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Known Issues and Updates

ATTENTION: The Health First Colorado Fee Schedule for July is in progress. Provider communication will be sent when the new fee schedules are available and the new rates for dates of service beginning July 1, 2024 have been loaded into the Colorado Interchange. It is anticipated that new rates found on the Health First Colorado fee schedules will be completed by early July. 

General Updates

Finance

Validation of Provider Taxpayer Identification Numbers (TIN) Against Internal Revenue Service (IRS) Data
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.


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, it is highly recommended to submit electronically as that will automatically set up an Accounts Receivable (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.

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.

Provider Web Portal

HCBS Program Aid Code Changes for Member Eligibility

Home and Community-Based Services (HCBS) providers may now see Universal Aid Code “MH” associated with some Waiver Benefit Plans for eligible members when they check a member's eligibility in the Provider Web Portal. The new MH Universal Aid Code replaces thirteen (13) prior aid codes, beginning March 1, 2024. Waiver Benefit Plans for eligible members may be missing from their Benefits Details list due to a known delay by the counties in determining the benefit plans. Members must show a benefit plan as well as the MH code for claims to process correctly. If the benefit plan is missing, HCBS providers may submit a request via this form to update a benefit plan. HCBS providers should not contact the county or the case manager to update the benefit plan. 


How to Look Up a PAR on the Provider Web Portal

HCBS providers can view a member's Prior Authorization Request (PAR) status in the Provider Web Portal. To look up a PAR on the Web Portal, users should choose the "Care Management" option from the home page and click "View Authorization Services". Users should then enter the member identification number and approved PAR number into the 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 contact the Provider Services Call Center to obtain a PAR number. PARs that are visible in the Web Portal are finalized PARs in the Colorado 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.


Claims Paid with “0” Date

 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). This is due to the claim being 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.


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 they have downloaded the most recent version of Microsoft Edge, or they are using another supported web browser. To see a list of supported web browsers, refer to the Website Requirements web page of the Provider Web Portal.


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. It appears a combination of internal factors in the system along with external factors with the user's network/internet connection is causing the problem. The following steps have proven helpful to several users to resolve this issue:

- 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 7:00 a.m. to 4:00 p.m. Monday through Friday). Please note that the Provider Web Portal is down for regularly scheduled maintenance every Wednesday night beginning at 7:00 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, contact the Provider Services Call Center. 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 Inactivity Setting Update
The Provider Web Portal will allow users 15 minutes of inactivity. If the 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 the Web Portal again.


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. The Effective Date and End Date for most CLIA licenses were updated in the Colorado interChange. 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.

The Effective Date and End Date are required fields when providers are updating CLIA Certification information. Updates were done on the Provider Web Portal so the effective dates will be automatically populated.


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.

An implementation fix was done on 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 Internal Control Number (ICN), contact the Provider Services Call Center.
  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.


Denials for Duplicate Services
Duplicate claims are being reviewed to ensure proper payment.


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.
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

EOB 0000 - This claim/service is pending for program review.

Explanation: Physician Administered Drugs (PADs) require a National Drug Code (NDC) assignment and may take up to 90 days before implementation. The Colorado interChange is updated with the billing codes based on the Centers for Medicare & Medicaid Services (CMS) release of deletions, changes and additions. Claims will be released from suspense once the update is complete.

Estimated Time for Processing: May be under review for 30 - 60 days.


EOB 1786 - 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 the fiscal agent.

Estimated Time for Processing: 7 days


EOB 0101 - This is a duplicate service.

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

Estimated Time for Processing: 7 days


EOB 0110 - Multiple Surgery Review

Explanation: A resolution is under review to implement a more efficient process.

Estimated Time for Processing: 7 days


EOB 2013 - Claim Processed With Closest Elig Span-Deny or EOB 2960 - 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 the fiscal agent to price.

Estimated Time for Processing: 7 days

 

Note: If claims are over 14 days from the date of receipt, contact the Provider Services Call Center so they can be escalated for processing.

 

Claim Processing Times for New Procedure Codes

Providers are reminded to check the Provider Rates & Fee Schedule web page before billing to ensure procedure codes are a covered benefit. All codes must be reviewed for medical necessity, prior authorization coverage standards and rates before they are reimbursable.

