Known Issues and Updates

General Updates

Fiscal Agent Name Change: Effective October 1, 2020, references to the current fiscal agent will now be Gainwell Technologies. Visit the News and Media web page of the Gainwell Technologies website to review the Press Releases.

Finance

Validation of Provider Taxpayer Identification Numbers (TIN) Against Internal Revenue Service (IRS) Data
Effective April 24, 2019, provider Taxpayer Identification Numbers (TIN) are being validated against IRS data. If a provider's TIN does not match the IRS data, the provider will receive a letter notifying them that their contract has been put on hold until the TIN is verified. The letter will include what type of IRS documentation is required to verify the TIN and specific instructions on how to submit the required documentation.


Notifications of Expiring Checks on Remittance Advice (RA) Summary Page
Effective May 1, 2019, the Summary Page of the RA will be updated to include notifications when a provider has received a paper check which is now expiring or has expired.

Notifications on the status of any uncashed paper checks will be displayed on the RA under one of three categories:

  • Outstanding Checks (Checks within 90 days to six weeks of expiration) - A notification will continue to appear on all RAs generated until the check moves to the next status (Expiring) or is cashed or voided.
  • Expiring Checks (Checks within six weeks of expiration) - A notification will appear on all RAs generated until the check is expired, cashed or voided.
  • Expired Checks (Checks beyond the 180 day Void by expiration date printed on the check. They are no longer eligible to be cashed by the bank.) - A notification will appear once on the next RA generated for the provider.

Refer to the example of the RA Summary Page. For more information, refer to the Reading the Remittance Advice (RA) Dated on or after 1/9/2019 Provider Web Portal Quick Guide, located on the Quick Guides web page. Providers should contact the Provider Services Call Center at 1-844-235-2387 with any questions.

Effective 3/1/18: Checks for Refund Payment Must Be Made Out to 'Colorado Department of Health Care Policy and Financing'

When writing a check to refund payment, make the check out to "Colorado Department of Health Care Policy and Financing" and mail it to:

Gainwell Technologies
P.O. Box 30
Denver, CO 80201

However, we highly recommend submitting electronically as we will automatically set up an AR balance. To learn how to copy, adjust or void a claim in the Provider Web Portal, reference the Provider Web Portal Quick Guide - Copy, Adjust, or Void a Claim, available on the Quick Guides web page.

Effective 3/1/18, checks made out to other entities (such as ACS, Consultec, DXC, Hewlett Packard, HP, HPE, Xerox, etc.) will be returned. "Colorado Department of Health Care Policy and Financing" is the only pay-to name that will be accepted as of 3/1/18.

Eligibility
Updated Process for Member Date of Death (DOD) Verification
Effective 10/25/19, Colorado interChange will match the member DOD to the DOD in the Colorado Benefits Management System (CBMS), the eligibility system of record. This update will ensure Colorado interChange has valid and complete member information and prevent billing issues for providers.
Alternative Benefit Plan Member Must Have Medicaid State Plan (TXIX) Coverage to Be Eligible for Services

The Alternative Benefit Plan (ABP) is an extended plan which must be accompanied by Medicaid State Plan (TXIX) coverage. If the member does not have TXIX coverage, they are not eligible for services and claims will be denied for EOB 3261 - "The procedure code currently is not a benefit for date of service billed. Refer to the CPT or the HCPCS listing for valid procedure codes."

Providers should verify coverage under Benefit Details (example shown here) on the Provider Web Portal before rendering services. For detailed, step-by-step instructions on verifying member eligibility, refer to the Provider Web Portal Quick Guide - Verifying Member Eligibility (including Managed Care Assignment Details and Benefit Plan Information) and Co-Pay, available under the Quick Guides section on the Quick Guides web page.


Claim Denials for EOB 2580 - Services Must be Billed to HMO/PHP Listed on Eligibility Inquiry

Claims denied for Explanation of Benefits (EOB) 2580 - "The services must be billed to the HMO/PHP listed on the eligibility inquiry" may have caused confusion for providers billing for medical or mental services rendered to members with a Behavioral Health Organization (BHO) listed on the eligibility inquiry. In the previous MMIS, there was an EOB code for HMO and a separate EOB code for the BHO. The new Colorado interChange system combines these two EOB codes into one. Claims may have been denied for this EOB whether an HMO, Prepaid Health Plan (PHP), or BHO was listed on the eligibility inquiry.

To mitigate the confusion, the Department and DXC have updated the description for this EOB code to more clearly define the reason for the denial. The description for EOB 2580 now reads: "The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry."

If the member has a BHO/Regional Accountable Entity (RAE) listed on the eligibility inquiry, providers should refer to the 2017 Uniform Service Coding Standards Manual to verify that the services are covered under the BHO/RAE. If the services are listed as covered by the BHO/RAE, providers should bill to them.

Provider Web Portal
Colorado interChange Update - ClaimsXten™ Claims Editing Solution
Effective September 26, 2020, the Colorado interChange was updated with a claims editing solution in accordance with Senate Bill (SB) 18-266, which requires the Department to implement new initiatives intended to help control Health First Colorado's costs and ensure appropriate claims payment. Professional and Outpatient claims received in Colorado interChange will automatically process through ClaimsXten™ to apply additional editing based on State and Federal policies. This additional editing tool will help to identify inappropriate bill coding and reduce potential overpayments. Refer to the Provider Claim Types Processed Through ClaimsXten™ chart for a complete list of included and excluded provider/claim types. Visit the Ensuring Appropriate Claims Payment web page for more information.
 

Resolved 6/24/19: No Error Message in Provider Web Portal for Overlapping License Effective Dates
When updating a license, the License panel of the Provider Web Portal did not display an error message when there were overlapping license effective dates on Provider Maintenance requests and Revalidation applications. Users were prevented from progressing through the request or application and the "Effective Date" field was highlighted in red. The License panel now displays the error message, The Covered Dates overlap an existing record.

Providers are reminded that a copy of the current license must be submitted as an attachment with the request.

Issue resolved 6/24/19


Outdated Version of Microsoft Edge Browser May Cause Provider Web Portal Errors

Providers should not use older versions of the Microsoft Edge browser, such as version 42.17134, when accessing the Provider Web Portal.Providers should ensure that they have downloaded the most recent version of Microsoft Edge, or that they are using another supported web browser. To see a list of supported web browsers, refer to the Website Requirements page of the Provider Web Portal.

Provider Enrollment Portal Change to Prevent Future Enrollment Effective Date
Effective 1/2/19, providers can no longer enter a future enrollment effective date on a new enrollment application. If a provider enters a future date in the Requesting Enrollment Effective Date field on the Request Information Panel, they will receive the following error message, Requesting Enrollment Effective Date cannot be in the future. See the example below:

Request Information Panel - Provider Web Portal

This change applies to providers starting a new enrollment application and providers resuming an application that is still in process. A future enrollment effective date will continue to be allowed for revalidation, since the future date equates to the revalidation date.


Provider Enrollment Portal Change Regarding a Backdated Enrollment Effective Date

Providers can now request an enrollment effective date up to 365 days prior to the current date on their enrollment application from the Request Information Panel by entering the specified date in the Requesting Enrollment Effective Date field. Refer to the example in the Backdating a New Enrollment Application Provider Enrollment Portal Quick Guide, available on the Quick Guides web page.

This change will apply only to providers starting a new enrollment application and providers resuming an application that is still in process. For providers who are already enrolled and approved, an Enrollment Backdate Form, available under the Provider Enrollment and Update Forms drop-down section of the Provider Forms web page, must be completed and mailed to DXC.


Resolved 2/13/20: Provider Web Portal Error when Atypical Providers Add Taxonomy Using the Additional Taxonomies Section
The Provider Web Portal displayed an error when Atypical providers attempted to add a taxonomy using the Additional Taxonomies section of the Provider Maintenance Specialty and Contact panel. This error affected current providers that are updating an existing enrollment record, not for new enrollments. Only Atypical providers, such as Home and Community Based Services (HCBS) or Transportation providers, were affected.

Note: If an Atypical provider has an National Provider Identifier (NPI), they must add a taxonomy using the Additional Taxonomies section. If an Atypical provider does not have an NPI, a taxonomy cannot be entered in the Additional Taxonomies section.

Issue resolved 2/13/20


National Provider Identifiers (NPIs) and the Provider Web Portal

Once a provider adds the newly obtained National Provider Identifiers (NPIs) to the enrollment records by completing a Provider Maintenance request, there is no need to re-register the new NPI in the Provider Web Portal. The new NPI will automatically display at Web Portal login once it becomes effective.


Off-campus hospital locations should refer to the Provider Maintenance - Hospital Provider Adding an NPI Provider Web Portal Quick Guide and all other providers should refer to the Provider Maintenance - Adding an NPI Provider Web Portal Quick Guide located on the Quick Guides web page for detailed instructions on adding a new NPI to the enrollment records.


Provider Web Portal Password Change to Require 9 Characters

An upcoming change to the Provider Web Portal password requirements will require all Web Portal users to change their passwords from 8 characters to 9 characters. Once this change goes into effect, Web Portal users will be prompted to reset their password to 9 characters the next time it is about to expire.


Provider Web Portal Error Message When Submitting Claims

Some Provider Web Portal users have experienced an intermittent "Error" message asking them to "try again later" when trying to submit claims. DXC believes a combination of internal factors in the DXC system along with external factors with the user's network/internet connection is causing the problem. While DXC is still working to resolve this issue, the following steps have proven helpful to several users:

-Clear your browser's cache
- Run a connection speed test
- Log out and come back at a later time - even a few minutes may help
- Use the system during non-peak hours (peak hours are 7 a.m. to 4 p.m. Monday through Friday). Please note that the Provider Web Portal is down for regularly scheduled maintenance every Wednesday night beginning at 7 p.m. MT. Anticipated downtime is usually less than 2 hours, but could be up to 5 hours.
- Try using another browser (Internet Explorer is the recommended browser)

If this does not resolve the issue, please call the Provider Services Call Center (1-844-235-2387) and press the option for "web portal." Please let the agent know you have tried the suggestions above and provide them with your log-on ID, Provider ID, an explanation of what you were doing on the portal at the time of the error and contact information for follow-up.


Provider Web Portal Update to Add Remove Link to Service Details Section

Effective 7/31/19, the Provider Web Portal has been updated so providers can remove claim details when adjusting a previously paid claim. A Remove link has been added to the Submit Dental Claim, Submit Institutional Claim and Submit Professional Claim screens in the Service Details section under the Action column. Providers can use the link to remove the applicable claim detail lines before resubmitting the claim.

Refer to Step 3 in the Submitting an Institutional Claim and Submitting a Professional Claim Provider Web Portal Quick Guides located on the Quick Guides web page for more information.


Updated Processing Timeline for Third-Party Liability (TPL) Information Submitted Through the Provider Web Portal
Effective 5/22/19, a new weekly automated system process will reduce turnaround time on the processing of TPL information entered in the Provider Web Portal. Additional processing will still be required if a member has multiple active policies on file.

The Effective To date will be automatically updated to 12/31/2299. If the policy is no longer active, providers should update the TPL record with a valid termination date.

Refer to the Adding and Updating Third-Party Liability (TPL) Information - Provider Web Portal Quick Guide, available on the Quick Guides web page, for illustrated, step-by-step instructions on adding and updating TPL information via the portal.


