- Hospice Care
- Billing Information
- Hospice Benefits
- Revenue Coding
- Post Eligibility Treatment of Income (PETI) Nursing Facility Supplemental Benefits
- Payments to Licensed Hospice Facilities for Residential Care
- UB-04 Paper Claim Reference Table
- Timely Filing
- Institutional Provider Certification
- Early and Periodic Screening, DIagnosis and Treatment
- Electronic Visist Verification
- Hospice Revisions Log
Providers must be enrolled as a Health First Colorado (Colorado's Medicaid Program) provider in order to:
- Treat a Health First Colorado member
- Submit claims for payment to the Health First Colorado
Hospice services are available to Health First Colorado members with a terminal illness (life expectancy of nine (9) months or less). The palliative treatment includes services and interventions that are not curative but provide the greatest degree of relief and comfort for the symptoms of the terminal illness.
Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10), for specific information when providing hospice care.
Refer to the General Provider Information manual for general billing information.
The member may receive Health First Colorado Hospice Benefit (MHB) services in a:
- Private residence
- Residential care facility (Alternative Care)
- Licensed hospice facility
- Intermediate Care Facility for the Mentally Retarded (ICFMR)
- Skilled Nursing Facility (SNF)
- Nursing Facility (NF)
Health First Colorado Hospice Benefit members residing in a nursing facility must meet hospice level of care and financial Health First Colorado eligibility criteria.
Hospice SNF/NF room and board reimbursement is made to the hospice provider for each home care level day (routine or continuous care).
- The member must choose MHB services.
- The member's attending physician must certify that the member is terminal.
- Both the member and the attending physician must agree to the plan of care developed by the hospice provider.
- A participating MHB provider must provide all MHB services.
- Hospice services are co-payment exempt.
- Physician services are not a covered MHB, they are billed by the physician as a regular physician service.
- The SNF/NF provides the hospice with the room and board per diem amount for hospice members residing in an SNF/NF. The hospice bills room and board on behalf of the member to the Health First Colorado which reimburses 95% of the per diem amount, and the hospice passes the room and board payment through to the SNF/NF.
The patient liability amount may apply when a hospice member resides in a NF. This is payment made by the member for NF care, after the personal needs allowance and other approved expenses are deducted from member income. The personal needs allowance and other approved deductions are determined by County Income Maintenance Technicians. The patient liability amount must be applied to the member's care.
When reporting the patient liability amount for the entire month, regardless of the number of days in that month, apply the total patient liability.
Bill the full $100.00 (Per Diem Rate) amount
The processing system automatically deducts 5% - $100 X .95= $95.00
$95.00 X 31 = $2,945.00
$2,945.00 - $500.00 = $2,445.00 (NF R & B)
$2,445.00 + $3,500.00 (routine home care amount) = $5,945.00 Total Reimbursement.
Use the per diem calculation to calculate the correct amount when reporting the patient liability amounts for less than one full month of NF care. The per diem calculation is the number of days in the facility, excluding the date of discharge, times the facility's per diem rate.
To calculate NF partial patient liability:
- Calculate the Health First Colorado amount by multiplying the number of days for payment times the per diem amount.
- If the Health First Colorado amount exceeds the patient liability amount, the partial month's patient liability amount remains the same as the regular patient liability amount.
- If the patient liability is more than the Health First Colorado amount, the partial month's patient liability is the same as the Health First Colorado amount. The excess of the patient liability over the partial month's patient liability belongs to the resident and, if it has already been paid to the facility, shall be refunded to the resident. It is the SNF's/NF's responsibility to collect patient liability. The hospice does not have to collect patient liability. The hospice may choose to collect this amount and pay the SNF/NF.
Bill Hospice services with the following revenue codes:
|Hospice Routine Home Care||650
|Care Days 1-60 One Unit = 1 day
Care Days 61+ One Unit = 1 day
|Continuous Home Care||652||One Unit=1 hour (must be at least 8 hours in a 24 hour period with more than half provided by a nurse)|
|Service Intensity Add-on
Hospice Inpatient Respite
|One Unit=1 hour
(up to 4 hours and member must be seen by a nurse or social worker within the last 7 days of life)
One Unit = 1 day
|Hospice General Inpatient Care||656||One Unit = 1 day|
|Hospice Physician Service (Visit)||657||One Unit = 1 visit Non-covered MHB service (Non-covered charges must be shown in both FL 53 and 54)|
|Hospice NF Room and Board Per/Diem||659||One unit = 1 day|
Post Eligibility Treatment of Income (PETI) Nursing Facility Supplemental Benefits
Post Eligibility Treatment of Income (PETI) is defined as the reduction of resident payment to a nursing facility for costs of care provided to an individual for services not covered by the Medical Assistance Program, by the amount that remains after certain approved deductions are applied, and paid to the providers to reduce the individual's total payment.
