Known Issues and Updates

ATTENTION: 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.

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.

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.

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, 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 as of 3/1/18.

Provider Web Portal

Claims Paid with “0” Date

Occasionally, claims will appear as “Paid” (with a Paid date of “0”) in the Provider Web Portal but not on the Remittance Advice (RA). This is due to the claim being flagged by a prepayment cycle. The claim is being reviewed before it is released. This process may take a few weeks.

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:

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.
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.

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 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 4000 - Member has other insurance, verify member coverage, bill carrier appropriately.

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: 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 2023 Deductible Amounts

The Medicare annual deductibles amounts have changed for 2023. Medicare Part A increased from $1,556 to $1,600. Medicare Part B decreased from $233 to $226. The Colorado interChange has been updated with these new deductible amounts for claims with dates of service on or after January 1, 2023.

Known Issues and Resolved Issues

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

All Provider Types

Resolved 6/29/2023: National Provider Identifier (NPI) Error with Revalidation Applications
Some providers were experiencing issues resubmitting returned Revalidation applications. Providers were incorrectly seeing an error showing a provider's National Provider Identifier (NPI) number being already in use.

Issue resolved 06/29/23.

Resolved 06/09/23: Claims Suspending for Explanation of Benefits (EOB) 7900 - CXT-S Claim suspended for internal review

Some claims were suspending due to system connectivity issues for Explanation of Benefits (EOB) 7900 -" CXT-S Claim suspended for internal review".

Affected claims were reprocessed 06/08/23 and 06/09/23.

Issue resolved 06/09/23.

Resolved 5/15/2023: Issues Sending Batch Files via Secure File Transfer Protocol (SFTP)

Some submitters are currently experiencing issues sending batch files depending on the Secure File Transfer Protocol (SFTP) client used. Use the following link as a temporary solution if the SFTP client is failing: https://mft.gainwelltechnologies.com/colorado-fts.

Issue resolved 5/15/23

Claims for HCPCS 2023 Procedure Codes Suspending for Explanation of Benefits (EOB) 0000

Effective 1/1/23, claims billed with a HCPCS 2023 procedure code were suspending for EOB 0000 - "This claim/service is pending for program review." The Colorado interChange has been updated with the 2023 HCPCS billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual release of deletions, changes and additions.

Claims were released from suspense 3/10/23.

Refer to the Special Provider Bulletin - Healthcare Common Procedure Coding System (HCPCS) Updates for 2023 (B2300489 - 01/23) for more information.

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

Issue resolved 3/10/23

Resolved 08/24/22: Some Claims Denying for Explanation of Benefits (EOB) 4000 - "The Member Has Other Insurance"

Some provider claims 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," when the member had limited Third Party Liability (TPL) coverage unrelated to the services on the claim. For example, inpatient or outpatient claims may have denied for a prescription-only policy.

Claims should adjudicate appropriately.

Note: Claims may still be denied if the member has other insurance that is related to the service that is not entered on the claim. Providers must first bill the TPL prior to submitting claims to Health First Colorado.

Issue resolved 08/24/22.

Resolved 2/10/22: Claims for HCPCS 2022 Procedure Codes Suspending for Explanation of Benefits (EOB) 0000

Effective 1/1/22, claims billed with a HCPCS 2022 procedure code were suspending for EOB 0000 - "This claim/service is pending for program review." The Colorado interChange has been updated with the 2022 HCPCS billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual release of deletions, changes and additions.

Claims were released from suspense 2/11/22.

Reference the Healthcare Common Procedures Coding System (HCPCS) Updates for 2022 Special Provider Bulletin (B2200474) for more information.

Issue resolved 2/10/22

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
Duplicate claims are being reviewed to ensure proper payment.

Resolved 3/10/23: Claims Denying for Invalid Prior Authorization (PA)

Some claims submitted from 3/8/23 through 3/10/23 may have denied in error. Any providers who used the ColoradoPAR program, excluding Home and Community-Based Services (HCBS) providers, are encouraged to resubmit claims if the provider received PA-related denials and believes the claims have a valid PA.

Affected claims were reprocessed on 3/14/23.

