required for accurate completion. Paper claims may be completed by computer, typewriter, or by hand. All claim information must be legible. Handwritten claims should be neatly printed. Do not strike over typing errors. Keep entries within the designated boxes and lines.

Paper claims that cannot be imaged are returned to the provider. Paper claims must be the red-ink forms and cannot be photocopied. Use black ink to complete the claim form. Faint printing caused by worn or poor-quality typewriters or printer cartridges cannot be imaged.

Never use highlighters to mark paper claims or claim attachments. Highlighted information cannot be imaged. Use a broad black pen to circle or underline information requiring special attention.

If field completion is not required, leave the field blank. Do not enter comments or "N/A."

Continuation claims may be submitted. Each claim 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 billing lines than allowed on the form can be continued onto an additional page and totaled at the end.

If a paper claim is submitted that has an attachment, place the attachments behind the claim form. If several claims require the same attachment, the attachment must be photocopied as many times as necessary and stapled behind each of the submitted claim forms.

Claims for more than one occurrence of the same procedure on the same date should be billed on one billing line using multiple units of service and increasing the charges accordingly.

Claim Coding

All Health First Colorado claims require diagnosis codes and procedure codes. The appropriate diagnosis code must be entered on all claims. Procedure codes are dependent on the type of service and claim type.

Diagnosis Coding

The Health First Colorado program recognizes only those diagnosis codes published in the ICD-10-CM by the U.S. Department of Health and Human Services, Public Health Service, and Centers for Medicare & Medicaid Services (CMS).

ICD-10-CM codes must be entered properly on the claim form and must relate to the services for which charges are being submitted. The Health First Colorado program provides benefits for services that are medically necessary. The diagnosis code must be specific and indicate an appropriate cause for and relationship to the services provided. In general, non-specific codes (e.g., for radiology examinations or gynecology examinations) are not acceptable for Health First Colorado reimbursement. Common medical practice indicates that some procedures are appropriate only when specific conditions are present. Providers must assure that the diagnosis entered supports the validity and appropriateness of the billed service. DSMIV codes are not accepted.

Diagnosis Coding for Members with AIDS or AIDS-related Diagnoses

Federal and State legislation impose severe penalties for failure to keep AIDS-related information confidential. This legislation, however, is not intended to prevent Health First Colorado providers from accurately and appropriately submitting Health First Colorado claims.

Health First Colorado providers, the State, and the fiscal agent are prohibited from disclosing any information related to public assistance applicants or members. Federal Regulation 430.331, State Statute 26-1-114, and HIPAA Privacy CFR 45 provide sanctions for disclosing confidential information. However, these legal documents do allow information to be disclosed for the purpose of administering a public assistance program.

Health First Colorado claim information is necessary for Health First Colorado administration. This information meets Federal and State requirements and is used to process claims, calculate costs, and project future funding. Information shared for these purposes does not endanger the member's confidentiality. AIDS or AIDS-related diagnoses codes should be entered on the claim form like any other diagnosis or condition.

Procedure Coding - HCPCS

The Health First Colorado program uses the CMS HCPCS to identify services provided to Health First Colorado members. The HCPCS includes codes identified in the Physician's Current Procedural Terminology (CPT) and codes developed by CMS.

The State approves using HCPCS codes when submitting claims for services billed in the following formats:

CMS 1500
Institutional-Outpatient
Dental
EPSDT

Providers should use the most current CPT version. The Health First Colorado program adds and deletes codes as they are published in annual revisions of CPT. The CPT can be purchased at local university bookstores or from the American Medical Association at the following address:

Book & Pamphlet Fulfillment: OP-341/9
American Medical Association
PO Box 10946
Chicago, IL 60610

Always use the current HCPCS publication when submitting the Health First Colorado claims. Updates and revisions to HCPCS listings are documented in the Provider Bulletins.

HCPCS publications vary in length and are replaced annually. Providers should keep the current HCPCS publication with the Provider Manual.

