Health First Colorado (Colorado's Medicaid program) pays for all medically necessary hospital services. These include inpatient, emergency and outpatient services. Surgery, therapies, laboratory, X-ray and other diagnostic services are provided when ordered by a doctor.
How do I get hospital services?
You can get hospital services if you are referred for hospital services by your primary care provider. If you are very ill or injured, you may go to an emergency room. You should always see your primary care provider for non-emergency medical needs.
I've heard that some services are not approved. Why is that?
Services must be medically necessary. Some procedures - for example, surgeries for cosmetic reasons - have to be approved before the surgery. If surgery is not medically necessary, Health First Colorado will not pay for it. Health First Colorado also does not pay for experimental treatments or treatments not covered by Medicare.
How do I find out if my surgery can be approved?
To get approval for your surgery or other procedure, your doctor must send a prior authorization request to the Colorado PAR Program. You, your doctor, and the facility will find out if the surgery is approved or denied.
What if my surgery is denied?
Health First Colorado has an appeals process which includes a second review of the request, followed by a hearing before an administrative law judge. Someone will explain to you and your doctor how to request a second review or a hearing when you receive a denial letter.
What kinds of outpatient services are available?
Each hospital offers its own kinds of outpatient services. These can include clinics, therapies and day programs. Your doctor can help refer you to the best place for needed services.