Issue resolved 3/10/23

Resolved 10/20/21: 2022 CMS Diagnosis Code Release - M5450 and R053 Diagnosis-Related Claim Denials
The Colorado interChange has been updated with diagnosis codes listed in the most recent release from Centers for Medicare and Medicaid Services (CMS). This update included diagnosis codes M5450 and R053. Providers were seeing multiple, diagnosis-related claim denials prior to the update.

Providers are reminded, that not all new diagnosis codes are immediately billable through Health First Colorado when initially released by CMS. All codes must be reviewed for medical necessity, prior authorization coverage standards and rates before the codes are reimbursable.

Affected claims were reprocessed 12/1/21. Additional claims were identified and reprocessed on 1/11/22.

Issue resolved 10/20/21

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 2/3/21: 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

Ambulatory Surgical Centers (ASC)

Resolved 07/01/2022

Ambulatory Surgical Center (ASC) Claims for Procedure Code 36561 Paying at Incorrect Rate

Some ASC claims for procedure code 36561 were being paid at the incorrect rate of $1,813.06. The correct ASC grouper rate is $1,831.06. Providers are requested to continue to bill usual and customary charges or the correct rate of $1,831.06.

Affected claims were reprocessed on 07/01/22.

Issue resolved 07/01/22.

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.

Birthing Center (Free-standing)

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

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 the Web Portal, users should choose the "Care Management" option from the home page and click "View Authorization Services". Next, users should 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.

Durable Medical Equipment (DME)/Supply

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.

Resolved 06/16/23: Durable Medical Equipment (DME) Supply Claims Suspending Explanation of Benefits (EOB) 3530

Claims billed with procedure code E1399 and Modifier U1 for dates of service (DOS) 04/07/23 - 06/16/23 were suspending for EOB 3530 - “There is no rate on file for the date of service. Charges cannot be processed.”

This only impacted claims with both E1399 and Modifier U1. Claims with E1399 and no modifier are processing normally.

Affected claims were recycled on 06/23/23.

Issue resolved 06/16/23.

Resolved 06/09/23: PAD Claims Paid or Denying due to HCPCS/NDC Crosswalk File

Some claims that have Physician-Administered Drugs (PADs) with dates of service (DOS) 04/01/23 - 06/07/23 were denied due to an issue with the HCPCS/NDC Crosswalk file.

Claim reprocessing started on 06/09/23 and was completed on 06/16/23.

Issue resolved 06/09/23.

Resolved 04/07/23: Durable Medical Equipment (DME) Supply Claims Paying at Incorrect Rate

Some DME claims with dates of service after 07/01/22 were paying at the old default rate instead of the DME rural and non-rural rate.

Affected claims were reprocessed 06/30/23.

Issue resolved 04/07/23.

Resolved 04/26/23: Durable Medical Equipment (DME) Supply Claims Paying at Incorrect Rate

Some DME claims with procedure code E2512 were paying at the incorrect rate of $501.57. The correct rate is $4,465.18.

DME claims with procedure code A9274 and U1 modifier were paying at a set rate. This code should be manually priced when the U1 modifier is used.

Affected claims were reprocessed 04/28/23.

Issue resolved 04/26/23.

Resolved 05/04/23: Some Durable Medical Equipment (DME) Supply Claims Paying at Incorrect Rate

Some DME claims with Procedure Codes, A4267, A4268, A4269, A4351, A4352, E1130, E1140, K0739 and K0740 were paying at the old default rate instead of the DME rural and non-rural rate.

Affected claims were reprocessed 06/30/23.

Issue resolved 05/04/23.

Resolved 05/19/23: Durable Medical Equipment (DME) Supply Claims Suspending Explanation of Benefits (EOB) 2861

Claims for procedure codes E0118, E0274, E0370, E0565, E0785, E0786, E0850, E0856, E0930, E0936, E0958, E0959, E0967, E0968, E0969, E0970, E0980, E0983, E0984, E0986, E0988 were suspending for Explanation of Benefits (EOB) 2861 - “No Rate on File for the Date(s) of Service”.

Affected claims were recycled on 06/16/23.

Issue resolved 05/19/23.