Revenue Coding

The Health First Colorado Revenue Code Table contains, by type of service, revenue codes for billing services to the Health First Colorado program. The listed revenue codes are not all Health First Colorado benefits. When valid non benefit revenue codes are used, the claim must be completed according to the billing instructions for non-covered charges. Claims submitted with revenue codes that are not listed are denied.

Use the codes listed in the current revenue code table when submitting institutional claims. Notices of updates and revisions to the revenue code table are made in Health First Colorado bulletins. Refer to Appendix Q located on the Billing Manuals web page under the Appendices drop-down for the current Revenue Code Table.

Claims Processing

Claims Processing Overview

The Department contracts with the fiscal agent for the processing of Health First Colorado claims. The fiscal agent receives and processes all Health First Colorado claims in accordance with established Health First Colorado policies. Claims can be submitted via paper, interactively via the Provider Web Portal or via Electronic Data Interchange (EDI) using the 837 transactions.

Internal Control Number

A unique, 13-digit, Internal Control Number (ICN) is assigned to each claim for identification and tracking. Refer to the Internal Control Number (ICN) Information Sheet located on the Quick Guides web page for more information.

Paper Claims

When required information is not included or is illegible on paper claims, the claims are returned to the provider for correction and/or completion. Returned claims are date stamped and sent to the provider with a Return To Provider (RTP) form letter. The date-stamped claim is proof of timely filing.

The provider should enter or correct the required information and check additional missing, invalid, or illegible information to avoid further processing delay. If needed, the provider may contact the Provider Services Call Center for assistance.

Attach the RTP letter or a copy to the corrected claim. Retain the RTP letter for your files.

Electronic Claims

The 999 is the acknowledgement when using any of the HIPAA 837 transactions. After each system cycle, claims pay, suspend, or deny.

Claims suspend when they have errors or, according to state guidelines, require manual review. Claims processors review suspended claims and process the claims according to State policy. See the Provider Web Portal information in the Billing section of this manual.

Payment Cycle

Each Friday, the weekly payment cycle prepares claims for payment, processes the payment, updates the provider's Accounts Receivable (AR), if applicable, posts Electronic Funds Transfer (EFT) the next week, and produces a RA. Except when holidays create a one to two-day delay, providers should receive their warrant by the beginning of the following week.

The Health First Colorado RA or the 835 is the official document that reports the results of claim processing. For every billing provider with claims processed during the week, a RA posted electronically to the provider web portal.

Information on the RA or 835 must be used to post payments, reconcile member accounts, track claims, comply with timely filing requirements, and detect payment or billing errors. The RA should be retained for reference.

Providers may also request to receive the HIPAA 835 Health Care Claim Payment Advice for receiving claim payment information. To receive this transaction, the provider must be able to receive compliant HIPAA transactions, or use a clearinghouse to receive and transmit the data for them. Refer to the Updating Electronic Remittance Advice (ERA) Quick Guide located on the Quick Guides web page to obtain more information about receiving this transaction.

General Information

Remittance Advice (RA) information varies according to the type of claim submitted and the type of provider submitting the claim. Providers who submit claims under more than one provider number receive a separate RA for each billing provider number.

If the provider bills for more than one service category, each category is displayed separately on the same RA. The sort order within each claims section is by the following five fields: Last Name, First Name, Middle Name, Medicaid ID and ICN.

As appropriate and applicable, claim status information is printed for each claim type under the following categories: Compound Drug, Dental, Drug, Professional, Inpatient, Long-Term Care, Outpatient, Medicare Crossover Institutional, and Medicare Crossover Professional. Within each of these categories, claims are divided into Paid, Denied, Adjusted, and In-Process sections.

Note: Drug and Compound Drug categories do not have an In-Process section.

The RA also contains a Financial Transactions page that summarizes the provider's weekly financial activity. The information contained on this page enables providers to better reconcile their RAs. Refer to the Read the Remittance Advice (RA) Quick Guide located on the Quick Guides web page for more information concerning the RA.

Remittance Advice (RA) Sections

Each RA page carries a heading with the following information:

Claim detail information is reported under a number of headings according to the type of claim submitted and the adjudication status of the claim. Payments, Denials, Adjustments and In Process Claims are reported using distinctive headings.