Provider Web Portal Inactivity Setting Update
Effective 4/24/19, the Provider Web Portal will allow users 15 minutes of inactivity. If Web Portal is left idle for 15 minutes, the user will be logged out and must go to the login page and enter their credentials to access Web Portal again.


Provider Web Portal Invalid Login Attempt Change
Effective 3/11/19, the Provider Web Portal will allow users three login attempts. If the user fails to enter the correct log in and password after three attempts, the account will be locked for 15 minutes before login can be attempted again or credentials can be reset.


Clinical Laboratory Improvement Amendments (CLIA) Certification Effective and End Dates

Providers should not be concerned if the Effective Date displayed on the Provider Web Portal does not match the Effective Date they entered or the date of their most recent certification. DXC updated the Effective Date and End Date for all CLIA licenses in the Colorado interChange as of 8/10/18. The Effective and End Dates for all CLIA licenses are as follows:

Effective Date: 1/1/1900

End Date: 12/31/2299

When updating CLIA Certification information via the Provider Web Portal, providers should enter the Effective Date and End Dates as shown above.

Claims submitted with any other Effective and End Dates on the CLIA license will be denied if the dates of service (DOS) precede the Effective Date.

Currently, the Effective Date and End Date are required fields when providers are updating CLIA Certification information. DXC and the Department are working on updating the Provider Web Portal so the effective dates will be automatically populated.


Provider Web Portal Eligibility Page - Additional Required Verification Step (CAPTCHA)

Effective 11/30/17, the Eligibility page on the Provider Web Portal will require users to complete a CAPTCHA human verification step by identifying which images fit the given description. CAPTCHA (an acronym for "Completely Automated Public Turing test to tell Computers and Humans Apart") is a type of challenge-response test used in computing to determine whether or not the user is human. Requests from scripted code or robots will no longer be allowable. This change is intended to minimize issues and slowness affecting all portal users. Batch submitters must utilize the X12 270 for large eligibility requests.

For information on submitting batch 270 Eligibility, visit the EDI Support web page.

For additional questions on how to use the portal or to verify eligibility, please call the Provider Services Call Center at 1-844-235-2387.


Claim Submissions, Adjustments and Voids Limited to 50 or Less Detail Lines in the Provider Web Portal

The Provider Web Portal does not allow for claim submissions, adjustment or voids with over 50 detail lines. Claims with over 50 detail lines must be submitted, adjusted or voided via the Electronic Data Interchange (EDI) batch process, which allows for up to 999 detail lines per claim.

When viewing a claim with more than 50 detail lines in the Web Portal, the copy, void, adjust and reconsideration buttons may be disabled, and the portal user will receive the following error message - Not all service lines can be displayed due to the size of the claim. If these buttons are available, and the portal user attempts to copy or adjust a claim with more than 50 detail lines, the claim will be denied for EOB 1330 - The total claim charge is invalid. Re-calculate and correct the total claim charge.

DXC and the Department are working to implement a fix within the Web Portal to ensure these buttons are consistently disabled when viewing a batch claim with over 50 detail lines.


Void Button Will Only Appear in the Provider Web Portal if the Paid Claim Has Not Already Been Adjusted/Voided and Has 50 or Less Detail Lines

The void button will only appear in the Provider Web Portal if:

  1. The paid claim has not already been adjusted or voided. If you need assistance to determine the appropriate ICN, call the Provider Services Call Center at 1-844-235-2387.
  2. The claim has 50 or less detail lines. Claims with over 50 detail lines must be voided via the Electronic Data Interchange (EDI) batch process, which allows for up to 999 detail lines per voided claim.

Refer to the Provider Web Portal Quick Guide - Copy, Adjust, or Void a Claim, available on the Quick Guides web page, for more information.


Rendering Provider ID Does Not Return a Single Provider - Provider Web Portal

Symptoms: When entering claims on the Provider Web Portal, providers receive "Rendering Provider ID does not return a single Provider" error message.
Cause: Provider is not using the magnifying glass button when an NPI is tied to multiple locations. System does not know which location to use, and generates an error message.
Solution: If NPI is tied to multiple locations, providers must use the magnifying glass to select the correct location.

Suspended Claims

Suspended claims only show up once on the Remittance Advice (RA). The claim won't appear again on the RA until the claim either denies or pays. Once the claim is finalized, it will be reported on the RA and the 835. Suspended claims are not reported on the 835, only on the RA.

Common Reasons for Claim Denials and Suspends

Suspends

EOB1786 - The date of service date is out of timely filing. Refer to the new billing manual.

Explanation: The claim is outside of the initial timely filing period of 240 days. Claims with a timely filing attachment must be reviewed by DXC.

Estimated Time for Processing:20 business days


EOB 0101 - Possible duplicate: practitioner to practitioner.

Explanation: This may be a duplicate claim, but not all parameters for an exact duplicate are met, so the claim must be reviewed by DXC to determine if it is a duplicate.

Estimated Time for Processing: 30 days


EOB 4000 - "The client has other insurance. Bill the charges to the other insurance before billing Medicaid. Complete the other insurance payment information fields on the claim and retain a copy of the explanation of benefits."

Explanation: The client has other insurance. Medicaid [Health First Colorado (Colorado's Medicaid Program)] is always the payer of last resort. The claim must be sent to the primary carrier first. Due to a system defect claims must be reviewed to determine if the TPL information was entered on the claim.

Estimated Time for Processing: One week


EOB 6172 - "Multiple Surgery Review"

Explanation: The department and DXC are currently working to implement a more efficient process.

Estimated Time for Processing:30 days


EOB 2013 - "Claim Processed With Closest Elig Span-Deny" OR EOB 2690 - "Claim processed with closest eligibility span."

Explanation: The client is currently not eligible.

Estimated Time for Processing: This claim will be recycled after 15 calendar days. If after the 15 days the client is still not eligible for the DOS, the claim will deny.

 

EOB 0653 -"Claim requires manual pricing. Please attach invoice for medical services."

Explanation: This claim requires manual processing by DXC to price.

Estimated Time for Processing: 30 days

 

NOTE: If claims are over 60 days from the date of receipt, please notify the Provider Services Call Center at 844-235-2387 so they can be escalated for processing.


Denials

EOB 1473 - "Multiple Provider Locations for Billing Provider Specialty."

Explanation: In general, EOB 1473 is an indication that the system cannot determine which location to look at. If a National Provider Identifier (NPI) is associated with more than one (1) provider type or location address, additional steps are needed to ensure proper claims adjudication. A unique nine (9) digit zip code or taxonomy code is required to identify the correct billing provider ID.

Provider action: Confirm the address, NPI and taxonomy on the claim match the information reported on Provider Maintenance tab on the Provider Web Portal.


EOB 4100 - "Type of Bill Code Invalid."

Explanation: Home Health Claim with an invalid TOB (likely 33x).

Provider action: Refer to the new Home Health Billing Manual for claims submission.


EOB 1454 - "Procedure Code, Revenue Code, or Modifier is Invalid - Home Health"

Explanation: Home Health Claim without the Procedure Code, Revenue Code or Modifier Code. While these are not required fields on the Provider Web Portal, they are required for the claim to process correctly.

Provider action: Refer to the new Home Health Billing Manual for required fields. Don't forget to include all applicable procedure codes for PDN claims.

Example: Private Duty Nursing (PDN) claims will deny if submitted without the procedure code T1000, in addition to the revenue code for PDN.

The procedure code is not a required field in the Provider Web Portal, but page 11 of the Private Duty Nursing Billing Manuals does indicate this is required for the claim.


EOB 1786 - "The date of service is out of timely filing. Refer to the new billing manual."

Explanation: Claims must be submitted within timely filing limits. The Department has extended timely filing limits from 120 days from DOS to 240 days from DOS.

Provider action: Submit the claims and reference the ICN of the last submission within 60 days.


EOB 1381 -"No billing rule for procedure."

Explanation: The claim includes a procedure which is not a defined billing rule for the provider type. The rendering provider is not permitted to render the procedure to Health First Colorado members based on the provider type.

Provider action: Ensure the correct procedure code was submitted on the claim. Refer to billing manual to confirm allowable procedures for the provider type.

If the procedure is allowable for the provider type, contact DXC.


EOB 1030 - "The place of service code is invalid for procedure code. Correct the place of service."

Explanation: The procedure and place of service cannot be billed together. This could be because the procedure can't be performed at a specific POS (transplant in an office) or the combination is not allowed on the providers billing rule.


EOB 3261 - "The procedure code currently is not a benefit for date of service billed."

Explanation: This is not a covered procedure.

Provider action: Confirm the correct procedure code was submitted on the claim. Refer to billing manual for information on covered procedures.


EOB 2590 - "The client has Medicare. Charges must billed to Medicare before billing Medicaid."

Explanation: This member has other coverage with Medicare. Medicare would be the primary insurance and should be submitted.

Provider action: Rebill the claim after billing Medicare first.


EOB 1010 - "This is a duplicate item that was previously processed and paid"

Explanation: The denied claim was a duplicate of a claim that has already been processed and paid (or denied).

Provider action: Providers who believe this error is returned incorrectly should contact Provider Services (1-844-235-2387) with the interChange Control Number (ICN).


EOB 0678 - "Billing Provider Type and Specialty is not allowable for the Rendering Provider"

Explanation: The claim will deny if the Rendering provider type/specialty do not match or if the expected billing provider type/specialty do not match.

Provider action: Providers who believe this error is returned incorrectly should contact Provider Services (1-844-235-2387) with the interChange Control Number (ICN).

 
Claims Extensions
EOB 3110 - Claims will Not Deny for Individual Not Being Linked to the Group

Providers have questions about claims with EOB code 3110 for "the rendering provider is not a group member." While it may be unclear on the remittance advice, notations that affiliations are missing do not cause the claim to deny and are informational only. Currently, the Department is giving providers an extended grace period to make all necessary updates to their affiliations to avoid future claims denials. If EOB code 3110 appears on a claim, providers should check their affiliations and make sure they are up to date, and check other EOB codes to see why the claim denied. Updated affiliations are currently taking up to three weeks for final approval. Providers should not submit duplicate update requests.


Timely Filing Period Extended to 365 Days - Effective 6/1/18

In May 2017, the Department of Health Care Policy & Financing (the Department) temporarily extended the timely filing period from 120 to 240 calendar days. Effective 6/1/18, the timely filing period will be extended to 365 days. This is a permanent change, not a temporary extension.

Please note that this timely filing extension does not apply to pharmacy (point of sale) claims submitted through Magellan, however, Durable Medical Equipment (DME) claims are subject to the updated 365-day timely filing policy.

For all updated timely filing policy details, reference the General Provider Information manual, available on the Billing Manuals web page, and the Timely Filing Frequently Asked Questions (FAQs), located on the Provider FAQ Central web page.

Known Issues and Resolved Issues

Please note that this is not an all-inclusive list of known issues.

 

All Provider Types

Claim shows as Paid in Provider Web Portal but not on the Remittance Advice

Symptoms: A claim may show as "Paid" (with a Paid date of "0") in the Provider Web Portal, but does not show as "Paid" on the Remittance Advice (RA).
Cause: Claim is caught in a pre-payment cycle that checks for errors that may cause problems with the financial cycle. The claim is reviewed before being released but may take a few weeks to review.

Denials for Duplicate Services
DXC is working with the Department to closely review duplicate claims to ensure proper payment.