New Procedure Codes Suspending for Explanation of Benefits (EOB) 0000 "This claim/service is pending for program review." may be under review for 30 - 60 days. Physician Administered Drugs (PADs) require a National Drug Code (NDC) assignment and may take up to 90 days before implementation. The Colorado interChange is updated with the billing codes based on the Centers for Medicare & Medicaid Services (CMS) release of deletions, changes and additions. Claims will be released from suspense once the update is complete.

 
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 (RA), 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 (3) weeks for final approval. Providers should not submit duplicate update requests.


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

The timely filing period is 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.

New Medicare Part A and Part B 2024 Deductible Amounts

The Medicare annual deductibles amounts have changed for 2024. Medicare Part A increased from $1,600 to $1,632. Medicare Part B increased from $226 to $240. The Colorado interChange has been updated with these new deductible amounts for claims with dates of service on or after January 1, 2024.

Known Issues and Resolved Issues

This is not an all-inclusive list of known issues.

All Provider Types

 

Ambulatory Surgical Centers (ASC)

 

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.

Audiology

Resolved 05/22/24: Some Speech Therapy Claims Denying for Explanation of Benefits (EOB) 0192, 1599 and 4211

Some speech therapy claims submitted on or after 07/01/23 were denying incorrectly with various procedure codes and modifiers, which are listed below.

Procedure Codes

92507  92508  92605  92606  92607  92609
92610  92611  92612  92614  92626  92627
96105  96112  96113  97129  97130

Modifiers

  • GN modifier billed along with 96 modifier
  • GN modifier billed along with 97 modifier

Explanation of Benefits (EOB) Codes and Descriptions

  • 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.
  • 1599 - Rendering Provider Type and/or Specialty is not allowable for the service billed.
  • 4211 - Modifier is invalid for procedure code. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.

Affected claims were reprocessed on 05/24/24.

Issue resolved 05/22/24.

Behavioral Health

Resolved 4/11/24: Some Claims for Behavioral Health Services with SC Modifier Were Denying Incorrectly for Explanation of Benefits (EOB) 2029

Some claims for behavioral health services with the SC modifier were denying incorrectly for (EOB) 2029 – “The Services Must Be Billed to the Members RAE.”  

Affected claims were reprocessed 4/11/24.

Issue resolved 4/11/24.

Birthing Center (Free-standing)

Resolved 11/01/23: Maternity Claims Denying for Explanation of Benefits (EOB) 1087 and EOB 1088

Maternity claims were denying incorrectly for EOB 1087 - "Quantity of one or more services billed is not allowed" and EOB 1088 - "Single Date of Service billing requirement not met" when submitted with non-maternity procedures with more than one unit billed.

Affected claims were reprocessed on 11/06/23.

Issue resolved 11/01/23.

 

Resolved 11/10/21: Upcoming Colorado interchange Update to Add Multiple Procedures Codes to Free-Standing Birth Centers (FSBC) Billing 

The Colorado interChange was updated for procedure codes 82247, 86769, 87491, 88720, 90471, 90715, 96127 and 97022 to be eligible and billable by free-standing birth centers (FSBC). Previously, FSBC claims billed from dates of services (DOS) 11/09/2019 through 11/09/2021 for these codes were denying for Explanation of Benefits (EOB) 0182 - Billing Provider Type and/or Specialty is not allowable for the service billed.

Affected claims were reprocessed on 11/19/21. 
 
Issue resolved 11/10/21

Case Manager

Care and Case Management Known Issues web page

Durable Medical Equipment (DME)/Supply

Resolved 05/23/24: Some Professional Claims for Durable Medical Equipment (DME) Wheelchair Repair Services with Modifier RB Denying for Explanation of Benefits (EOB) 1997

Some professional claims for DME wheelchair repair services with modifier RB were denying incorrectly for EOB 1997 - “The referring, ordering, prescribing or attending provider is missing or not enrolled. Please resubmit with a valid individual National Provider Identifier (NPI) in the attending field.”

Affected claims were reprocessed on 05/29/24.

Issue resolved 05/23/24.

 

Resolved 03/19/24: Some Professional Claims for Durable Medical Equipment (DME) Services for Procedure Code E0154 with Modifier NU Denying for Explanation of Benefits (EOB) 3530

Some professional claims for DME procedure code E0154 with modifier NU for dates of service 07/01/2022 through 06/30/2023 were denying for EOB 3530 - “There is no rate on file for the date of service. Charges cannot be processed."