- The individual is liable to pay the remaining amount to the institution.
- Members who reside in a nursing facility, are receiving hospice services and who are making a patient liability payment must have a letter from their primary care physician stating why these additional services are medically necessary and requested by the resident.
- These requests will be considered individually and the Department will determine whether or not to approve the request.
- The Long Term Care (LTC) facility or the family determines the need for Non-Medical Assistance Program covered services.
- The facility or family arranges for the member to see the provider.
All PETI expenses must be prior authorized by the Department. Prior Authorization Requests (PARs) should be sent to:
Department of Health Care Policy & Financing
1570 Grant Street
Denver, CO 80203
|PETI Revenue Codes|
Hospice agencies are responsible for adding PETI codes to their claims for Medical Assistance Program members living in nursing facilities and who also make a patient liability payment. Once the charges are approved, the hospice agency may submit claims for the PETI payment on the claim with the member's room and board minus patient liability amount. The claims processing system will automatically complete the calculations.
Bill PETI charges in units. One unit equals one dollar.
Example with Claim: If a member has been approved for the purchase of eyeglasses at a cost of $175, the PETI amount equals 175 units at $1.00 each. Do not bill partial units or cents.
Payments to Licensed Hospice Facilities for Residential Care
Senate Bill 21-214 created a limited fund ($684,000) for State Payments to Licensed Hospice Facilities for Residential Care. Separate invoicing for these services is required to accommodate the specific nature of this funding.
As stated in Senate Bill 21-214, all services must be performed by eligible providers to eligible members.
Eligibility for providers includes:
- Has been continuously enrolled as a hospice provider with the State Department since at least January 1, 2021
- Provided hospice services to the eligible patient in a licensed hospice facility during the period beginning in the last quarter of the 2020-2021 State Fiscal Year through the 2021-2022 State Fiscal Year" (between April 1, 2021 and July 30, 2022); and
- Complies with any billing or administrative requests of the State Department for purposes of determining eligibility for and administering the state payment
Eligibility for Health First Colorado Members includes:
- Is an Eligiblemember. "Eligible member" means a person who is enrolled in the medical assistance program at the time the service is provided and is eligible under the medical assistance program for care in a nursing facility at the time the service is provided;
- has a hospice diagnosis
- despite attempts to secure a bed, is unable to secure a Medicaid bed in a nursing facility due to covid-19 impacts, complexity of medical care, behavioral health issues, or other issues as determined by the state department.
Fund Limitations and administrative policies:
- Total fund amount is $684,000 for all eligible payments. When this funding is exhausted this billing manual will be updated to reflect that no further invoices will be paid.
- 1. Care must be provided between April 1, 2021 and June 30, 2022.
Fund Invoice Process:
When funds are exhausted or the eligibility period ends, this section of the billing manual will be updated, the invoice form will no longer accept submissions, and notice will be provided to Hospice Providers via the provider bulletin.
All questions regarding SB21-214 payments may be directed to John.Lentz@state.co.us
UB-04 Paper Claim Reference Table
The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBC UB-04 Reference Manual.
All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.
The UB-04 Certification document must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.
Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form.
Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.
Bill with a date span (From and To dates of service) only if the service was provided every consecutive day within the span. The From and To dates must be in the same month.
The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to Health First Colorado for nursing facility services.<,
Form Locator and Labels Completion Format Instructions 1. Billing Provider Name, Address, Telephone Number Text Required
Enter the provider or agency name and complete mailing address of the provider who is billing for the services:
- Zip Code
2. Pay-to Name, Address, City, State Text Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:
- Street/Post Office box City
- State Zip Code
- Abbreviate the state using standard post office abbreviations. Enter the telephone number.
3a. Patient Control Number Up to 20 characters: Letters, numbers or hyphens Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
3b. Medical Record Number 17 digits Optional
Enter the number assigned to the member to assist in retrieval of medical records.
4. Type of Bill 3 digits Required
Use the following code range for Hospice:
811-815 for non-hospital based Hospice services
821-825 for hospital based Hospice services
The three-digit code requires one digit from each of the sequences (Type of facility, Bill classification, & Frequency).