Resolved 06/09/23: Durable Medical Equipment (DME) Supply Claims Suspending Explanation of Benefits (EOB) 2861

Claims were suspending for Explanation of Benefits (EOB) 2861 - “No Rate on File for the Date(s) of Service”. A secondary issue was affecting claims.

Affected claims were recycled on 06/16/23.

Issue resolved 06/09/23.

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).

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 05/25/22: Claims with TW Modifier Denying for Explanation of Benefits (EOB) 7814 and 7816

Some claims with procedure codes K0001 through K0898 may have denied with EOBs 7814 or 7816 "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" when the modifier TW was present.

Issue resolved 05/25/22

Resolved 09/1/21: 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 09/01/21

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

Federally Qualified Health Center (FQHC)

Resolved 08/16/23: Vaccine Claims with Procedure Code 0113A were Denying for Explanation of Benefits (EOB) 3280 - “The member’s age is invalid for this procedure code. Verify the member’s birth date/procedure code.”

Some vaccine claims with Procedure Code 0113A were denying for Explanation of Benefits (EOB) 3280 - “The member’s age is invalid for this procedure code. Verify the member’s birth date/procedure code.”

This policy allows for the billing of procedure code 0113A for children aged 0 - 5 years.

Affected claims were reprocessed on 08/17/23.

Issue resolved 08/16/23.

Resolved 07/28/23: COVID Booster Claims Using Procedure Code 0174 Denying for EOB 3261
Claims for COVID boosters using procedure code 0174A were denying for Explanation of Benefits (EOB) 3261 "The procedure code currently is not a benefit for date of service billed."

Affected claims were reprocessed 07/28/23

Issue resolved 07/28/23

Resolved 06/02/23: Claims for Immunizations Denying for Explanation of Benefits (EOB 7803) “Service is denied because a single procedure code exists to describe the service”

Resolved 06/02/23: Claims for Immunizations Denying for Explanation of Benefits (EOB 7803) “Service is denied because a single procedure code exists to describe the service”

Claims for immunizations billed with codes 90707 and 90716 concurrently were incorrectly denying for Explanation of Benefits (EOB 7803) “Service is denied because a single procedure code exists to describe the service”.

Affected claims were reprocessed on 06/02/23.

Issue resolved 06/02/23.

Resolved 01/18/23: COVID-19 Vaccine Claims with Procedure Codes 0044A and 90471 were Denying for Explanation of Benefits (EOB) 7809 and/or EOB 1381

Some claims for COVID-19 vaccines with procedure codes 0044A and 90471 were denying for Explanation of Benefits (EOB) 7809 - “Only one new patient visit is allowed to the same provider group practice and specialty within three years.” and/or EOB 1381 - “No billing rule for procedure.”

Affected claims were reprocessed on 01/19/23.

Issue resolved 01/18/23.

Claims should adjudicate appropriately.

Issue resolved 08/24/22.

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

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

Home & Community Based Services (HCBS)

Resolved 07/19/23: Elderly, Blind, and Disabled Waiver (EBD) Claims for Procedure Code S5170 Denying for Explanation of Benefits (EOB) 1544 - “Procedure is not billable with member’s benefit plan” and EOB 4758 - "Billing provider type/specialty restriction on procedure coverage rule."

Some Elderly, Blind, and Disabled Waiver (EBD) claims for procedure code S5170 “Home Delivered Meals” billed with modifiers TG and U1 were denying for Explanation of Benefits (EOB) 1544 - “Procedure is not billable with member’s benefit plan” and EOB 4758 - "Billing provider type/specialty restriction on procedure coverage rule."

Affected claims were reprocessed on 07/19/23.

Issue resolved 07/19/23.

How to Look Up a PAR on the Provider Web Portal

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:

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.
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.
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.
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 the fiscal agent 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.

Home & Community-Based Services (HCBS) Claims for H0038, S5130, T1019 and T2016 Paid at Incorrect Rate - Specialties 656, 666, 664, 652, 673 and 674

Some HCBS claims subject to the Denver Minimum Wage rate for procedure codes H0038, S5130, T1019 and T2016 for dates of service on or after 1/1/21 are not being reimbursed at the correct rate. Some member profiles in the Colorado Benefits Management System (CBMS) were missing county of residence data.

A resolution to this issue is in process. Affected claims will be reprocessed.