Note: The In-Process section only reports claims that enter a "Suspense" status within eight days of the RA date.

If no claims are processed during the week, the RA will not contain any claims sections.

Each of the following sections appears on the RA with a distinctive heading indicating the type of information presented:

Address Cover Page

The first page of the RA displays the provider's name and mailing address.

Banner Message Section

The Banner Message section of the RA notifies providers of special updates and policy and/or claims processing information. These messages contain the timeliest notification of changes in billing and payment conditions and should be read each time a RA is received.

Messages are often repeated for two or more weeks to assure that infrequent billers have access to information in the same way as those providers who submit claims weekly. Even though the messages may appear unchanged over a several-week period, providers should always read the RA messages each time the RA is received.

Claims Paid

Information in this section of the RA must be used to reconcile member accounts and make appropriate accounting and adjustment entries. The provider is responsible for reconciling the RA.

Claim payment information is reported on the RA under the headings of Claims Paid or Claim Adjustments.

Incorrect payments must be adjusted and cannot be re-billed. The fiscal agent must receive requests for adjustment within the applicable timely filing period. The total number of paid claims and total dollar amount of the payment for the identified claims is listed at the end of Claims Paid section of the RA.

Refer to the Read the Remittance Advice (RA) Quick Guide located on the Quick Guides web page for more information concerning the RA.

Claim Adjustments

Claim payments may be adjusted for increased payment, decreased payment, or recovery without repayment. Adjustments that increase or decrease the payment amount are processed as two separate transactions. The first transaction recovers the previously made payment and the second transaction repays the claim at the corrected rate.

The Claim Adjustment section displays the original claim being adjusted. The adjusted claim will either pay more, pay less or pay $0. If a claim that previously paid is adjusted to pay less than the original claim or deny (pay $0), the adjustment will result in a balance due and the system will establish an Accounts Receivable (AR).

Denied adjustments identify the reason for denial. Denied adjustments may be resubmitted with additional or corrected information within the applicable timely filing period of the RA showing the adjustment denial. Resubmitted adjustments display a new ICN.

Following the last transaction in the Claim Adjustments section, the total number of adjustments is indicated as well as the net result, payment, or recovery for all adjustment transactions.

Note: The Adjustment Summary section of the RA is found on the Financial Transaction page. The Adjustment Summary includes the total number of adjustments, total additional payments, total payments to be withheld and the total refund amount applied for the entire RA.

Claims Denied

Denied claims identify the reason for denial with an EOB description. Claims that are duplicates will be denied as such. Claims denied because of billing errors, incorrect eligibility information, etc., may be rebilled with additional or corrected information at any time during the applicable timely filing period. Rebilled claims appear on the RA as a new claim with a new ICN.

The total number of denied claims is identified at the end of the Claims Denied section of the RA.

Claims in Process

Claims that entered a "Suspended" status within the past eight days will appear on the RA under the Claims In Process section. An In Process or "Suspended" claim will not be reported again on the paper RA until the claim is finalized or re-suspends for another issue.

Do not re-bill or submit adjustment transactions for claims in process. Suspended claims will be adjudicated and appear in the Claims Paid or Claims Denied sections on a subsequent RA.

Financial Transactions

The Financial Transactions page of the RA summarizes the provider's weekly financial activity. As of January 9, 2019, new information was added to the Financial Transactions page to help providers reconcile RAs with their financial information. Financial transactions reported on this page include the Adjustment Summary, Non-Claim Specific Payouts to Payee, Non-Claim Specific Refunds from Payee and Accounts Receivable.

The Adjustment Summary provides the grand total of all the adjustment sections in the RA. The Non-Claim Specific Payouts to Payee section includes the Expenditure Reason for each transaction and the Total Payouts. Refer to Appendix S located on the Billing Manuals web page under the Appendices drop-down for the full list of Remittance Advice Expenditure Reason Codes. The Non-Claim Specific Refunds to Payee section includes the Cash Disposition Reason for each transaction and the Total Refunds. The Accounts Receivable section reports Manual, Repayment and outstanding Automatic ARs.