Claim Denials for EOB 4000 - Member Has Other Insurance
Secondary Claims with TPL information were incorrectly denying for EOB 4000 - "The member has other insurance. Bill the charges to the other insurance before billing Medicaid. Complete the other insurance payment information fields on the claim and retain a copy of the explanation of benefits."

As an interim solution, starting 6/5/17, claims will suspend for review rather than deny. During this time, providers may see the claim temporarily suspend for EOB 4000, but no action is required. Claims will be adjudicated appropriately by DXC. DXC is working on a permanent fix.

In order for claims prior to 6/5/17 to be processed correctly, providers are asked to resubmit any claims denying for 4000 that included TPL information.

Providers Unable to Access Update RTPs

Providers are unable to re-enter an update if it's been RTP'd for additional information.

Submit a new (correct) update request, then call the Provider Services Call Center (1-844-235-2387) to have them deny the original RTP'd update request.


Resolved 6/30/21: Professional Claims with Modifier 50 Denying for Explanation of Benefits (EOB) 7823 when Ambulatory Surgery Center (ASC) Claim Billed
Some professional claims for dates of service on or after 9/26/2020 billed with modifier 50 were denying for EOB 7823 – “The bilateral procedure or proc/mod combination billed is not allowed.” when the Ambulatory Surgery Center (ASC) claim has been billed for the same procedure code, modifier and date of service.
 
Affected claims were reprocessed 7/2/21.

Issue resolved  6/30/21

Resolved 2/17/21: Claims Suspending for HCPCS 2021 Quarterly Update for Explanation of Benefits (EOB) 0000 - "This Claim/Service Is Pending for Program Review"

Claims billed with HCPCS 2021 Quarterly Update procedure codes were suspending for EOB 0000 - "This claim/service is pending for program review." The Colorado interChange will be updated with the 2021 HCPCS Quarterly Update billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual release of deletions, changes and additions." The Colorado interChange has been updated with the 2021 HCPCS Quarterly Update billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual release of deletions, changes and additions.

For more information, refer to the Healthcare Common Procedures Coding System (HCPCS) Updates for 2021 Special Provider Bulletin.

Claims were released from suspense 2/19/21

Issue resolved 2/17/21

Resolved 2/6/21: New Medicare Part A and Part B 2021 Deductible Amounts
The Medicare annual deductibles amounts have increased for 2021 from $1,408 to $1,484 for Part A and $198.00 to $203.00 for Medicare Part B. Effective February 6, 2021, the Colorado interChange has been updated with these new deductible amounts for claims with dates of service on or after January 1, 2021.

Some claims denied for Explanation of Benefits (EOB) 3620 - The Medicare deductible on the claim is greater than the annual amount. The deductible amount must match the amount on the Medicare explanation of benefits. Correct the deductible amount.

Claims were reprocessed 2/11/21.

Issue resolved 2/6/21

Resolved 2/3/21: Professional Claims with LT Modifier Denying for Explanation of Benefits (EOB) 7813
Some professional claims billed with the LT modifier were denying for Explanation of Benefits (EOB) 7813 - A National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) sets when the units of service are billed in excess of established standards for services that a member receives on a single date of service.

Claims were reprocessed 2/25/21.

Issue resolved 2/3/21

Resolved 12/15/20: Professional Claims Denying for Explanation of Benefits (EOB) 7802 or 7817
Professional claims billed with the following procedure codes and modifiers were denying for EOB 7802 - "The non-payment modifier is not appropriate with the billed procedure code."

Modifier Procedure Codes
TG S8120, S8121, 98969
EP 90791, 90792, 90785, 90832, 90833, 90834, 90836, 90837, 90839, 90840, 90846, 90847, 90853, 90863, 96101, 96102, 96110
HD 59899
AB 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866

AND

Professional claims billed with the following procedure codes and modifiers were denying for EOB 7817 - "The payment modifier is not appropriate with the procedure code billed."

Modifier Procedure Codes
52 59899
AA, AD 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866

Claims were reprocessed 12/18/20.

Issue 12/15/20

Resolved 12/9/20: Professional Claims Denying for Unbundling Explanation of Benefits (EOB) 7804
Some professional claims were denying for EOB 7804 - Separately billed services must be bundled as they are considered components of the same procedure. Separate payment is not allowed.

  • Where the services are included in the unbundling rule, AND
  • Where the billing provider is the same but the rendering provider is different

Example: Certified nurse midwives may serve as assistant surgeon during a cesarean section. Both the certified nurse midwife claim and surgeon claim are allowable as long as the detailed rendering providers are different on each claim.

Claims were reprocessed 12/29/20.

Issue resolved 12/9/20

Resolved 10/28/20: Delegate Provider Web Portal Users Unable to Resume Revalidation Application

Provider Web Portal users with delegate access were previously unable to access a previously opened Application Tracking Number (ATN) in order to resume their revalidation application. Only users that were signed in to the Web Portal as the account administrator could access the previously opened ATN and resume the revalidation application.

Issue resolved 10/28/20

Resolved 7/2/20: Claims Suspending for HCPCS 2020 Quarterly Update Procedure Codes for Explanation of Benefits (EOB) 0000 - "This Claim/Service Is Pending for Program Review"
Claims billed with HCPCS 2020 Quarterly Update procedure codes were suspending for EOB 0000 - "This claim/service is pending for program review." The Colorado interChange has been updated with the 2020 HCPCS Quarterly Update billing codes based on the Centers for Medicare & Medicaid Services (CMS) release of deletions, changes and additions.

Claims were released by DXC on 7/2/20.

Issue resolved 7/2/20

Resolved 3/13/20: Upcoming Reprocessing of Third Party Liability (TPL) Recoupments

The reprocessing of multiple claims identified for recoupment by Health Management Systems (HMS), the Department's Third Party Liability (TPL) vendor, had been delayed within Colorado interChange. These claims identified the member as having commercial insurance or third party liability for the member which should be billed primary.

DXC has reprocessed affected claims and recouped funds.

Issue resolved 3/13/20

Resolved 1/17/20: Provider Web Portal Claims Submitted on 1/16-1/17/2020 Suspending for Member Information Review
Claims submitted through the Provider Web Portal on 1/16/2020 and 1/17/2020 were suspending for review of the member's information, such as date of birth.

Claims were released from suspense 1/17/20 by DXC. The updated status of claims can be found on the Remittance Advice (RA).

Issue Resolved 1/17/20

Resolved 1/15/20: Claims Suspending for HCPCS 2020 Procedure Codes for Explanation of Benefits (EOB) 0000 - "This Claim/Service Is Pending for Program Review"

Claims billed with a HCPCS 2020 procedure code were suspending for EOB 0000 - "This claim/service is pending for program review." The Colorado interChange was updated with the 2020 HCPCS billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual release of deletions, changes and additions.

Claims were released from suspense 1/17/20by DXC.

For more information, refer to the Healthcare Common Procedures Coding System (HCPCS) Updates for 2020 Special Provider Bulletin.

Issue resolved 1/15/20

Anesthesia

Anesthesia Claims for 01968 Denying for Explanation of Benefits (EOB) 7800
Claims billed with anesthesia procedure code 01968 are denying for EOB 7800 – “The procedure code billed on claim is missing the primary/base service procedure.” when the primary/base procedure code 01967 is performed on and billed with a different date of service.
When 01967 and 01968 are performed across two dates of service, providers are advised to bill both procedures with a date span that includes both dates of service.

Providers may adjust denied claims and change the date of service from a single date to a date span that includes both dates of service.

Case Manager

Resolved 12/16/20: Case Managers/Transition Services Claims Suspending for Explanation of Benefits (EOB) 5765 - Targeted Case Mgmt-Trans Svcs (TCM-TS) is Limited to 240 Units per Transition

Case managers/transition services claims were suspending for using procedure code T1017 for EOB 5765 - "Targeted Case Mgmt-Trans Svcs (TCM-TS) is limited to 240 units per transition."

Claims were reprocessed on 12/18/20.

Issue resolved 12/16/20

Resolved 3/7/20: Prior Authorization Revisions for Procedure Codes T2031 and T2033
Case managers were temporarily unable to revise PAR lines with codes T2031 (Alternative Care Facility)and T2033 (Supported Living Program). This may have allowed claims to pay higher than the approved daily rate that is listed on the PAR. This may have potentially caused the total approved dollars to be exhausted before the end of the certification period, and before all units are utilized.

No action is necessary for case managers or providers at this time.

Issue resolved 3/7/20

Colorado Choice Transitions (CCT)

How to Look Up a PAR on the Provider Web Portal

Providers can now view a member's Prior Authorization Request (PAR) status in the Provider Web Portal. In order to look up a PAR on Web Portal, users should choose the "Care Management" option from the home page and click on "View Authorization Services." Next, users should enter the member identification number and approved PAR number into Web Portal to search for the PAR status. Providers should still be receiving PAR letters and/or PAR numbers from the case managers. Providers may also call the Provider Services Call Center (1-844-235-2387) to obtain a PAR number. PARs that are visible in the Web Portal are finalized PARs in the interChange. PARs that are in process in the Bridge cannot be viewed through the Web Portal. For more information on viewing PARs on the Web Portal, refer to the Viewing Prior Authorizations in the Portal quick guide, available on the Quick Guides web page.

Durable Medical Equipment (DME)/Supply

Durable Medical Equipment (DME) Claim Denials for EOB 1064 and 1065

Claims for procedure codes E0951, E0952, E0961, E0971, E1161, E2211, E2213, E2214, E2361, E2359, E2365, E2363 and K0040 are incorrectly denying for EOB 1064 - The maximum number of units allowed for this procedure code is two units per state fiscal year.

Claims for procedure codes E0978 and E0960 are incorrectly denying for EOB 1065 - The maximum number of units allowed for this procedure code is one unit per state fiscal year (July - June).

The Department and DXC are working to resolve the issue. As a workaround until the issue is resolved, providers can submit PARs above the unit limits to get approval for the limit and resubmit affected claims.


Resolved 9/1/21: Durable Medical Equipment (DME) Backup Wheelchair Claims Billed with TW Modifier Denying for Explanation of Benefits (EOB) 7814

Some Durable Medical Equipment (DME) claims for the wheelchair procedure codes listed below with dates of service on or after 9/26/20 billed with the TW modifier (back-up equipment) were denying for EOB 7814 – “This service is not payable for the same date of service as another service included on the current or history claim per National Correct Coding Initiative.”

E1050 E1060 E1070 E1083-E1090
E1092 E1093 E1100 E1110
E1130 E1140 E1150 E1160
E1170-E1172 E1180 E1190 E1195
E1200 E1221-E1224 E1230 E1240
E1250 E1260 E1270 E1280
E1285 E1290 E1295 K0001-K0007
K0010-K0012 K0014 K0800-K0802 K0806-K0808
K0812-K0816 K0820-K0831 K0856 K0861
K0899      


Affected claims will be reprocessed. 

Issue resolved 9/1/21.

Resolved 7/7/21: Supply Claims for E2359 Billed with Modifier RB Denying for Explanation of Benefits (EOB) 4211

Some supply claims for procedure code E2359 billed with the RB Modifier for dates of service on or after 10/01/20 were denying for EOB 4211 – “Modifier is invalid for procedure code. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.”
 
Affected claims were reprocessed 7/7/21.
 