County of residence is based on information in the member's profile in the Colorado Benefit Management System, which is then transmitted to the Colorado interChange.

Resolved 12/28/2022: Home & Community-Based Services (HCBS) In Home Support Services (IHSS) Claims for H0038 with the U5 Modifier Paid at Incorrect Rate

Some IHSS claims for procedure code H0038 billed with the U5 modifier for dates of service on or after 1/1/2022 were being paid at an incorrect rate. The rate for Health Maintenance Services, outside Denver County on the Children’s Home and Community Based Services waiver was decreased in error during the month of December 2022.

Affected claims were reprocessed on 1/9/23.

Issue resolved 12/28/22

Resolved 5/26/22: Home and Community-Based Services (HCBS) Procedure Codes T2025 for Explanation of Benefits (EOB) Codes 4758 and 1553

Some HCBS claims for procedure code T2025 with specific option modifiers of U8 and SE for Specialty 702 were not reimbursing for Explanation of Benefits (EOB) Codes 1553 "the procedure code and modifier combination is not covered for the member’s benefit," and 4758 "Billing Provider Type/Specialty Restriction on Procedure Coverage Rule."

Affected claims were reprocessed on 5/26/22.

Issue resolved 5/26/22

Resolved 5/18/22: Home and Community-Based Services (HCBS) Procedure Codes T2021 and S5165 and Option Modifiers for Explanation of Benefits (EOB) Codes 4758 and 1553

Some HCBS claims for procedure codes S5165 and T1021 with specific option modifiers of TU for Specialties 648 and 651 are not reimbursing for Explanation of Benefits (EOB) Codes 4758 - "the procedure code and modifier combination is not covered for the member’s benefit plan" and 1553 -"the procedure code and modifier combination is not covered for the member’s benefit plan."

Affected claims were reprocessed on 5/19/22.

Issue resolved 5/18/22

Resolved 5/6/2022: Elderly, Blind, and Disabled Waiver (EBD) Claims Denying with Procedure Code S5130

Some Elderly, Blind, and Disabled Waiver (EBD) claims for procedure code S5130 billed with modifiers SC and U1 were denying for Explanation of Benefits (EOB) 1553 - The procedure code and modifier combination is not covered for the member’s benefit plan.

Affected claims were reprocessed on 5/9/22.

Issue resolved 5/6/22

Resolved 1/25/22: Home & Community Based Services (HCBS) Alternative Care Facility/Supported Living Program (ACF/SLP) Claims for T2031 with TU Modifier Denying for Explanation of Benefits (EOB) 1010
Some HCBS ACF/SLP waiver claims for procedure code T2031 billed with the TU modifier (enhanced rate for COVID-19) with dates of service on or after 01/01/22 were denying for EOB 1010 – “This is a duplicate item that was previously processed and paid.” The Colorado interChange was allowing one line item to process for payment but denying the other line item as a duplicate.

Affected claims were reprocessed 1/28/22.

Issue resolved 1/25/22

Resolved 12/23/21: Home & Community-Based Services (HCBS) Respite Care Claims for S5151 Paying Incorrectly with Explanation of Benefits (EOB) 2391
Some HCBS Respite Care claims for procedure code S5151 received and processed on or after 12/1/21 were paying incorrectly with EOB 2391 – “BH Per Diem benefit is limited to 1 per day.”

Affected claims were reprocessed for the additional units billed 1/14/22.

Issue resolved 12/23/21

Resolved 12/7/21: Home & Community-Based Services (HCBS) In Home Support Services (IHSS) Claims for T1019 Paid at Incorrect Rate

Some IHSS claims subject to the Denver Minimum Wage Rate for procedure code T1019 billed with U1, HR and KX modifiers for dates of service on or after 7/1/2021 were being under paid.

Providers are reminded that for the Denver Minimum Wage Rate the county of residence is based on information recorded on the member’s profile in the Colorado Benefits Management System (CBMS), which is then transmitted to the Colorado interChange.

Affected claims were reprocessed between 12/10 and 12/31/21. Only claims billed at the higher, increased rate were reprocessed. Claims billed at the original rate without the increase will need to be adjusted by the provider with an adjusted billed amount.