Affected claims were reprocessed on 03/22/24.

Issue resolved 03/19/24.

 

Resolved 03/13/24: Some Professional Claims with Durable Medical Equipment (DME) E2599, K0108 and T5999 Procedure Codes Denying for Explanation of Benefits (EOB) 7827

Some professional claims with DME procedure codes E2599, K0108 and T5999 with date of service prior to 07/01/23 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 on 03/15/24.

Issue resolved 03/13/24.

 

Resolved 02/27/24: Some Professional Claims for Procedure Code A4287 Denying for Explanation of Benefits (EOB) 0192

Some professional claims for procedure code A4287 were 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.”

Procedure code A4287 became effective 01/01/24 as a replacement for temporary code K1005. A4287 will not require a Prior Authorization Request (PAR).

Affected claims were reprocessed on 02/29/24.

Issue resolved 02/27/24.

 

Resolved 02/24/24: Some Professional Claims for Durable Medical Equipment (DME) Services for Procedure Code E0955 with Modifier NU were Suspending for Explanation of Benefits (EOB) 2861 - “No Rate on File for the Date(s) of Service.”

Some professional claims for DME services for procedure code E0955 with modifier NU were suspending for EOB 2861 - “No Rate on File for the Date(s) of Service.”

Affected claims were reprocessed on 02/29/24.

Issue resolved 02/24/24.

 

Resolved 01/25/24: Some Professional Claims for Durable Medical Equipment (DME) Services for Procedure Code E0310 with Modifier NU Denying for Explanation of Benefits (EOB) 1512 - “The Procedure Code/Modifier combination is not payable for the Date of Service.”

Some professional claims for DME services for procedure code E0310 with modifier NU were denying for EOB 1512 - “The Procedure Code/Modifier combination is not payable for the Date of Service.”  The Colorado interChange was updated to allow NU as the appropriate modifier for purchase.

Affected claims were reprocessed on 01/30/24.

Issue resolved 01/25/24.

 

Resolved 11/22/23: Some Professional Claims with DME Procedure Codes E2599, K0108 and T5999 were Denying for Explanation of Benefits (EOB) 7577 - “CXT-S service is an unlisted procedure.”

Some professional claims with DME procedure codes E2599, K0108, and T5999 were denying for EOB 7577 - “CXT-S service is an unlisted procedure.”

Affected claims were reprocessed on 12/04/23.

Issue resolved 11/22/23. 

 

Resolved 07/07/23: Claims for Durable Medical Equipment (DME) Denying for Explanation of Benefits (EOB) 4070 or EOB 2861

Some procedure codes billed on DME claims without the NU modifier were denying for Explanation of Benefits (EOB) 4070 - “The Procedure Code/Modifier combination is not payable for the Date of Service.” or EOB 2861 - “No Rate on File for the Date(s) of Service.”

Affected claims were reprocessed and completed on 07/14/23.

Issue resolved 07/07/23.

Federally Qualified Health Center (FQHC)

Resolved 3/20/24: Some Institutional Claims Billed with Physician-Administered Drugs Denying for Explanation of Benefits (EOB) 0192 

Some institutional claim details with Physician Administered Drugs (PADS) were denying incorrectly for EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found.” 

Affected claims were reprocessed on 3/21/24.

Issue was resolved on 3/20/24.

 

Resolved 11/01/23: Maternity Claims Denying for Explanation of Benefits (EOB) 1087 and EOB 1088

Maternity claims were denying incorrectly for EOB 1087 - "Quantity of one or more services billed is not allowed" and EOB 1088 - "Single Date of Service billing requirement not met" when submitted with non-maternity procedures with more than one unit billed.

Affected claims were reprocessed on 11/06/23.

Issue resolved 11/01/23.

 

Resolved 10/04/23: Updated COVID Vaccine Codes

The Common Procedural Terminology (CPT) codes were loaded into interChange on October 4, 2023. Providers can begin to use these codes for billing. 

Affected claims were reprocessed on October 6, 2023.

Issue resolved 10/04/23.

Effective September 11, 2023, COVID-19 vaccination is only reimbursable via the following Common Procedural Terminology (CPT) product codes: 91304, 91318, 91319, 91320, 91321, 91322 and the corresponding administration code, 90480. 