Enter the three digit number indicating the specific type of bill. The three digit code requires one digit each in the following sequences:
Digit 1 Type of Facility:
8 - Special Facility (Hospice)
Digit 2 Bill Classification (Special facilities Only):
1 - Hospice (Non Hospital Based)
2 - Hospice (Hospital Based)
Digit 3 Frequency:
0 - Non-Payment/Zero Claim
1 - Admit Through Discharge Claim
2 - Interim - First Claim
3 - Interim - Continuous Claim
4 - Interim - Last Claim
5 - Late Charge(s) Only Claim
5. Federal Tax Number None Submitted information is not entered into the claim processing system. 6. Statement covers period From/Through From:6 digits MMDDYY
Through: 6 digits MMDDYY
"From" date is the actual start date of services.
"From" date cannot be prior to the start date reported on the initial prior authorization, if applicable, or is the first date of an interim bill.
"Through" date is the actual discharge date, or final date of an interim bill.
"From" and "Through" dates cannot exceed a calendar month (e.g., bill 01/15/18 thru 01/31/18 and 02/01/18 thru 02/15/18, not 01/15/18 thru 02/15/18).
Match dates to the prior authorization if applicable.
If the member is admitted and discharged on the same date, that date appears in both form locators.
Detail dates of service must be within the "Statement Covers Period" dates.
8a. Patient Identifier Text Required
Enter the Health First Colorado ID number for the member.
8b. Patient Name Up to 25 characters, letters & spaces Required
Enter the member's last name, first name and middle initial.
9a. Patient Address - Street Characters Letters & numbers Required
Enter the member's street/post office box as determined at the time of admission.
9b. Patient Address - City Text Required
Enter the member's city as determined at the time of admission
9c. Patient Address - State Text Required
Enter the member's state as determined at the time of admission.
9d. Patient Address - ZIP Digits Required
Enter the member's zip code as determined at the time of admission.
9e. Patient Address - Country Code Digits Optional 10. Birthdate 8 digits (MMDDCCYY) Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDCCYY format). Example: 01012010 for January 1, 2010.
11. Patient Sex 1 letter Required
Enter an M (male) or F (female) to indicate the member's sex.
12. Admission Date 6 digits Required
Enter the date care originally started from any funding source (e.g., Medicare, Health First Colorado, Third Party Resource, etc.).
13. Admission Hour 6 digits Not Required 14. Admission Type 1 digit Not Required 15. Source of Admission 1 digit Required 16. Discharge Hour 2 digits Not Required 17. Patient Discharge Status 2 digits Required
Enter member status as ongoing member (code 30) or as of discharge date. Agencies are limited to the following codes:
*Hospice use only
01 Discharged to Home 02 Discharged to Hospital 03 Discharged/Transferred to SNF 04 Discharged/Transferred to Another type of institution 06 Discharged/Transferred to organized Home Health Care Program (HCBS) 07 Left Against Medical Advice 20 Deceased/Expired (not for Hospice use) 30 Still a patient (ongoing) 40* Expired at home 41* Expired in hospital, SNF, ICF, or freestanding hospice 42* Expired - place unknown 50 Discharged to Hospice - Home 51 Hospice - Medical Facility 18-28. Conditions Codes 2 digits Required
Z4 necessary for paper claims.
Enter the code that matches the program and the prior authorization.
Condition Codes (as applicable) 04 HMO Medicare enrollee 07 Treatment of non-terminal condition/hospice patient 17 Patient over 100 years old 39 Private room medically necessary 29. Accident State 2 digits Not Required 31 - 34. Occurrence Code/Date 2 digits & 6 digits Required
Enter the appropriate code and the date on which it occurred. Enter the date using MMDDYY format.
27 Date Hospice Plan Established 42 Date of Discharge (Hospice Benefit Termination) 35-36. Occurrence Span Code From/ Through Digits Not Required 38. Responsible Party Name/Address None Leave blank 39 - 41. Value Codes and Amounts 2 characters and up to 9 digits Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
Most Common Codes:
01 semiprivate rate (Accommodation Rate) 06 Medicare blood deductible 14 No fault including auto/other 15 Worker's Compensation 30 Preadmission testing 31 Member Liability Amount* 32 Multiple Member Ambulance Transport 37 Pints of Blood Furnished 38 Blood Deductible Pints 40 New Coverage Not Implemented by HMO 45 Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).