Issue resolved 12/7/21

11/16/21: Home & Community-Based Services (HCBS) Residential Habilitation Claims for T2016 Paid at Incorrect Rate
Some HCBS Residential Habilitation claims subject to the Denver Minimum Wage Rate for procedure code T2016 were paid at the incorrect rate. Please reference the information listed below:

Individual Residential Services and Supports (IRSS) – T2016 claims billed with the U3, TG and 22 modifier combination were paid at an incorrect rate of $238.37 due to a recent update. The correct rate is $283.87.
Individual Residential Services and Supports/Host Home (IRSS/HH) – T2016 claims billed with the U3, TG and TT modifier combination were paid at an incorrect rate of $72.97 due to a recent update. The correct rate is $205.97.

Affected claims were reprocessed 11/19/21 and 11/23/21.

Issue resolved 11/16/21

Resolved 11/1/21: Colorado interChange Update for Home & Community-Based Services (HCBS) American Rescue Plan Act (ARPA) Rates
Effective 11/1/21, the Colorado interChange was updated with a temporary rate increase for some Home and Community-Based Services (HCBS) waiver benefits in response to the COVID-19 public health emergency. A temporary 2.11% rate increase will be applied to impacted services retroactively to 4/1/21 and will be in effect through 3/31/22.

The affected HCBS provider claims that have an increase due to the American Rescue Plan Act (ARPA) were reprocessed by the fiscal agent between December 10 and December 31, 2021. Only claims that were billed with the higher rate were reprocessed. Providers are instructed to submit an adjustment with an adjusted billed amount for claims billed at the original lower rate without the increase. Refer to the December 2021 Provider Bulletin (B2100471) for more information on the reprocessing effort.

Providers should refer to Operational Memo Number OM 21-071 for more information on impacted services, billing instructions, and the total percentage increase for each service.

Issue resolved 11/1/21

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

Home Health

Resolved 7/7/23: Private Duty Nursing (PDN) Claims Denying Incorrectly for EOB 5548
Private Duty Nursing (PDN) claims for clients under 21 years old were posting (Explanation of Benefits) EOB 5548 "benefit is limited to 23 units per day" incorrectly.

Affected claims were reprocessed 7/7/23.

Issue resolved 7/7/23

Resolved 4/26/23: Some Claims for Adult Home Health Services Denying for Prior Authorization
Some claims for adult home health services may have denied due to no Prior Authorization (PA) being found as some PAs were not entered into the Colorado interChange. Data entry has been delayed on more recently submitted PARs. Please allow at least three business days prior to sending an email inquiry to hcpf_lthhpars@state.co.us.

Some affected claims were reprocessed on 5/4/23, and additional reprocessing was completed on 5/15/23. In addition, some claims must be resubmitted by the provider with the correct date plan established.

Issue resolved 4/26/23

Resolved 4/10/23: Home Health Claims are Denying for Explanation of Benefits (EOB) 4761
Claims for Home Health using Private Duty Nurse (PDN) revenue codes 552, 559, 580, 581, and 582 billed were denying for EOB 4761 “Contract Restriction on Revenue Code Coverage Rule” only.

Providers are encouraged to resubmit these denied claims, separating each detail so that the claim detail must end on 4/2, or start on 4/3.

For example, if a claim has one detail with the span of 4/1/23-4/6/23, this must be separated into 2 details putting the relevant units, etc. into each one:

Detail 1: 4/1/23-4/2/23
Detail 2: 4/3/23-4/6/23

Issue resolved 4/10/23

Resolved 4/7/23: Home Health Claims are Denying for Explanation of Benefits (EOB) 1331
Claims for Home Health using Private Duty Nurse (PDN) revenue codes 552, 559, 580, 581, and 582 were denying for EOB 1331 - "No billing rule for revenue code."

Affected claims were reprocessed on 4/7/2023.

Issue resolved 4/7/23

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

Hospital - General

Resolved 08/16/23: Outpatient Hospital Claims Paying Incorrect Rate

Some outpatient hospital claims were paying at the incorrect Enhanced Ambulatory Patient Group (EAPG) rate for dates of service beginning July 1, 2023. The across-the-board rate was implemented in the Colorado interChange on August 16, 2023.