Effective September 12, 2023, all other COVID-19 vaccine and administration codes are closed in accordance with existing Emergency Use Authorization (EUA) or Biologics License Application (BLA) from the US Food and Drug Administration (FDA). 

Effective September 12, 2023, COVID-19 vaccines for members under 19 years of age are now part of the Vaccines for Children (VFC) program. Providers who are enrolled with Health First Colorado (Colorado’s Medicaid program) must also enroll with the VFC program in order to receive reimbursement for COVID-19 vaccine administration to pediatric Health First Colorado members. 

Effective April 27, 2023, the age range for CPT code 90677 is 6 weeks of age and up.

Reimbursement rates and age ranges for each CPT code are located on the Immunization Rate Schedule.

Home & Community-Based Services (HCBS)

 

Home Health

 

Hospital - General

Resolved 05/23/24: Some Institutional Claims with Diagnosis Codes F840, F842, F845 with Date of Service 01/01/24 or after were Denying Explanation of Benefits (EOB) 2029

Some institutional claims with diagnosis codes F840, F842, F845 for date of service 01/01/24 or after were denying incorrectly for EOB 2029 - “The Services Must Be Billed to The Members RAE.”

Affected claims were reprocessed on 05/30/24.

Issue resolved 05/23/24.

 

Resolved 3/20/24: Some Institutional Claims Billed with Physician-Administered Drugs Denying for Explanation of Benefits (EOB) 0192 

Some institutional claim details with Physician Administered Drugs (PADS) were denying incorrectly for EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found.” 

Affected claims were reprocessed on 3/21/24.

Issue was resolved on 3/20/24.

 

Resolved 12/27/2023: Inpatient Claims Paying at Full Diagnosis-Related Group (DRG) Rates

Some inpatient claims were paying at the full DRG calculated rates for the entire length of stay, even when a member gained or lost Medicaid eligibility mid-stay.

Per CCR 8.300.5.A.2.d, when a client is not Medicaid-eligible for an entire Inpatient Hospital stay, reimbursement shall be equal to the DRG per diem rate for every eligible day, with payment up to the full DRG base payment. If applicable, the Hospital shall receive outlier reimbursement.

Affected claims will not be reprocessed at this time.

Hospital - Mental

 

Independent Laboratory

 

Indian Health Services

 

Non-Physician Practitioner

Resolved 4/11/24: Some Claims for Behavioral Health Services with SC Modifier Were Denying Incorrectly for Explanation of Benefits (EOB) 2029

Some claims for behavioral health services with the SC modifier were denying incorrectly for (EOB) 2029 – “The Services Must Be Billed to the Members RAE.”  

Affected claims were reprocessed 4/11/24.

Issue resolved 4/11/24.

 

Resolved 04/03/24: Some Claims for Physician-Administered Drug (PAD) for Procedure Code J0256 Denying for Explanation of Benefits (EOB) 7827

Some claims for Physician-Administered Drug (PAD) for procedure code J0256 were denying for Explanation of Benefits (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 on 04/08/24.

Issue resolved 04/03/24.

Nursing Facility

 

Occupational Therapist

Resolved 06/17/24: Some Professional Claims for Physical, Occupational and Speech Therapy with Procedure Codes 92526, 96112, 96113, 97129, 97130 were Denying Explanation of Benefits (EOB) 1030 and 4211

Some professional claims for Physical, Occupational and Speech Therapy with dates of service 07/01/2023 or later for procedure codes 92526, 96112, 96113, 97129, 97130 with additional place of service (POS) codes and modifiers were denying incorrectly for Explanation of Benefits (EOB) 1030 – “The place of service code is invalid for procedure code. Correct the place of service code. Refer to the Provider Manual or Help Screens for valid place of service codes” and 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 on 06/19/24.

Issue resolved 06/17/24.

 

Resolved 04/15/24: Some Physical Therapy and Occupational Therapy Claims for Procedure Codes 90911, 90912, 90913 Denying for Explanation of Benefits (EOB) 2305

Some Physical Therapy and Occupational Therapy Claims for procedure codes 90911, 90912, 90913 were denying for Explanation of Benefits (EOB) 2305 - “Occupational therapy and Physical therapy services limited to a maximum of 48 units per 366 days.”