Accounts Receivable (AR) Information

An Accounts Receivable (AR) account is established when circumstances result in a provider owing money to the Health First Colorado program.

The Accounts Receivable (AR) section is found on the Financial Transactions page and provides information on recoupments under "Payee Recoup Percentage" and "Payee Recoup Amount" and a list of all outstanding ARs owed by the service location. The AR may be partially recouped or not recouped at all which will be indicated by these two fields. A recouping restriction is an established guideline in Colorado interChange that limits or prevents the automatic recovery of all monies owed on an AR when there are available provider funds.

The only recouping restriction displayed on the RA is the Payee Max Recoup restriction, where the payee is the provider. This restriction is displayed in the following fields:

Payee Recoup Percentage - The maximum percentage of a provider’s payment that can be used to recover monies owed to Health First Colorado in that payment cycle.
or
Payee Recoup Amount - The flat, maximum amount to recover up to, but not exceeding the payment due to the provider.

If there is a Payee Max Recoup restriction in place for the provider, the "Payee Recoup Percentage", "Payee Recoup Amount", "AR Effective Date" and "AR End Date" fields are specified.

If there is no Payee Max Recoup restriction in place, the "Payee Recoup Percentage" field will read 100% and all of the monies paid to the provider in that payment cycle can be used to recover monies owed to Health First Colorado.

Note: Any existing agreement between the provider and the Department regarding specific accounts receivables owed will be honored regardless of these recouping restrictions.

Below the Payee Recoup fields, the following information is displayed for each outstanding AR. New fields are defined below:

A/R Number - The Accounts Receivable section includes Manual, Repayment and outstanding Automatic ARs without current cycle activity.
Setup Date
Previous ICN
Original A/R Amount - This is the original accounts receivable setup amount.
Recouped in Current Cycle
Balance
Adjustment ICN
Adjustment Amount - This is the amount paid on the adjusted claim.
Member Number - Member ID
DOS From - This is the first date of service on the claim.
DOS To - This is the last date of service on the claim.

Refer to the Read the Remittance Advice (RA) Quick Guide located on the Quick Guides web page for more information concerning the RA.

Re-Bills

Denied claims can be re-billed. Claims that are paid incorrectly must be adjusted. Do not re-bill claims that appear on the RA as "In-Process."

Re-bills must be received by the fiscal agent within the applicable timely filing period.

Re-bills should be submitted electronically. Re-bills must be submitted as a newly created claim. Required attachments must accompany each applicable claim and can be attached via the Provider Web Portal. Attachments cannot be sent for batch claims.

Adjustments

Claims that appear in the Claims Paid section of the RA should be adjusted electronically. The fiscal agent must receive requests for adjustment to paid claims within the initial 365-day timely filing period or within 60 days of the last payment or denial. If the claim is outside the 365 days but within 60 days of the last payment or denial, the previous ICN must be reported on the claim. If corrections to paid claims are not submitted as adjustments, but are re-billed, they will be denied as duplicates.

Refer to the Copy, Adjust, or Void a Claim Quick Guide for instructions on how to submit an electronic adjustment via the Provider Web Portal.

Paper Adjustments

If the provider submits a paper claim as an adjustment, an original claim form must be submitted with a valid signature. The adjustment must include the ICN of the previous claim and should be coded as follows:

Payment Errors

The provider is responsible for notifying the fiscal agent immediately when payment errors occur. The claim must indicate the appropriate corrected or additional information necessary for claim reprocessing. If a claim has been underpaid, the fiscal agent must receive a claim adjustment within the applicable timely filing period.

Underpayments

If a claim has been underpaid, the fiscal agent must receive the claim adjustment within the applicable timely filing period.

The adjustment must indicate the appropriate corrected or additional information necessary for claim reprocessing.

Claims Paid at Zero

A claim payment of $0.00 (zero) is a paid claim even though the provider does not actually receive payment. The most common reason for zero payment is third-party payment deduction from the allowable Health First Colorado benefit or a Medicare crossover paid under lower-of-pricing. If a zero payment is incorrect, the provider must submit a claim adjustment. Re-billed zero payment claims are denied as duplicates.