Issue resolved 7/7/21
 

Resolved 7/7/21: Supply Claims for Procedure Code A4421 Denying for Explanation of Benefits (EOB) 7827
Some supply claims for procedure code A4421 for dates of service on or after 9/26/20 were denying for EOB 7827 – “Unlisted procedure code should not be used when a more descriptive procedure code representing the service provided is available.”
 
Affected claims were reprocessed 7/9/21.
 
Issue resolved 7/7/21. 

Resolved 5/21/21: Mid-Month Appendix X Update Not Completed Due to Transmission Issue

The Appendix X - HCPCS and NDC Crosswalk for Billing Physicians-Administered Drugs update scheduled for May 15, 2021, had not been completed due to a transmission issue. The updated version has been posted to the Billing Manuals web page.
 
Issue resolved 5/21/21

Resolved 5/4/21: Supply Claims for E2361 Billed with KR, RR or RB Modifiers Denying for Explanation of Benefits (EOB) 1381 or 4211
Some supply claims for procedure code E2361 with dates of service on or after 10/1/20 billed with the KR, RR or RB modifiers were denying for:

  • EOB 1381  – “No billing rule for procedure." or
  • EOB 4211 – “Modifier is invalid for procedure code. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.”

Claims were reprocessed 5/10/21.

Issue resolved 5/4/21

Resolved 4/21/21: Supply Claims for B4149 Billed with Modifier BO Denying for Explanation of Benefits (EOB) 7802
Some supply claims for procedure code B4149 billed with the BO Modifier were denying for EOB 7802 – “The non-payment modifier is not appropriate with the billed procedure code.”
 
Affected claims were reprocessed 4/26/21
 
Issue resolved 4/21/21

 

Resolved 2/25/21: Durable Medical Equipment (DME) Supply Claims Billed with RB Modifier Denying for Explanation of Benefits (EOB) 4211
Some Durable Medical Equipment (DME) supply claims for the following procedure codes with dates of service from 12/1/2020 through 2/24/2021 billed with the RB modifier were denying for EOB 4211 - Modifier is invalid for procedure code. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.

  • E2211 - E2222
  • E2224 - E2228
  • E2366, E2367
  • E2371, E2372
  • E2381 - E2392
  • E2394 - E2397
  • K0069 - K0072
  • K0077
  • K0733

Claims were reprocessed 3/3/21.

Issue resolved 2/25/21

Resolved 2/3/21: Durable Medical Equipment (DME) Supply Claims Billed with RR Modifier Denying for Explanation of Benefits (EOB) 7802

Some Durable Medical Equipment (DME) supply claims billed with the RR modifier were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code.

Claims were reprocessed 2/8/21.

Issue resolved 2/3/21

Resolved 1/13/21: Durable Medical Equipment (DME) Supply Claims Billed with TW Modifier Denying for Explanation of Benefits (EOB) 7802

Some Durable Medical Equipment (DME) supply claims billed with the TW modifier were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code.

Claims were reprocessed 1/19/21.

Issue resolved 1/13/21

Resolved 1/13/21: Durable Medical Equipment (DME) Supply Claims Billed with RB or RA Modifiers Denying for Explanation of Benefits (EOB) 7802
Some Durable Medical Equipment (DME) supply claims billed with the modifiers RB or RA were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code.

Claims were reprocessed 1/19/21.

Issue resolved 1/13/21

Resolved 1/13/21: Durable Medical Equipment (DME) Supply Claims Billed with NU Modifier Denying for Explanation of Benefits (EOB) 7802

Some Durable Medical Equipment (DME) supply claims billed with the NU modifier were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code.

Claims were reprocessed 1/19/21.

Issue resolved 1/13/21

Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Resolved 9/30/20: Geographic Rates Updated for Durable Medical Equipment (DME) Codes Subject to Medicare Upper Payment Limit (UPL)

Effective for claims with dates of service on or after 1/1/20, geographic rates for DME codes subject to the Medicare Upper Payment Limit (UPL) were implemented in the Colorado interChange on 9/30/20.

The Durable Medical Equipment fee schedule for 2020 has been posted under the Durable Medical Equipment, Upper Payment Limit drop-down section located on the Provider Rates & Fee Schedule web page.

Claims with dates of service from 1/1/20 - 5/31/20 were reprocessed on 10/30/20. Claims with dates of service from 6/1/20 - 9/30/20 were reprocessed on 11/6/20 and 12/15/20.

Issue resolved 9/30/20

Resolved 3/16/20: Durable Medical Equipment (DME) Claim Denials for EOB 5110

Claims billed for procedure code A4225 were incorrectly denying for EOB 5110 - The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed. This procedure code does not require a prior authorization.

Providers should resubmit affected claims.

Issue resolved 3/16/20

Federally Qualified Health Center (FQHC)

Resolved 7/15/21: Telehealth Outpatient Crossover Claims for Procedure Code G2025 Denying for Explanation of Benefits (EOB) 5807

Some outpatient crossover, short-term behavioral health claims for procedure code G2025 for dates of service on or after 1/27/20 were denying for EOB 5807 – “The short-term behavioral health service limit has been met, please submit the service to the member’s RAE.”

Affected claims were reprocessed 8/12/21.

Issue resolved 7/15/21

Partially Resolved 5/26/21: Claims Denying for Explanation of Benefits (EOB) 4000 - "The Member Has Other Insurance" 
Some provider claims have been incorrectly denying for EOB 4000 - "The member has other insurance. Bill the charges to the other insurance before billing Medicaid. Complete the other insurance payment information fields on the claim and retain a copy of the explanation of benefits," when the member had limited Third Party Liability coverage unrelated to the services on the claim. For example, inpatient or outpatient claims may have denied for a prescription-only policy. An interim solution will be ongoing until a permanent solution is in place.
 
Impacted claims will need to be resubmitted by providers.
 
Issue partially resolved 5/26/21

Resolved 5/21/21: Mid-Month Appendix X Update Not Completed Due to Transmission Issue

The Appendix X - HCPCS and NDC Crosswalk for Billing Physicians-Administered Drugs update scheduled for May 15, 2021, had not been completed due to a transmission issue. The updated version has been posted to the Billing Manuals web page.
 
Issue resolved 5/21/21

Resolved 3/2/21: Evaluation & Management (E&M) Services Claims Billed with 24 Modifier Denying for Explanation of Benefits (EOB) 1460

Some professional, Evaluation & Management (E&M) services claims billed with modifier 24 (indicating an unrelated E&M service provided by same physician during a postoperative period) were denying when billed with other E&M services for EOB 1460 - "There is no additional benefit for this service. Payment for this procedure was included in the payment for the surgery."

Providers may resubmit affected claims.

Issue resolved 3/2/21

Resolved 12/12/20: Behavioral Health Claims Billed by Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs) or Indian Health Services (IHS) - FQHC Denying for Explanation of Benefits (EOB) 2029

Some outpatient behavioral health claims billed by FQHC, RHC or IHS-FQHC providers were denying for EOB 2029 - The Services Must Be Billed to The Members RAE.

Claims were reprocessed 12/21/20.

Issue resolved 12/12/20

Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Resolved 4/13/20: Federally Qualified Health Center (FQHC) Claims Using Procedure Code 90791 Were Denying for Explanation of Benefits (EOB) 2028
FQHC Claims using procedure code 90791 were denying for EOB 2028 - "Behavioral health revenue 900 requires behavioral health procedure code"

Claims were reprocessed on 4/17/20.

Issue resolved 4/13/20

Home & Community Based Services (HCBS)

How to Look Up a PAR on the Provider Web Portal

Providers can now view a member's Prior Authorization Request (PAR) status in the Provider Web Portal. In order to look up a PAR on Web Portal, users should choose the "Care Management" option from the home page and click on "View Authorization Services." Next, users should enter the member identification number and approved PAR number into Web Portal to search for the PAR status. Providers should still be receiving PAR letters and/or PAR numbers from the case managers. Providers may also call the Provider Services Call Center (1-844-235-2387) to obtain a PAR number. PARs that are visible in the Web Portal are finalized PARs in the interChange. PARs that are in process in the Bridge cannot be viewed through the Web Portal. For more information on viewing PARs on the Web Portal, refer to the Viewing Prior Authorizations in the Portal quick guide, available on the Quick Guides web page.

Claim Denials for PAR When an Approved PAR is On File - EOB 0192 or 5110

To understand why your claims are denying for a Prior Authorization Request (PAR) despite having an approved PAR on file, it is important to know how the Bridge system works with the Colorado interChange. The Bridge is a system used by case managers to submit Prior Authorization Requests (PARs) to the Colorado interChange. Only after a PAR is approved in the Bridge is it transmitted to the Colorado interChange. It will take at least one day after the PAR is approved in the Bridge to appear in the Colorado interChange and be available for claims processing. Once the PAR is on file in the Colorado interChange, there is no further interaction between the Bridge and the claim.

When a claim requires a PAR, the Colorado interChange will use a series of criteria to find the matching authorization. Providers do not need to indicate the PAR number on the claim. The system will automatically populate the PAR number on the claim if it finds a match. If a claim denies for a PAR despite an approved PAR being on file, it means the PAR on file does not match all the criteria that is on the claim.

If your claims have denied for either of the following EOBs despite having an approved PAR on file:

  • E0B 0192 - "Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim."
  • EOB 5110 - "The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed.

One of the following issues may apply:

  1. The prior authorization was never fully approved in the Bridge. Check the Provider Web Portal for prior authorization. If there is no approved PAR for the dates of service on the claim, contact the case manager to confirm status in the Bridge.
  2. The benefit plan for the member's eligibility has terminated. Please verify member eligibility for the waiver benefit plan prior to submitting claims. If the member does not show an active waiver benefit plan, contact the case manager. A PAR is not a guarantee of member eligibility as the PAR is valid for a span of time (typically one year) and eligibility could change at some point during that span.
  3. The PAR units are exhausted. If all units have been billed, the claim will deny. If you believe you need additional units, contact your case manager.
  4. The modifiers do not match. Check the billing manuals to make sure you are using the correct modifiers. The Web Portal has been updated to display up to four modifiers on the detail line within the PA record.

Home and Community Based Services (HCBS) Post Eligibility Treatment of Income (PETI) Gross Income Modification

Currently, the gross income information in interChange and the Bridge does not always match the information contained in the Colorado Benefits Management System (CBMS). The Department and DXC are working to display all income information from CBMS on interChange with manual edit capability and to calculate the PETI Rate based on the actual income as reported by CBMS.

An estimated resolution date has yet to be determined.


Resolved 8/12/21: Colorado interChange Updated with Rate Increase for Procedure Code H2021 with U8 Modifier

Effective 7/1/21, the reimbursement rate was increased for procedure code H2021 billed with the U8 modifier, and the Colorado interChange was updated accordingly on 8/12/21. 

Affected HCBS claims were reprocessed on 8/19/21. 

Issue resolved 8/12/21 

Resolved 8/10/21: Home and Community-Based Services (HCBS) Procedure Codes and the Denver Minimum Wage

Some HCBS claims for procedure code H0038, S5130, T1019 and T2016 with specific modifier combinations dates of service on or after 7/1/21 were not reimbursed at the Denver Minimum Wage rate effective on those dates of service.
 
Affected claims were reprocessed on 8/10/21.
 
Issue resolved 8/10/21

Resolved 3/27/21: Home & Community Based Services (HCBS) Waiver Claims for T2031 with UA & TU Modifiers Denying for EOB 1010 and 0101

Some HCBS waiver claims for procedure code T2031 billed with the UA and TU modifiers (enhanced rate for COVID-19) with dates of service on or after 1/1/21 were denying for EOB 1010 – “This is a duplicate item that was previously processed and paid” or EOB 0101 – “This is a duplicate service.” The Colorado interChange was allowing one line item to process for payment but denying the other line item as a duplicate.