Affected claims may be resubmitted by the provider.

Issue resolved 04/15/24.
 

Resolved 01/25/24: Some Physical Therapy and Occupational Therapy Claims for Procedure Codes 97129 and 97130 with Modifiers GO or GP Denying for Explanation of Benefits (EOB) 4211 - “Modifier is invalid for procedure code. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.”

Some Physical Therapy and Occupational Therapy claims for procedure codes 97129 and 97130 with modifiers GO or GP were denying for Explanation of Benefits (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 on 01/30/24.

Issue resolved 01/25/24.

Pediatric Behavioral Therapy Providers
 
Personal Care

 

Pharmacy

 

Physical Therapist

Resolved 06/17/24: Some Professional Claims for Physical, Occupational and Speech Therapy with Procedure Codes 92526, 96112, 96113, 97129, 97130 were Denying Explanation of Benefits (EOB) 1030 and 4211

Some professional claims for Physical, Occupational and Speech Therapy with dates of service 07/01/2023 or later for procedure codes 92526, 96112, 96113, 97129, 97130 with additional place of service (POS) codes and modifiers were denying incorrectly for Explanation of Benefits (EOB) 1030 – “The place of service code is invalid for procedure code. Correct the place of service code. Refer to the Provider Manual or Help Screens for valid place of service codes” and 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 on 06/19/24.

Issue resolved 06/17/24.

 

Resolved 04/15/24: Some Physical Therapy and Occupational Therapy Claims for Procedure Codes 90911, 90912, 90913 Denying for Explanation of Benefits (EOB) 2305

Some Physical Therapy and Occupational Therapy Claims for procedure codes 90911, 90912, 90913 were denying for Explanation of Benefits (EOB) 2305 - “Occupational therapy and Physical therapy services limited to a maximum of 48 units per 366 days.”

Affected claims may be resubmitted by the provider.

Issue resolved 04/15/24.

 

Resolved 01/25/24: Some Physical Therapy and Occupational Therapy Claims for Procedure Codes 97129 and 97130 with Modifiers GO or GP Denying for Explanation of Benefits (EOB) 4211 - “Modifier is invalid for procedure code. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.”

Some Physical Therapy and Occupational Therapy claims for procedure codes 97129 and 97130 with modifiers GO or GP were denying for Explanation of Benefits (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 on 01/30/24.

Issue resolved 01/25/24.

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"

Gainwell Technologies 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, and these adjustments were reprocessed by Gainwell Technologies.

The Department and Gainwell Technologies are continuing to work on a long-term resolution for this issue to address adjusted claims. While the initial issue affected only Gainwell Technologies-initiated adjustments, 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

Physician Services/Clinics

Resolved 4/11/24: Some Claims for Behavioral Health Services with SC Modifier Were Denying Incorrectly for Explanation of Benefits (EOB) 2029

Some claims for behavioral health services with the SC modifier were denying incorrectly for (EOB) 2029 – “The Services Must Be Billed to the Members RAE.”  

Affected claims were reprocessed 4/11/24.

Issue resolved 4/11/24.

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"

Gainwell Technologies 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, and these adjustments were reprocessed by Gainwell Technologies.

The Department and Gainwell Technologies are continuing to work on a long-term resolution for this issue to address adjusted claims. While the initial issue affected only Gainwell Technologies-initiated adjustments, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.

Rural Health Clinic

Resolved 3/20/24: Some Institutional Claims Billed with Physician-Administered Drugs Denying for Explanation of Benefits (EOB) 0192 

Some institutional claim details with Physician Administered Drugs (PADS) were denying incorrectly for EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found.” 

Affected claims were reprocessed on 3/21/24.

Issue was resolved on 3/20/24.

Speech Therapy

Resolved 06/17/24: Some Professional Claims for Physical, Occupational and Speech Therapy with Procedure Codes 92526, 96112, 96113, 97129, 97130 were Denying Explanation of Benefits (EOB) 1030 and 4211

Some professional claims for Physical, Occupational and Speech Therapy with dates of service 07/01/2023 or later for procedure codes 92526, 96112, 96113, 97129, 97130 with additional place of service (POS) codes and modifiers were denying incorrectly for Explanation of Benefits (EOB) 1030 – “The place of service code is invalid for procedure code. Correct the place of service code. Refer to the Provider Manual or Help Screens for valid place of service codes” and 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 on 06/19/24.