Claims that are line item processed and document-adjudicated may show some line items as paid and others as denied. Line item denials show allowed charges as $0.00 with a code printed to the right of the procedure code modifier for the denied line. Denied line items may be re-billed.

Overpayments

Providers must report all overpayments to the fiscal agent immediately. Overpayments are adjusted and recovered upon discovery even if the timely filing period has expired. Adjustments to overpaid claims may be made in one of the following ways:

Overpayments are recovered through (1) the claims processing system with credit (recovery) amounts subtracted from current claim payments or (2) held as an AR balance designated for recovery against future claim payments.

The provider may send a personal check payable to the State of Colorado for the total claim payment amount. Send the check and a fully completed Refund to Health First Colorado or Returned Warrant form with attachments to the fiscal agent for processing. The check must be for the full amount of the incorrect claim payment.

If repayment of the claim is appropriate, the revised claim is processed through the claims processing system and the repayment appears on the RA. The repayment amount is included in the warrant.

Warrants and RAs containing large or numerous payment errors may be returned, non-negotiated, with an explanation to the fiscal agent.

Third-Party Payments

The Health First Colorado program is always the payer of last resort. If a third-party pays for services that were previously processed and paid by Health First Colorado, notify the fiscal agent and refund the full Health First Colorado claim payment. Third-party payment recoveries are processed in the same manner as overpayments.

Medicare Crossover Adjustments

Medicare adjustments to previously processed Medicare claims cannot be processed as automatic crossovers. Medicare adjustments may show the crossover message, but automatic crossover processing is not possible. The provider must submit an adjustment transaction and include the Medicare adjustment Standard Paper Remit (SPR) date to correct the Health First Colorado payment.

Changes to Claim History

An adjustment transaction should be submitted to correct processed, non-payment related claim information to assure proper data for utilization review and cost reporting, e.g., a corrected date of service.

Requests for Reconsideration

The fiscal agent is the primary source for providers to obtain satisfactory resolution of submitted and processed claims and is authorized by the single state agency to apply all applicable State and Federal rules and regulations to process Health First Colorado claims.

The provider must exhaust all authorized fiscal agent rebilling and adjustment procedures before filing a Request for Reconsideration with the fiscal agent. Requests for Reconsideration must be filed with the fiscal agent within 60 days of the last action, if initial timely filing has expired.

Extenuating Circumstances

If claim filing requirements are not met because of circumstances beyond the control of the provider, the provider can contact the fiscal agent. The fiscal agent will forward the request to the department for review. The Claims Processing unit is authorized to evaluate and validate alternative information resources when the provider can show the following conditions:

Appropriate documentation for a timely filing waiver is attached

Billing and claim preparation errors are not recognized as beyond the provider's control. Examples include:

Employee negligence
The provider's failure to provide sufficient, well-trained employees
The provider's failure to monitor the activities of employees and agents (billing services)

Reconsideration is available only when extenuating circumstances or mitigating factors prevent compliance with filing requirements.

Denied claims do not need to be adjusted or sent as a request for reconsideration. A denied claim should be resubmitted electronically as a new claim once corrections have been made. Resubmissions should not be sent on paper, even if the claim is over 1 year old or out of timely filing.

Administrative Procedures

Reconsideration claims are acknowledged on the Health First Colorado RA Reconsideration claims that are processed as adjustments appear in the Adjustment Section of the RA. Health First Colorado RA information constitutes official written notification of reconsideration activity.

Providers should contact the Provider Services Call Center for assistance in preparing requests for reconsideration or resubmission, or to ask questions about reconsideration processing.

If all means of achieving satisfactory claim resolution through the fiscal agent and the Claims Processing unit have been exhausted, providers may file a written appeal with the Office of Administrative Courts, at the address listed in Appendix A on the Billing Manuals web page under the Appendices drop-down.

Appeals submitted to the Office of Administrative Courts must be received within 30 days from the mailing date of the last notice of action.