Providers are encouraged not to reprocess or resubmit claims. Affected claims with dates of service from 1/1/21 – 3/31/21 will be reprocessed by the fiscal agent.

Providers should refer to Operational Memo Number OM 21-009 for more information on how to bill the impacted services, including the total percentage increase for each service.

Issue resolved 3/27/21

Resolved 3/24/21: Home & Community Based Services (HCBS) Waiver Claims for A0120, A0130, H2023, S5100, S5102, S5105, T2003, T2019 & T2021 Not Paying at COVID-19 Enhanced Rate

Some HCBS waiver claims for the following procedure codes billed with appropriate modifier combinations with dates of service on or after 7/18/20 were not being processed for increased reimbursement at the COVID-19 enhanced rate: A0120, A0130, H2023, S5100, S5102, S5105, T2003, T2019 and T2021.

Providers may adjust affected claims to receive the increased reimbursement.

Providers should refer to Operational Memo OM 21-034 for more information on how to bill the impacted services, including the total percentage increase for each service.

Issue resolved 3/24/21

Resolved 3/1/21: Claims for Procedure Code H0038 with the U1 or UC Modifier and the Denver Minimum Wage Reimbursement
 
Claims for procedure code H0038 billed with only the U1 or UC modifier with dates of service on or after January 1, 2021, were not included in the interim solution for the Denver Minimum Wage increased reimbursement.
 
Claims were reprocessed 3/2/21.
 
Refer to the Home & Community-Based Services (HCBS) Providers email sent December 24, 2020, for more information regarding the wage increase.
 
Issue resolved 3/1/21

Resolved 3/1/21: Home & Community Based Services (HCBS) Waiver Claims for T2031 with TU Modifier Denying for EOB 1010 and 0101

Some HCBS waiver claims for procedure code T2031 billed with the TU modifier (enhanced rate for COVID-19) with dates of service on or after 1/1/21 were denying for EOB 1010 – “This is a duplicate item that was previously processed and paid” or EOB 0101 – “This is a duplicate service.” The Colorado interChange was allowing one line item to process for payment but denying the other line item as a duplicate.

Affected claims with dates of service from 1/1/21 – 3/1/21 were reprocessed 3/2/21.

Providers should refer to Operational Memo Number OM 21-009 for more information on how to bill the impacted services, including the total percentage increase for each service.

Issue resolved 3/1/21

Resolved 11/14/20: Home & Community-Based Services Children's Habilitation Residential Program (HCBS CHRP) Waiver Claims Denying for Explanation of Benefits (EOB) 4758

Some HCBS CHRP claims were denying for EOB 4758 - "Billing Provider Type/Specialty Restriction on Procedure Coverage Rule."

Affected claims were reprocessed on 11/20/20

Issue resolved 11/14/20

Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Resolved 8/3/20: Alternative Care Facility (ACF) Claims Suspending for Explanation of Benefits (EOB) 3051 or EOB 3090 - Provider Under Review - Suspend All Claims
Due to rate changes implemented 7/1/20, some ACF providers had all claims with dates of service on or after 7/1/20 temporarily put in a suspended status through the month of July 2020. Claims suspended for EOB 3051 - "Rendering provider under review - suspend all claims" or EOB 3090 - "Billing provider under review - suspend all claims."

This allowed for Post-Eligibility Treatment of Income (PETI) Prior Authorization Request (PAR) rate adjustments on all affected PARs for procedure code T2031, Alternative Care Facility (ACF).

Providers were encouraged to continue to submit claims during this time, however, procedure code T2031 should have been billed on a separate claim from all other procedure codes.

Some claims that included the T2031 procedure code were released from suspense on 8/7/20, and those with dates of service on 7/1/20 were released from suspense on 8/14/20. Targeted rate updates have been completed on the PARs. Claims that did not include the T2031 procedure code may have been reviewed and released before 7/31/20, if possible.

Affected providers received an email communication to notify them of this issue.

Issue resolved 8/3/20

Resolved 5/21/20: Eligibility Impacting Foster Care Members Waiver Benefits

If there is an eligibility break for members with Foster Care Eligibility spans, providers should contact their case managers as case managers can now manage Home & Community Based Services (HCBS) waiver eligibility for these members.

Issue resolved 5/21/20

Resolved 5/27/20: Home & Community Based Services (HCBS) Alternative Care Facility (ACF) for Elderly, Blind or Disabled (EBD) and Community Mental Health Services (CMHS) Waiver Claims for T2031 Denying for EOB 1010 and 0101
Some HCBS ACF for EBD and CMHS waiver claims for procedure code T2031 billed with the U1 or UA modifiers with or without the TU modifier (enhanced rate for COVID-19) were denying for EOB 1010 - This is a duplicate item that was previously processed and paid or EOB 0101 - This is a duplicate service. The Colorado interChange was allowing one line item to process for payment but was denying the other line item as a duplicate.

Claims were reprocessed by DXC 5/28/20.

Issue resolved 5/27/20

Resolved 5/27/20: Home & Community Based Services (HCBS) Developmental Disabilities (DD) Waiver Level 7 Claims for T2016 Denying for EOB 2384
HCBS DD waiver claims for procedure code T2016 billed with the following modifier combinations with or without the TU modifier (enhanced rate for COVID-19) were denying for EOB 2384 - Residential Habilitation Services and Support DIDD benefit limited to 1 unit per day. The Colorado interChange was allowing one line item to process for payment but was denying the other line item as benefit limited to one per day.

  • U3, SC
  • U3, SC and TT
  • U3, SC and HQ

Claims were reprocessed by DXC 5/28/20.

Issue resolved 5/27/20

Resolved 5/9/20: Home & Community Based Services (HCBS) Brain Injury (BI) Waiver Claims for T2033 Denying for EOB 1553
Some HCBS BI waiver claims for procedure code T2033 billed with modifiers U6, HB, HE and HK were denying for EOB 1553 - The procedure code and modifier combination is not covered for the member's benefit plan.

Claims were reprocessed by DXC 5/13/20.
 

Issue resolved 5/9/20

Resolved 4/13/20: Procedure Code T1019 Was Denying for Explanation of Benefits (EOB) 2029

Procedure code T1019 was denying for EOB 2029 - "Services must be billed to members RAE"

Claims were reprocessed on 4/17/20.

Issue resolved 4/13/20

 

Resolved 3/7/20: Prior Authorization Revisions for Procedure Codes T2031 and T2033
Case managers were temporarily unable to revise PAR lines with codes T2031 (Alternative Care Facility)and T2033 (Supported Living Program). This may have allowed claims to pay higher than the approved daily rate that is listed on the PAR. This may have potentially caused the total approved dollars to be exhausted before the end of the certification period, and before all units are utilized.

No action is necessary for case managers or providers at this time.

Issue resolved 3/7/20

Home Health
Resolved 5/6/21: Overpayment of Acute Home Health, Long-Term Home Health and Private Duty Nursing (PDN) Claims
Some Acute Home Health, Long-Term Home Health and Private Duty Nursing (PDN) claims with dates of service on or after 7/1/20 were overpaid due to a rate decrease in the maximum daily allowed amount for these claim types. Refer to the Home Health and PDN Rate Schedules available on the Provider Rates & Fee Schedule web page for more information on current rates and revenue codes.
 
Claims were reprocessed and overpaid monies recouped on 5/19/21. This will appear on remittance advices beginning Monday, 5/24/21.
 
Issue resolved 5/6/21
 
Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Resolved 10/8/20: Claims for Pediatric Home Health Services Submitted with Revenue Codes 421, 431 or 441 Denying for Prior Authorization (PA)
Some pediatric home health UB-04 claims for members aged 18 to 20 submitted with revenue codes 421, 431 or 441 were incorrectly denying for EOB 0192 - Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.

Claims with dates of service on or after 1/1/20 were reprocessed on 10/8/20.

Issue resolved 10/8/20

Hospital - General

Partially Resolved 5/26/21: Claims Denying for Explanation of Benefits (EOB) 4000 - "The Member Has Other Insurance" 
Some provider claims have been incorrectly denying for EOB 4000 - "The member has other insurance. Bill the charges to the other insurance before billing Medicaid. Complete the other insurance payment information fields on the claim and retain a copy of the explanation of benefits," when the member had limited Third Party Liability coverage unrelated to the services on the claim. For example, inpatient or outpatient claims may have denied for a prescription-only policy. An interim solution will be ongoing until a permanent solution is in place.
 
Impacted claims will need to be resubmitted by providers.
 
Issue partially resolved 5/26/21

Resolved 5/21/21: Mid-Month Appendix X Update Not Completed Due to Transmission Issue

The Appendix X - HCPCS and NDC Crosswalk for Billing Physicians-Administered Drugs update scheduled for May 15, 2021, had not been completed due to a transmission issue. The updated version has been posted to the Billing Manuals web page.
 
Issue resolved 5/21/21

Partially Resolved 5/14/21: Hospital Claims with Split Eligibility Interim Solution

Some hospital provider claims where the member is not actively enrolled in an MCO on the from date of service (FDOS) but becomes MCO eligible during the inpatient stay are denying for one of the following:

  • EOB 2029 - The Services Must Be Billed to The Members RAE.
  • EOB 2030 - The Services Must Be Billed to Denver Health Medicaid Choice Plan.
  • EOB 2031 - The Services Must Be Billed to Rocky Mountain Health Plan Prime.
  • EOB 2580 - The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry.

As an ongoing, interim solution, affected claims will be reprocessed once a month until a permanent solution is in place.

Issue partially resolved 5/14/21

This issue has been updated since original publication. 

Resolved 4/15/21: Hospital Emergency Department Claims Denying for Explanation of Benefits (EOB) 2029

Some hospital emergency department claims billed with a non-Substance Use Disorder primary diagnosis and revenue code 906 were previously denying for EOB 2029 – “The services must be billed to the members RAE.” These claims will now process for payment through Fee for Service.

For more information on billing SUD Benefits, refer to the Ensuring a Full Continuum of SUD Benefits web page.

Affected claims were reprocessed on 6/18/21.
 
The issue was previously published as resolved on 4/1/21.

National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

  • First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
  • If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
  • Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Resolved 7/1/20: Claim Denials for Newborn Services

Claims were denying when a male baby is receiving gender-specific services such as circumcision, and the claim was submitted with the mother's Health First Colorado Provider ID. This was due to the mother's gender not matching the baby's. This was affecting claims where the gender-specific or age-specific service is identified by either procedure or diagnosis codes.

This could have caused claims to deny for any of the following EOBs:
Diagnosis/Gender related errors - 0801, 1100, 1105, 1106, 1107, 1108, 1109, 1120, 3241, 3242, 3243, 3244, 4192, 7310, 7316, 7322, 7328, 7334, 7340, 7346, 7352, 7358, 7364, 7370, 7376, 7382, 7388, 7394, 7400.
Procedure/Gender related errors - 3290, 1281

If the mother and baby are together in the hospital, providers should continue to submit claims under the mother's Health First Colorado Provider ID for dates of service prior to 7/1/20, once either member is discharged the baby's Provider ID should be used. Please note that at this time, the UK modifier cannot be used to identify that the claim is for the baby and not the mother.