49 Hematocrit Reading - EPO Related 58 Arterial Blood Gas (PO2/PA2) 68 EPO-Drug 80 Covered Days 81 Non-Covered Days Enter the deductible amount applied by indicated payer:
Deductible Payer A
B1 Deductible Payer B
C1 Deductible Payer C
Enter the amount applied to member's co-insurance by indicated payer:
A2 Coinsurance Payer A
B2 Coinsurance Payer B
C2 Coinsurance Payer C
Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C
Medicare and TPL see A1-A3, B1-B3 and C1-C3 above.
*Member Liability Amount is payment made by the member for care. This amount is determined by the County Income Maintenance Technicians. This member liability amount must be applied to the member's care at the beginning of each month using code 31.
When reporting the member liability amount for the entire month, regardless of the number of days in that month, apply the total member liability amount.
When reporting member liability amount for less than one full month of care, use the per diem calculation to calculate the correct amount.
The per diem calculation is the number of days in the facility, excluding the date of discharge, times the facility's per diem rate.
To calculate patient liability:
- Calculate the Health First Colorado amount by multiplying the number of days for payment times the per diem amount.
- If the Health First Colorado amount exceeds the patient liability, the partial month's patient liability remains the same as the regular patient liability amount.
- If the patient liability is more than the Health First Colorado amount, the partial month's patient liability is the same as the Health First Colorado amount. The excess of the patient liability over the partial month's patient liability belongs to the resident and, if it has already been paid to the facility, shall be refunded to the resident.
When member has Medicare "Part B only" coverage, and the provider is billing for the Health First Colorado Accommodation Per Diem and the payer source code is H, enter the "Part B only" ancillary services payment in this form locator on the Medicare line.
42. Revenue Code 4 digits Required
If billing for nursing facility per diem charges (Revenue Code 0659 or 0651), the nursing facility provider number must be entered in FL 78 (Other Phys. ID)
See Revenue Code table.
43. Revenue code Description Text Required
Enter the revenue code description or abbreviated description.
44. HCPCS/Rates/ HIPPS Rate Codes 5 digits Not Required 45. Service Date 6 digits Required
For span bills only.
Enter the date of service using MMDDYY format for each detail line completed.
Each date of service must fall within the date span entered in FL 6 (Statement Covers Period).
46. Service Units 3 digits Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers.
Example: Do not enter 1.0 to signify one unit.
For span bills, the units of service reflect only those visits, miles or treatments provided on dates of service in FL 45.
47. Total Charges 9 digits Required
Enter the total charge for each revenue code.
For Medicare Part B claims, enter the total ancillary charges billed to Medicare.
A grand total on line 23 is required for all charges.
48. Non-covered Charges Up to 9 digits conditional
Enter incurred charges that are not payable by the Health First Colorado.
Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges.) Each column requires a grand total.
50. Payer Name 1 letter and text Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.
Source Payment Codes B Workmen's Compensation C Medicare D Health First Colorado E Other Federal Program F Insurance Company G Blue Cross, including Federal Employee Program H Other - Inpatient (Part B Only) I Other Line A Primary Payer Line B Secondary Payer Line C Tertiary Payer 51. Health Plan ID 10 digits Required
Enter the provider's Health Plan ID for each payer name.
Enter the Health First Colorado number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
52. Release of Information N/A Submitted information is not entered into the claim processing system. 53. Assignment of Benefits N/A Submitted information is not entered into the claim processing system. 54. Prior Payments Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
55. Estimated Amount Due Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
56. National Provider Identifier (NPI) 10 digits Required
Enter the billing provider's 10-digit National Provider Identifier(NPI).
57. Other Provider ID Not Required 58. Insured's Name Up to 30 characters Required
Enter the member's name on the Health First Colorado line.
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.
60. Insured's Unique ID Up to 20 characters Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
61. Insurance Group Name 14 letters Conditional
Complete when there is third party coverage.
Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.
62. Insurance Group Number 17 digits Conditional
Complete when there is third party coverage.
Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.
63. Treatment Authorization Code Up to 18 characters Conditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
ASs of March 1, 2017, PETI/IMEs require a PAR.
64. Document Control Number none Conditional 65. Employer Name Text Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
66. Diagnosis Version Qualifier Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0ICD-10-CM (DOS 10/1/15 and after)
67. Principal Diagnosis Code Up to 6 digits Required
Enter the exact ICD-10-CM diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
67A. - 67Q. - Other Diagnosis 6 digits Optional
Complete when there are additional conditions that affect treatment.