General Provider Information 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 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)
5/3/2017	Updates made to Non-Citizens section by Policy	RC
5/5/2017	Updates based on Fiscal Agent name change from HPE to DXC	DXC
9/15/2017	Update to Timely Filing	HCPF
12/13/2017	Update to copay information	HCPF
3/13/2017	Update to record keeping and retention	HCPF
5/30/2018	Timely filing information updated, Outpatient Claim Pricing Methods and Outpatient Crossover Claim information removed, Remittance Advice information removed, Health First Colorado Eligibility Response System (CMERS)/Interactive Voice Response System (IVRS) information removed	HCPF
6/14/2018	Minor grammar update	HCPF
6/28/2018	Minor grammar update	HCPF
7/6/2018	Updated "copayments" to 'co-pays' Added TPL example	HCPF
7/9/2018	Added additional information about TPL claims	HCPF
8/23/2018	Minor edits added.	DXC
8/30/2018	Updated TPL verbiage Added link to load letters	HCPF
1/9/2019	Added RA Content with recent Financial Transaction page updates	DXC
3/14/2019	Updated supervision and ordering requirements for non-physician practitioners and speech pathologists	HCPF
3/15/2019	Clarified Authorized Signatures	HCPF
4/23/2019	Updated supervision to include non-enrolled providers	HCPF
4/23/2019	Update to TPL section	HCPF
5/24/2019	Added pharmacy-specific clarification to timely filing	HCPF
6/7/2019	Updated Appendix links and verbiage	HCPF
8/5/2019	Corrected typos, removed superfluous sentence (did not conform with style guide)	HCPF
1/8/2020	Updated OOS emergency to "documentation must be on file"	HCPF
3/6/2020	Converted to web page	HCPF
5/28/2020	Added verbiage for "lower-of" logic with regard to rate increases	HCPF
9/24/2020	Added link to Ordering, Prescribing, and Referring (OPR) Providers section	DXC
10/1/2020	Updated references to DXC Technology (DXC) to fiscal agent/Gainwell Technologies	Gainwell Technologies (formerly DXC)
4/7/2021	Provider Responsibility to Review Delegate Provider Web Portal Accounts	HCPF
6/3/2021	Updated verbiage for Delayed Notification of Eligibility (clarification)	HCPF
6/11/2021	Added Prescribing Controlled Substances – SUPPORT Act requirements	HCPF
7/1/2021	Updated Prescribing Controlled Substances – SUPPORT Act requirements	HCPF
7/6/2021	Added EPSDT verbiage and requirements	HCPF
11/24/2021	Updated language to be consistent with the newly revised provider participation rule, 8.130, which will be effective January of 2022 (changes made concerning change of ownership, record retention, and inactivation).	HCPF
9/8/2022	Updated Prescribing Controlled Substances language to include documentation requires around good faith efforts.	HCPF
9/8/2022	Adding modifier 33 information and updated copay information.	HCPF
11/3/2022	Added Medicare-only provider types information in Medicare Resources section.	HCPF
12/28/2022	Updated link for electronic batch submission	HCPF
12/28/2022	Corrected line item formatting issues	HCPF
2/1/2023	Updated co-pay information regarding emergency co-pay policy change	HCPF
4/3/2023	Updated AWS URL Links	HCPF
4/26/2023	Removed requirement to obtain a physician statement when applying for emergency Medicaid in Non-Citizens sections.	HCPF
6/5/2023	Corrected line item formatting issues	HCPF
7/1/2023	Co-Pay Information updated	HCPF
8/8/2023	Edited to correct typos	HCPF
10/18/2023	Added instructions for re-billing to keep claims in timely status	HCPF
2/8/2024	Removed outdated information from Dual Eligibility section	HCPF
2/26/2024	Added in additional information for 60-day rule	HCPF
3/7/2024	Updated Re-Bills and Adjustments and the 60-Day Rule	HCPF
6/26/2024	Removed Psychologist from On-Premise Supervision and Non-Direct Reimbursement Exemptions	HCPF
9/26/2024	Updated Pharmacy vendor name to Prime Therapeutics	HCPF