Refer to the July 2020 Provider Bulletin (B2000450) for issue resolution details. Claims will be reprocessed by DXC.

Resolved 4/29/20: COVID-19 Update to 3M Enhanced Ambulatory Patient Grouping (EAPG) Grouper

The 3M software which utilizes the EAPG methodology has been updated to accommodate the new COVID-19 Current Procedural Terminology (CPT) code, Healthcare Common Procedure Coding System (HCPCS) codes, and ICD-10 diagnosis code. The Colorado interChange has been updated accordingly as listed below:
  • March 30 - Updated to include COVID-19 CPT code 87635 and HCPCS codes U0001 and U0002.
  • April 29 - Updated to include COVID-19 diagnosis code U07.1.
For more information on EAPG, refer to the IP and OP Hospital Billing Manual under the UB-04 drop-down and Appendix G under the Appendices drop-down on the Billing Manuals web page.

Issue resolved 4/29/20

Resolved 4/15/20: New HCPCS Codes for Specimen Collection for 2019 Novel Coronavirus (COVID-19)
New HCPCS codes G2023 and G2024 (used to identify and reimburse specimen collection for COVID-19 testing) have been released for dates of service on or after March 1, 2020, for an independent laboratory provider type only.
The Colorado interChange has been updated to receive and process claims for these codes.

Issue resolved 4/15/20

Resolved 3/25/20: Colorado interChange Update to Receive New ICD-10 Code for COVID-19

The Colorado interChange has been updated to receive and process claims billed with the new ICD-10 code for the diagnosis of COVID-19 U07.1 for dates of service on or after April 1, 2020.

Issue resolved 3/25/20

Resolved 3/25/20: Colorado interChange Update to Receive New CPT Code for Laboratory Testing for COVID-19
The Colorado interChange has been updated to receive and process claims billed with new CPT code 87635 for the laboratory testing of the novel coronavirus (COVID-19) for dates of service on or after March 13, 2020.

Issue resolved 3/25/20

Resolved 4/28/20: Inpatient Long Term Acute Care (LTACs) and Maternity Claim Denials for Explanation of Benefits (EOB) 3053 - Prior Authorization (PA) Is Required for Inpatient Services
 
Inpatient LTAC and maternity claims submitted on or after 3/31/20 which do not require a Prior Authorization Request were denying for EOB 3053 - Prior Authorization (PA) is required for inpatient services.
 
Claims were reprocessed by DXC on 04/29/20.
 
Issue resolved 4/28/20

Resolved 3/20/20: New Healthcare Common Procedure Coding System (HCPCS) Codes for 2019 Novel Coronavirus (COVID-19) Laboratory Tests

The Colorado interChange has been updated to receive and process claims billed with new HCPCS codes U0001 and U0002 for dates of service on or after February 4, 2020. Providers who test members for the 2019 Novel Coronavirus (COVID-19) using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill using code U0001. Providers may use code U0002 to bill for non-CDC laboratory tests for COVID-19. Billing with these specific codes will allow for better tracking of the public health response for COVID-19.

Billing with these specific codes will allow for better tracking of the public health response for COVID-19. Rates for U0001 and U0002 can be found on the Provider Rates & Fee Schedule web page under the Health First Colorado Fee Schedule heading.

Issue resolved 3/20/20

Resolved 2/26/20: Long Term Acute Care (LTAC), Rehabilitation (Rehab) and Spine/Brain Injury Treatment Specialty Hospital Hospitals Changed to Per Diem Reimbursement

Effective 7/1/19, Long Term Acute Care (LTAC) Hospitals and Rehabilitation (Rehab) hospitals changed from All Patient Refined - Diagnosis Related Groups (APR-DRG) reimbursement to per diem reimbursement. Colorado interChange was updated to reflect the change on 2/26/20, and claims submitted after 2/26/20 will process accordingly.

Instructions to re-bill claims that spanned the implementation date of 7/1/19, were uploaded to the Inpatient Hospital Per Diem web page and the Inpatient/Outpatient (IP/OP)Billing Manual on 4/24/20. Please re-bill qualifying claims according to directions provided.

Issue resolved 2/26/20

Hospital - Mental

Resolved 4/15/21: Hospital Emergency Department Claims Denying for Explanation of Benefits (EOB) 2029

Some hospital emergency department claims billed with a non-Substance Use Disorder primary diagnosis and revenue code 906 were previously denying for EOB 2029 – “The services must be billed to the members RAE.” These claims will now process for payment through Fee for Service.

For more information on billing SUD Benefits, refer to the Ensuring a Full Continuum of SUD Benefits web page.

Affected claims were reprocessed on 6/18/21.
 
The issue was previously published as resolved on 4/1/21.

Resolved 2/12/20: Provider Web Portal Eligibility Display and Short-Term Behavioral Health Service Limits

The eligibility responses on the Provider Web Portal were incorrectly calculating a fiscal year (July 1 to June 30) as a two-year span rather than a one-year span when calculating and displaying some short-term behavioral health visit benefit claims. This caused the Used units under the Limit Details panel to incorrectly show greater than the Limit.

Claims were not denying due to this eligibility response issue. If providers receive EOB 5807 - "The short-term behavioral health service limit has been met, please submit the service to the Member's RAE." denials on the procedure codes below, those claims should be billed to the member's Regional Accountable Entity (RAE) and not to DXC:

  • 90791
  • 90832
  • 90834
  • 90837
  • 90846
  • 90847

Providers are reminded to reference the Short-term Behavioral Health Services in the Primary Care Setting Fact Sheet regarding policy for the short-term behavioral health benefit.

Issue resolved 2/12/20

Independent Laboratory

Resolved 10/21/20: COVID-19 Laboratory Procedure Codes U0002 and 87635 Included as Clinical Laboratory Improvement Amendments (CLIA) Waived Tests

Effective 4/1/20, procedure codes U0002 and 87365 have been updated as Clinical Laboratory Improvement Amendments (CLIA) waived tests. Laboratory providers with a valid CLIA Certificate of Waiver (COW) may bill codes U0002 and 87635 with the QW modifier when billed with diagnosis code U07.0.

Affected claims with dates of service on or after 3/20/20 were reprocessed on 10/27/20.

Issue resolved 10/21/20

Resolved 6/1/20: COVID-19 Laboratory Procedures Codes U0003 and U0004 Paid Incorrectly

New COVID-19 procedure codes U0003 and U0004 for laboratory claims with dates of service 3/18/20 - 6/1/20 were paid without being reviewed for Clinical Laboratory Improvement Amendments (CLIA) certification requirements.

Claims were reprocessed by DXC on 6/12/20. Reprocessed claims which did not meet CLIA certification requirements were denied and funds were recouped. Recoupments appeared on Remittance Advices beginning 6/15/20.

Issue resolved 6/1/20

Resolved 4/15/20: New HCPCS Codes for Specimen Collection for 2019 Novel Coronavirus (COVID-19)
New HCPCS codes G2023 and G2024 (used to identify and reimburse specimen collection for COVID-19 testing) have been released for dates of service on or after March 1, 2020.
The Colorado interChange has been updated to receive and process claims for these codes.

Issue resolved 4/15/20

Resolved 3/25/20: Colorado interChange Update to Receive New ICD-10 Code for COVID-19

The Colorado interChange has been updated to receive and process claims billed with the new ICD-10 code for the diagnosis of COVID-19 U07.1 for dates of service on or after April 1, 2020.

Issue resolved 3/25/20

Resolved 3/25/20: Colorado interChange Update to Receive New CPT Code for Laboratory Testing for COVID-19
The Colorado interChange has been updated to receive and process claims billed with new CPT code 87635 for the laboratory testing of the novel coronavirus (COVID-19) for dates of service on or after March 13, 2020.

Issue resolved 3/25/20

Resolved 3/20/20: New Healthcare Common Procedure Coding System (HCPCS) Codes for 2019 Novel Coronavirus (COVID-19) Laboratory Tests

The Colorado interChange has been updated to receive and process claims billed with new HCPCS codes U0001 and U0002 for dates of service on or after February 4, 2020. Providers who test members for the 2019 Novel Coronavirus (COVID-19) using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill using code U0001. Providers may use code U0002 to bill for non-CDC laboratory tests for COVID-19. Billing with these specific codes will allow for better tracking of the public health response for COVID-19.

Billing with these specific codes will allow for better tracking of the public health response for COVID-19. Rates for U0001 and U0002 can be found on the Provider Rates & Fee Schedule web page under Health First Colorado Fee Schedule drop-down.

Issue resolved 3/20/20

Indian Health Services
National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

  • First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
  • If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
  • Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

Resolved 12/12/20: Behavioral Health Claims Billed by Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs) or Indian Health Services (IHS) - FQHC Denying for Explanation of Benefits (EOB) 2029

Some outpatient behavioral health claims billed by FQHC, RHC or IHS-FQHC providers were denying for EOB 2029 - The Services Must Be Billed to The Members RAE.

Claims were reprocessed 12/21/20.

Issue resolved 12/12/20

Non-Physician Practitioner

Resolved 7/16/21: Colorado interChange Update for Practitioner Claims for Listed Physician Administered Drug (PAD) Codes

The Colorado interChange has been updated so that Non-Physician Practitioner providers may be reimbursed for Professional/Professional Crossover claims for the following PAD procedure codes: J0202, J0595, J0717, J0897, J1300, J1569, J1599, J1823, J2182, J2916, J3262, J3357, J3489, Q5103 and Q5104. These claims were denying for Explanation of Benefits (EOB) 0182 – “Billing Provider Type and/or Specialty is not allowable for the service billed.”

Providers may resubmit affected claims that are within timely filing.

Issue resolved 7/16/21

Partially Resolved 5/26/21: Claims Denying for Explanation of Benefits (EOB) 4000 - "The Member Has Other Insurance" 
Some provider claims have been incorrectly denying for EOB 4000 - "The member has other insurance. Bill the charges to the other insurance before billing Medicaid. Complete the other insurance payment information fields on the claim and retain a copy of the explanation of benefits," when the member had limited Third Party Liability coverage unrelated to the services on the claim. For example, inpatient or outpatient claims may have denied for a prescription-only policy. An interim solution will be ongoing until a permanent solution is in place.
 
Impacted claims will need to be resubmitted by providers.
 
Issue partially resolved 5/26/21

Resolved 5/21/21: Mid-Month Appendix X Update Not Completed Due to Transmission Issue

The Appendix X - HCPCS and NDC Crosswalk for Billing Physicians-Administered Drugs update scheduled for May 15, 2021, had not been completed due to a transmission issue. The updated version has been posted to the Billing Manuals web page.
 
Issue resolved 5/21/21

Resolved 3/2/21: Evaluation & Management (E&M) Services Claims Billed with 24 Modifier Denying for Explanation of Benefits (EOB) 1460

Some professional, Evaluation & Management (E&M) services claims billed with modifier 24 (indicating an unrelated E&M service provided by same physician during a postoperative period) were denying when billed with other E&M services for EOB 1460 - "There is no additional benefit for this service. Payment for this procedure was included in the payment for the surgery."

Providers may resubmit affected claims.

Issue resolved 3/2/21

Previously Paid Physical and Occupational Therapy Claims Adjustments Denying for EOB 2305 - "Occupational Therapy and Physical Therapy Services Limited to a Maximum of 48 Units"

DXC and the Department initiated a mass adjustment for claims for the Fiscal Year 2017-2018 rate updates. Claims were incorrectly denied for EOB 2305 - Occupational therapy and physical therapy services limited to a maximum of 48 units. In the Colorado interChange, if an adjustment denies, it retracts the original paid claim.