Issue resolved 06/17/24.

 

Resolved 05/22/24: Some Speech Therapy Claims Denying for Explanation of Benefits (EOB) 0192, 1599 and 4211

Some speech therapy claims submitted on or after 07/01/23 were denying incorrectly with various procedure codes and modifiers, which are listed below.

Procedure Codes

92507  92508  92605  92606  92607  92609
92610  92611  92612  92614  92626  92627
96105  96112  96113  97129  97130

Modifiers

  • GN modifier billed along with 96 modifier
  • GN modifier billed along with 97 modifier

Explanation of Benefits (EOB) Codes and Descriptions

  • 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.
  • 1599 - Rendering Provider Type and/or Specialty is not allowable for the service billed.
  • 4211 - Modifier is invalid for procedure code. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.

Affected claims were reprocessed on 05/24/24.

Issue resolved 05/22/24.

 

Resolved 04/26/24: Some Speech Therapy Claims for Evaluation Services were Denying for Explanation of Benefits (EOB) 5551 - “Speech Therapy service limit of 12 sessions has been met.”
 
Some speech therapy claims for evaluation services with first date of service (FDOS) on 01/01/2024 were denying incorrectly for the following codes:

92520    92597    92611    96111
92521    92605    92612    96112
92522    92606    92614    96113
92523    92607    92626    Q3014
92524    92608    92627    V5011
92526    92610    96105
 

Affected claims were reprocessed on 04/30/24.  

Issue resolved 04/26/24.
 

Resolved 01/12/24: Some Speech Therapy Claims were Denying for Explanation of Benefits (EOB) 5550, 5551 and 5552

Some speech therapy claims with first date of service (FDOS) on or after 12/01/23 were denying incorrectly when a valid Prior Authorization (PA) is available.

Explanation of Benefits (EOB) Codes and Descriptions

5550 - Speech Rehabilitative Service Limit of 12 sessions has been met.
5551 - Speech Therapy Service Limit of 12 sessions has been met.
5552 - Speech Habilitative Service Limit of 12 sessions has been met.

Affected claims were reprocessed 01/12/24.

Issue resolved 01/12/24.

 

Resolved 12/27/23: Some Claims for Speech Therapy were Denying for Explanation of Benefits (EOB) 5550, 5551 and 5552

Some claims for Speech Therapy requiring a Prior Authorization (PA) submitted on or after 07/01/23 were denying incorrectly with various procedure codes and modifiers, which are listed below.

Procedure Codes

92507    92508    92520    92521    92522    92523    92524    92526    92597
92605    92607    92608    92609    92610    92611    92612    92614    92626
92627    96105    96111    96112    96113    97129    97130

Modifiers

  • GN modifier billed along with 96 modifier
  • GN modifier billed along with 97 modifier
  • GN modifier billed along with TL modifier

Explanation of Benefits (EOB) Codes and Descriptions

  • 5550 - Speech Rehabilitative Service Limit of 12 sessions has been met.
  • 5551 - Speech Therapy Service Limit of 12 sessions has been met.
  • 5552 - Speech Habilitative Service Limit of 12 sessions has been met.

Affected claims were reprocessed on 01/03/24.

Issue resolved 12/27/23.

 

Resolved 11/22/23: Claims for Speech Therapy Were Denying for Non-Physician Practitioner Group Providers

Claims for Speech Therapy submitted after 11/15/23 for Non-Physician Practitioner Group providers were denying incorrectly for codes 92507, 92508, 92605, 92606, 92607, 92608, 92610, 92611, and 92614.

Affected claims were reprocessed on 11/30/23.
 
Issue resolved 11/22/23.

Substance Use Disorder

 

Transportation - Non-Emergent Medical Transportation

 

Vision Services

Resolved 04/05/24: Some Claims Billed by Optical Outlets Denying for Explanation of Benefits (EOB) 1997

Some claims billed by optical outlets were denying for EOB 1997 - “The referring, ordering, prescribing or attending provider is missing or not enrolled. Please resubmit with a valid individual NPI in the attending or referring field.”

Affected claims were reprocessed on 04/05/24.

Issue resolved 04/05/24.

Women's Health