69. Admitting Diagnosis Code 6 digits Required
Enter the ICD-10-CM diagnosis code as stated by the physician at the time of admission.
70. Patient Reason Diagnosis Not Required 71. PPS Code Not Required 72. External Cause of Injury code (E-Code) 6 digits Optional
Enter the ICD-10-CM diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".
74. Principal Procedure Code/Date 7 characters and 6 digits Conditional
Complete when there are additional significant procedure codes.
Enter the ICD 10 CM procedure codes identifying all significant procedures other than the principle procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principle diagnosis. Enter the date using MMDDYY format.
74A. Other Procedure Code/Date 7 characters and 6 digits Not Required 76. Attending NPI - Required
Attending Last/First Name
NPI - 10 digits
Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL - Enter "1D" for Health First Colorado
Enter the attending physician's last and first name.
This form locator must be completed for all services.
77. Operating NPI Optional
Submitted information is not entered into the claim processing system.
78 - 79. Other ID
NPI - Conditional
NPI - 10 digits Conditional
Complete when attending physician is not the PCP or to identify additional physicians.
Ordering, Prescribing, or Referring NPI - when applicable
NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility and PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted.
The attending physician's last and first name are optional.
80. Remarks Text Enter specific additional information necessary to process the claim or fulfill reporting requirements. 81. Code - QUAL/CODE/VALUE (a-d) Qualifier: 2 digits
Taxonomy Code: 10 digits
Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.
Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system.
PETI Claim Example
Hospice Claim without Nursing Facility Room and Board with Physician Charges Example
Hospice Claim with Nursing Facility Room and Board Example
Hospice Claim with Patient Pay Example
For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.
Institutional Provider Certification
The Institutional Provider Certification form is available on the Provider Forms web page under the Claim Forms and Attachments drop-down menu.
Early and Periodic Screening, Diagnostic, and Treatment
Hospice benefits are provided in accordance with Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements as listed in 8.280.4.E: "Other EPSDT Benefits" 8.280.4.E reads as follows:
Other health care 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:
Providers can ask for these additional services by following the PAR process as outlined for this benefit.
- Eligible hospice providers submit invoices online using the Department SB 21-214 Invoice Form.
- All fields and boxes must be filled and checked respectively in order to validate invoice.
- Only one invoice may be submitted per Health First Colorado member.
- Department reviews submitted invoices
- Invoices will be paid on a "first come first served" basis in order of received submissions here in this form.
- Department will begin processing submissions every 1st and 15th of every month until funds are exhausted or the eligible period ends.
- 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 at 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 purposes 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 at 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.
More information regarding EPSDT may be found on the EPSDT web page.
Questions about EPSDT may be directed to Gina.Robinson@state.co.us
Electronic Visit Verification
Federal guidance requires Electronic Visit Verification (EVV) for Home and Community Based Services (HCBS) that include an element of Personal Care Services and State Plan Home Health Care Services. Colorado requires the use of EVV for several other services that are similar in nature and delivery to the federally mandated services. These additional services are included to enhance care coordination, promote quality outcomes for members, and to streamline requirements for providers.
Due to the unique federally mandated payment structure for Hospice services, Hospice services are exempt from EVV Pre-Payment Claim Adjudication, meaning EVV Records do not have to be on file prior to billing in order to pay. Hospice services are subject to Compliance Monitoring and Over-Payment Review only, meaning that the Department will still review EVV Records that match to billed claims.
Hospice providers may provide EVV records for any Hospice service but is currently focused on EVV records pertaining to In-Home Hospice services billed as Revenue Codes 650, 651, and 652.
Hospice Revision Log
Revision Date Section/Action 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 Manual Comment Log v0_2.xlsx. HPE (now DXC) 1/10/2017 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsx. HPE (now DXC) 1/19/2017 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_4.xlsx. HPE (now DXC) 1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC) 5/26/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC 6/15/2018 Updated timely filing information and removed references to LBOD, removed general billing information already available in the General Provider Information manual DXC 6/27/2018 Revision to timely filing HCPF 6/13/2019 Updated Appendices' links and verbiage DXC 12/12/2019 converted to web page HCPF 8/7/2020 Updated item 81 of the Paper Claim Reference Table for taxonomy code billing DXC 9/13/2021 Added sections for Payments to Licensed Hospice Facilities for Residential Care, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), and Electronic Visit Verification HCPF