This issue has been resolved for adjusted claims billed prior to 8/3/18, and these adjustments were reprocessed by DXC on 8/3/18.

The Department and DXC are continuing to work on a long-term resolution for this issue to address adjusted claims billed on or after 8/3/18. While the initial issue affected only DXC-initiated adjustments, after 8/3/18, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.

Resolved 2/3/21: Nurse Home Visitor Program (NHVP) Claims Billed with HD or TD Modifiers Denying for Explanation of Benefits (EOB) 7802
Some Nurse Home Visitor Program (NHVP) claims for the following procedure codes billed with the HD or TD modifiers were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code.

99401 99402 99403
99404 99406 99407
G8431 G8510 G9006
T1017    

Claims were reprocessed 2/5/21.

Issue resolved 2/3/21

Resolved 7/8/20: Behavioral Therapy Claims for Procedure Code 96110 EP Are Not Paying Correct Rate

Claims with a date of service on or after 6/1/20 for procedure code 96110 with modifier EP were not paying at the correct rate.

Claims were reprocessed by DXC on 7/17/20.

Issue Resolved 7/8/20

Resolved 6/1/20: COVID-19 Laboratory Procedures Codes U0003 and U0004 Paid Incorrectly

New COVID-19 procedure codes U0003 and U0004 for laboratory claims with dates of service 3/18/20 - 6/1/20 were paid without being reviewed for Clinical Laboratory Improvement Amendments (CLIA) certification requirements.

Claims were reprocessed by DXC on 6/12/20. Reprocessed claims which did not meet CLIA certification requirements were denied and funds were recouped. Recoupments appeared on Remittance Advices beginning 6/15/20.

Issue resolved 6/1/20

Resolved 2/12/20: Provider Web Portal Eligibility Display and Short-Term Behavioral Health Service Limits

The eligibility responses on the Provider Web Portal were incorrectly calculating a fiscal year (July 1 to June 30) as a two-year span rather than a one-year span when calculating and displaying some short-term behavioral health visit benefit claims. This caused the Used units under the Limit Details panel to incorrectly show greater than the Limit.

Claims were not denying due to this eligibility response issue. If providers receive EOB 5807 - "The short-term behavioral health service limit has been met, please submit the service to the Member's RAE." denials on the procedure codes below, those claims should be billed to the member's Regional Accountable Entity (RAE) and not to DXC:

  • 90791
  • 90832
  • 90834
  • 90837
  • 90846
  • 90847

Providers are reminded to reference the Short-term Behavioral Health Services in the Primary Care Setting Fact Sheet regarding policy for the short-term behavioral health benefit.

Issue resolved 2/12/20

Nursing Facility

Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Occupational Therapist
Previously Paid Physical and Occupational Therapy Claims Adjustments Denying for EOB 2305 - "Occupational Therapy and Physical Therapy Services Limited to a Maximum of 48 Units"

DXC and the Department initiated a mass adjustment for claims for the Fiscal Year 2017-2018 rate updates. Claims were incorrectly denied for EOB 2305 - Occupational therapy and physical therapy services limited to a maximum of 48 units. In the Colorado interChange, if an adjustment denies, it retracts the original paid claim.

This issue has been resolved for adjusted claims billed prior to 8/3/18, and these adjustments were reprocessed by DXC on 8/3/18.

The Department and DXC are continuing to work on a long-term resolution for this issue to address adjusted claims billed on or after 8/3/18. While the initial issue affected only DXC-initiated adjustments, after 8/3/18, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.


Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Resolved 2/13/20: Incorrect Quantity of Physical and Occupational Therapy Units Displayed in the Provider Web Portal

The quantity of physical and occupational therapy units displayed on the Provider Web Portal Coverage Details screen may not have reflected the total amount of units the member has used.

Providers are still encouraged to obtain and submit a PAR to the Department's prior authorization vendor, even if all the previous PAR units are not exhausted.

Issue Resolved 2/13/20

Pediatric Behavioral Therapy Providers
Resolved 12/15/20: Behavioral Health Claims for Code 97151, H0031, H0036, H2015 & TJ Modifier Denying for Explanation of Benefits (EOB) 7802
Behavioral health claims for procedure code 97151, H0031, H0036, and H2015 billed with the TJ modifier were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code."
Claims were reprocessed 12/18/20.
Issue resolved 12/15/20
 

Resolved 7/8/20: Behavioral Therapy Claims for Procedure Code 96110 EP Are Not Paying Correct Rate

Claims with a date of service on or after 6/1/20 for procedure code 96110 with modifier EP were not paying at the correct rate.

Claims were reprocessed by DXC on 7/17/20.

Issue Resolved 7/8/20

Personal Care

Resolved 8/12/21: Personal Care Claims for Procedure Code T1019 and Denver County Reimbursement 

Some pediatric personal care claims for procedure code T1019 with dates of service on or after 1/1/21 billed for members within Denver County were not reimbursed at the increased Denver County rate.

Affected claims were reprocessed 8/12/21.

Issue resolved 8/12/21 

Pharmacy

National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

  • First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
  • If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
  • Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

Resolved 6/29/21: Providers Unable to Submit Medication PARs to Magellan Rx Management on 6/25/2021
Providers were temporarily unable to submit medication prior authorization requests (PARs) by fax to Magellan Rx Management for several hours on Friday, June 25, 2021. Prescribers are asked to contact the Magellan Rx Management Pharmacy Call Center at (800) 424-5725 for any unresponded Prior Authorization Requests (PARs) submitted from 1:30 p.m. to 6:30 p.m. on Friday, June 25, 2021.

Resolved 8/24/20: Duplicate Payments for Some Pharmacy Claims

Some pharmacy claims submitted between 5/2/20 and 8/23/20 received duplicate payments. Not all pharmacies were affected by this issue.

Claims will be reprocessed by DXC Technology and funds will be recouped in the coming months. A future communication will be sent the week prior to the recoupment. This information will appear on the Remittance Advice. Providers are encouraged to not submit voids directly.

Contact Magellan atCOMedicaidSupport@magellanhealth.com with any questions or concerns regarding this upcoming recoupment.

Issue resolved 8/24/20

Resolved 2/25/20: Pharmacy Claim Denials for Procedure Code K0554 With Modifier NU for Explanation of Benefits (EOB) 4211 - Modifier Is Invalid for Procedure Code and EOB 0182 - "Billing Provider Type and/or Specialty Not Allowable for Service Billed

Pharmacy claims for procedure code K0554 with modifier NU were denying for EOB 4211 - Modifier is invalid for procedure code and EOB 0182 - "Billing Provider Type and/or Specialty is not allowable for the service billed.

Providers are advised to resubmit affected claims.

Issue resolved 2/25/20

Physical Therapist
Previously Paid Physical and Occupational Therapy Claims Adjustments Denying for EOB 2305 - "Occupational Therapy and Physical Therapy Services Limited to a Maximum of 48 Units"

DXC and the Department initiated a mass adjustment for claims for the Fiscal Year 2017-2018 rate updates. Claims were incorrectly denied for EOB 2305 - Occupational therapy and physical therapy services limited to a maximum of 48 units. In the Colorado interChange, if an adjustment denies, it retracts the original paid claim.

This issue has been resolved for adjusted claims billed prior to 8/3/18, and these adjustments were reprocessed by DXC on 8/3/18.

The Department and DXC are continuing to work on a long-term resolution for this issue to address adjusted claims billed on or after 8/3/18. While the initial issue affected only DXC-initiated adjustments, after 8/3/18, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.


Resolved 1/13/21: Physical Therapy Claims for Procedure Codes 20560 & 20561 Billed with GP, 96 or 97 Modifiers Denying for Explanation of Benefits (EOB) 7802
Some physical therapy claims for procedure codes 20560 and 20561 billed with the GP, 96 or 97 modifiers were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code.

Affected claims were reprocessed 1/15/21.

Issue resolved 1/13/21

Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Resolved 2/13/20: Incorrect Quantity of Physical and Occupational Therapy Units Displayed in the Provider Web Portal

The quantity of physical and occupational therapy units displayed on the Provider Web Portal Coverage Details screen may not have reflected the total amount of units the member has used.

Providers are still encouraged to obtain and submit a PAR to eQHealth Solutions, the Department's prior authorization vendor, even if all the previous PAR units are not exhausted.

Issue Resolved 2/13/20

Physician Services/Clinics

Partially Resolved 5/26/21: Claims Denying for Explanation of Benefits (EOB) 4000 - "The Member Has Other Insurance" 
Some provider claims have been incorrectly denying for EOB 4000 - "The member has other insurance. Bill the charges to the other insurance before billing Medicaid. Complete the other insurance payment information fields on the claim and retain a copy of the explanation of benefits," when the member had limited Third Party Liability coverage unrelated to the services on the claim. For example, inpatient or outpatient claims may have denied for a prescription-only policy. An interim solution will be ongoing until a permanent solution is in place.
 
Impacted claims will need to be resubmitted by providers.
 
Issue partially resolved 5/26/21

Resolved 3/2/21: Evaluation & Management (E&M) Services Claims Billed with 24 Modifier Denying for Explanation of Benefits (EOB) 1460

Some professional, Evaluation & Management (E&M) services claims billed with modifier 24 (indicating an unrelated E&M service provided by same physician during a postoperative period) were denying when billed with other E&M services for EOB 1460 - "There is no additional benefit for this service. Payment for this procedure was included in the payment for the surgery."

Providers may resubmit affected claims.

Issues resolved 3/2/21

Resolved 10/28/20: Claims Denying for Evaluation & Management (E&M) Services and Procedure Code 99050 for Explanation of Benefits (EOB) 7801- "Content of Service of Another Procedure on Current/Previous Claim" When Billed with Other E&M Services

Professional claims for procedure code 99050 (services provided in the office when the office is normally closed after-hours) were previously denying when billed with other E&M services for EOB 7801 - "Service is denied because it is content of service of another procedure on the current and/or previous claim."

Claims were reprocessed on 10/30/20.

Issue resolved 10/28/20

Resolved 10/21/20: COVID-19 Laboratory Procedure Codes U0002 and 87635 Included as Clinical Laboratory Improvement Amendments (CLIA) Waived Tests

Effective 4/1/20, procedure codes U0002 and 87365 have been updated as Clinical Laboratory Improvement Amendments (CLIA) waived tests. Laboratory providers with a valid CLIA Certificate of Waiver (COW) may bill codes U0002 and 87635 with the QW modifier when billed with diagnosis code U07.0.

Affected claims with dates of service on or after 3/20/20 were reprocessed on 10/27/20.

Issue resolved 10/21/20

Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Resolved 6/1/20: COVID-19 Laboratory Procedures Codes U0003 and U0004 Paid Incorrectly

New COVID-19 procedure codes U0003 and U0004 for laboratory claims with dates of service 3/18/20 - 6/1/20 were paid without being reviewed for Clinical Laboratory Improvement Amendments (CLIA) certification requirements.

Claims were reprocessed by DXC on 6/12/20. Reprocessed claims which did not meet CLIA certification requirements were denied and funds were recouped. Recoupments appeared on Remittance Advices beginning 6/15/20.

Issue resolved 6/1/20

Resolved 4/15/20: New HCPCS Codes for Specimen Collection for 2019 Novel Coronavirus (COVID-19)
New HCPCS codes G2023 and G2024 (used to identify and reimburse specimen collection for COVID-19 testing) have been released for dates of service on or after March 1, 2020.
The Colorado interChange has been updated to receive and process claims for these codes.

Issue resolved 4/15/20

Resolved 3/25/20: Colorado interChange Update to Receive New ICD-10 Code for COVID-19

The Colorado interChange has been updated to receive and process claims billed with the new ICD-10 code for the diagnosis of COVID-19 U07.1 for dates of service on or after April 1, 2020.

Issue resolved 3/25/20

Resolved 3/25/20: Colorado interChange Update to Receive New CPT Code for Laboratory Testing for COVID-19
The Colorado interChange has been updated to receive and process claims billed with new CPT code 87635 for the laboratory testing of the novel coronavirus (COVID-19) for dates of service on or after March 13, 2020.

Issue resolved 3/25/20

Resolved 3/20/20: New Healthcare Common Procedure Coding System (HCPCS) Codes for 2019 Novel Coronavirus (COVID-19) Laboratory Tests

The Colorado interChange has been updated to receive and process claims billed with new HCPCS codes U0001 and U0002 for dates of service on or after February 4, 2020. Providers who test members for the 2019 Novel Coronavirus (COVID-19) using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill using code U0001. Providers may use code U0002 to bill for non-CDC laboratory tests for COVID-19. Billing with these specific codes will allow for better tracking of the public health response for COVID-19.

Billing with these specific codes will allow for better tracking of the public health response for COVID-19. Rates for U0001 and U0002 can be found on the Provider Rates & Fee Schedule web page under Health First Colorado Fee Schedule drop-down.

Issue resolved 3/20/20

Resolved 2/12/20: Provider Web Portal Eligibility Display and Short-Term Behavioral Health Service Limits

The eligibility responses on the Provider Web Portal were incorrectly calculating a fiscal year (July 1 to June 30) as a two-year span rather than a one-year span when calculating and displaying some short-term behavioral health visit benefit claims.This caused the Used units under the Limit Details panel to incorrectly show greater than the Limit.

Claims were not denying due to this eligibility response issue. If providers receive EOB 5807 - "The short-term behavioral health service limit has been met, please submit the service to the Member's RAE." denials on the procedure codes below, those claims should be billed to the member's Regional Accountable Entity (RAE) and not to DXC:

  • 90791
  • 90832
  • 90834
  • 90837
  • 90846
  • 90847

Providers are reminded to reference the Short-term Behavioral Health Services in the Primary Care Setting Fact Sheet regarding policy for the short-term behavioral health benefit.

Issue resolved 2/12/20

Rehabilitation Agency
 
Previously Paid Physical and Occupational Therapy Claims Adjustments Denying for EOB 2305 - "Occupational Therapy and Physical Therapy Services Limited to a Maximum of 48 Units"

DXC and the Department initiated a mass adjustment for claims for the Fiscal Year 2017-2018 rate updates. Claims were incorrectly denied for EOB 2305 - Occupational therapy and physical therapy services limited to a maximum of 48 units. In the Colorado interChange, if an adjustment denies, it retracts the original paid claim.

This issue has been resolved for adjusted claims billed prior to 8/3/18, and these adjustments were reprocessed by DXC on 8/3/18.

The Department and DXC are continuing to work on a long-term resolution for this issue to address adjusted claims billed on or after 8/3/18. While the initial issue affected only DXC-initiated adjustments, after 8/3/18, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.


Partially Resolved 5/26/21: Claims Denying for Explanation of Benefits (EOB) 4000 - "The Member Has Other Insurance" 
Some provider claims have been incorrectly denying for EOB 4000 - "The member has other insurance. Bill the charges to the other insurance before billing Medicaid. Complete the other insurance payment information fields on the claim and retain a copy of the explanation of benefits," when the member had limited Third Party Liability coverage unrelated to the services on the claim. For example, inpatient or outpatient claims may have denied for a prescription-only policy. An interim solution will be ongoing until a permanent solution is in place.
 
Impacted claims will need to be resubmitted by providers.
 
Issue partially resolved 5/26/21

Resolved 2/13/20: Incorrect Quantity of Physical and Occupational Therapy Units Displayed in the Provider Web Portal

The quantity of physical and occupational therapy units displayed on the Provider Web Portal Coverage Details screen may not have reflected the total amount of units the member has used.

Providers are still encouraged to obtain and submit a PAR to the Department's prior authorization vendor, even if all the previous PAR units are not exhausted.

Issue Resolved 2/13/20

Rural Health Clinic

Resolved 7/15/21: Telehealth Outpatient Crossover Claims for Procedure Code G2025 Denying for Explanation of Benefits (EOB) 5807

Some outpatient crossover, short-term behavioral health claims for procedure code G2025 for dates of service on or after 1/27/20 were denying for EOB 5807 – “The short-term behavioral health service limit has been met, please submit the service to the member’s RAE.”

Affected claims were reprocessed 8/12/21.

Issue resolved 7/15/21

Resolved 5/21/21: Mid-Month Appendix X Update Not Completed Due to Transmission Issue

The Appendix X - HCPCS and NDC Crosswalk for Billing Physicians-Administered Drugs update scheduled for May 15, 2021, had not been completed due to a transmission issue. The updated version has been posted to the Billing Manuals web page.
 
Issue resolved 5/21/21

Resolved 3/2/21: Evaluation & Management (E&M) Services Claims Billed with 24 Modifier Denying for Explanation of Benefits (EOB) 1460

Some professional, Evaluation & Management (E&M) services claims billed with modifier 24 (indicating an unrelated E&M service provided by same physician during a postoperative period) were denying when billed with other E&M services for EOB 1460 - "There is no additional benefit for this service. Payment for this procedure was included in the payment for the surgery."

Providers may resubmit affected claims.

Issue resolved 3/2/21

Resolved 12/12/20: Behavioral Health Claims Billed by Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs) or Indian Health Services (IHS) - FQHC Denying for Explanation of Benefits (EOB) 2029

Some outpatient behavioral health claims billed by FQHC, RHC or IHS-FQHC providers were denying for EOB 2029 - The Services Must Be Billed to The Members RAE.

Claims were reprocessed 12/21/20.

Issue resolved 12/12/20

Resolved 2/12/20: Provider Web Portal Eligibility Display and Short-Term Behavioral Health Service Limits

The eligibility responses on the Provider Web Portal were incorrectly calculating a fiscal year (July 1 to June 30) as a two-year span rather than a one-year span when calculating and displaying some short-term behavioral health visit benefit claims. This caused the Used units under the Limit Details panel to incorrectly show greater than the Limit.

Claims were not denying due to this eligibility response issue. If providers receive EOB 5807 - "The short-term behavioral health service limit has been met, please submit the service to the Member's RAE." denials on the procedure codes below, those claims should be billed to the member's Regional Accountable Entity (RAE) and not to DXC:

  • 90791
  • 90832
  • 90834
  • 90837
  • 90846
  • 90847

Providers are reminded to reference the Short-term Behavioral Health Services in the Primary Care Setting Fact Sheet regarding policy for the short-term behavioral health benefit.

Issue resolved 2/12/20

Speech Therapy

Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - EVV Record Required and Not Found When Submitted After Professional Claim

Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - EVV Record Required and Not Found.

This issue primarily impacted Hospital - General and Nursing Facility providers, however, other provider types may also have been affected, including:

  • Clinic - Practitioner
  • Durable Medical Equipment
  • Federally Qualified Health Center
  • Home & Community-Based Services
  • Home Health & Private Duty Nursing
  • Outpatient Therapy (Physical, Occupational and Speech therapy)

While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.

No action is required from providers.

Substance Use Disorder

National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

  • First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
  • If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
  • Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.
Transportation - Non-Emergent Medical Transportation

Resolved 7/7/21: Transportation Claims for Procedure Codes A0425 and A0429 with Modifier 76 Denying for Explanation of Benefits (EOB) 7817 
Some claims for transportation procedure codes A0425 and A0429 billed with modifier 76 for dates of service on or after 9/26/20 were denying for EOB 7817 – “The payment modifier is not appropriate with the procedure code billed.”
 
Affected claims were reprocessed 7/9/21.

Issue resolved 7/7/21. 

Resolved 3/31/21: Transportation Claims for A0427 & A0429 with 77 Modifier Denying for Explanation of Benefits (EOB) 7802
Some transportation claims for procedure codes A0427 and A0429 for dates of service on or after 10/1/20 billed with the 77 modifier were denying for Explanation of Benefits (EOB) 7802 - “The non-payment modifier is not appropriate with the billed procedure code.”

Claims were reprocessed 4/5/21.

Issue resolved 3/31/21

Resolved 1/6/21: Non-Emergent Medical Transportation (NEMT) Claims Billed with Modifier 77 Denying for Explanation of Benefits (EOB) 7802
Some Non-Emergent Medical Transportation (NEMT) claims for the following procedure codes billed with modifier 77 were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code.

Affected NEMT Procedure Codes
A0021 A0100 A0200 A0428 T2001
A0080 A0130 A0210 A0430 T2005
A0090 A0140 A0422 A0433 T2049
A0110 A0180 A0425 A0434  
A0120 A0190 A0426 S0209  

Claims were reprocessed 1/7/21.

Issue resolved 1/6/21

Resolved 2/10/20: Non-Emergent Medical Transportation (NEMT) Claims Denials for Procedure Code A0425 - Explanation of Benefits (EOB) 1599

Non-Emergent Medical Transportation (NEMT) claims for procedure code A0425 were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed."

Claims were reprocessed by DXC on 2/21/20.

Issue resolved 2/10/20

Vision Services

Resolved 6/30/21: Vision Claims for Procedure Code 92071 with Modifier 55 Denying for Explanation of Benefits (EOB) 7817
Some claims for procedure code 92071 for dates of service on or after 9/1/2020 billed with the 55 modifier are denying for EOB 7817 – “The payment modifier is not appropriate with the procedure code billed.”

Claims were reprocessed on 7/2/21.

Issue resolved 6/30/21

Resolved 2/11/21: Claims for Vision Code 92310 with Modifier 55 Denying for Explanation of Benefits (EOB) 7817

Some claims for procedure code 92310 billed with the 55 modifier were denying for EOB 7817 - The payment modifier is not appropriate with the procedure code billed.

Claims were reprocessed 2/16/21.

Issue resolved 2/11/21

Resolved 10/28/20: Vision Claim Denials for Explanation of Benefits (EOB) 7817 - Payment Modifier Not Appropriate When Billed with Modifier 55

Professional claims for adult glasses and contact lens procedure codes were denying when submitted with modifier 55 for EOB 7817 - The payment modifier is not appropriate with the procedure code billed.

Claims were reprocessed on 10/30/20.

Issue resolved 10/28/20

Women's Health
National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

  • First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
  • If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
  • Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

Resolved 2/3/21: Nurse Home Visitor Program (NHVP) Claims Billed with HD or TD Modifiers Denying for Explanation of Benefits (EOB) 7802
Some Nurse Home Visitor Program (NHVP) claims for the following procedure codes billed with the HD or TD modifiers were denying for EOB 7802 - The non-payment modifier is not appropriate with the billed procedure code.

99401 99402 99403
99404 99406 99407
G8431 G8510 G9006
T1017    

Claims were reprocessed 2/5/21.

Issue resolved 2/3/21