Affected claims were reprocessed on 08/25/23.

Issue resolved 08/16/23.

Affected claims will be reprocessed.

Issue resolved 08/16/23.

Affected claims were reprocessed 07/28/23

Issue resolved 07/28/23

Resolved 05/03/23: Hospital Inpatient Claims Denying Explanation of Benefits (EOB) 2303 - “Hospital Readmission too close to last discharge”

Some hospital inpatient claims submitted after 03/24/23 were denying and then suspending for EOB 2303 - “Hospital Readmission too close to last discharge”.

Affected claims were reprocessed 05/04/23.

Issue resolved 05/03/23.

Resolved 01/18/23: COVID-19 Vaccine Claims with Procedure Codes 0044A and 90471 were Denying for Explanation of Benefits (EOB) 7809 and/or EOB 1381

Affected claims were reprocessed on 01/19/23.

Issue resolved 01/18/23.

Claims should adjudicate appropriately.

Issue resolved 08/24/22.

Resolved 7/28/22: Institutional Claims for Diagnosis Codes Z28310, Z28311, Z2839 Denying for Explanation of Benefits (EOB) 3014 EAPGS - “Diagnosis is either invalid for date(s) of service or requires greater specificity” and Enhanced Ambulatory Patient Grouping (EAPG) Error Code 3102 - “Secondary Diagnosis”

Some institutional claims for the diagnosis codes listed below were denying for EOB 3014 - “EAPGS Diagnosis is either invalid for date(s) of service or requires greater specificity” and Enhanced Ambulatory Patient Grouping (EAPG) Error Code 3102 - “Secondary Diagnosis”.

Z28310 - Unvaccinated for COVID-19
Z28311 - Partially vaccinated for COVID-19
Z2839 - Other under-immunization status

Approval from the Centers for Medicare and Medicaid Services (CMS) was received to implement EAPG version 3.16. This version has been implemented.

Issue resolved 07/28/22.

Resolved 08/24/22: Hospital Claims with Split Eligibility

Some inpatient hospital claims were denying for the following Explanation of Benefits (EOB) codes when subject to All Patient Refined Diagnosis Related Groups (APR/DRG) payment where the member was not Medicaid-eligible for the entire inpatient hospital stay.

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.

Claims should adjudicate and pay appropriately.

Issue resolved 08/24/22.

Resolved 4/29/2022: Inpatient Hospital Claims

Some inpatient hospital claims were incorrectly pricing which may have resulted in underpayments.

Affected claims were reprocessed on 5/6/22.

Issue resolved 4/29/22

Resolved 11/3/21: Colorado interChange Update for 2.5% Increase on Outpatient Hospital Enhanced Ambulatory Patient Grouping (EAPG) Rates

The Colorado interChange was updated according to Senate Bill (SB) 21-205, which authorized a 2.5% rate increase for outpatient hospital EAPG claim payments for dates of service on or after July 1, 2021. Visit the Outpatient Hospital Payment web page for more rate information for hospitals paid through the EAPG system.

Affected claims were reprocessed 12/24/21. Any adjustments that would have denied and recouped the first claim were not reprocessed so that the provider would still retain the original payment.

Issue resolved 11/3/21

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

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.

Hospital - Mental

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

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.

Independent Laboratory

Indian Health Services

Affected claims were reprocessed on 08/17/23.

Issue resolved 08/16/23.

Affected claims were reprocessed 07/28/23

Issue resolved 07/28/23

Resolved 01/18/23: COVID-19 Vaccine Claims with Procedure Codes 0044A and 90471 were Denying for Explanation of Benefits (EOB) 7809 and/or EOB 1381

Affected claims were reprocessed on 01/19/23.

Issue resolved 01/18/23.

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.

Non-Physician Practitioner

Affected claims were reprocessed on 08/17/23.

Issue resolved 08/16/23.

Affected claims were reprocessed 07/28/23

Issue resolved 07/28/23

Resolved 07/12/23: Prevention of Duplicate Injectables within Seven Days of Billing

Effective for dates of service beginning January 14, 2022, the Colorado interChange compares fee-for-service pharmacy and professional/professional crossover claim types to prevent duplicate reimbursement payments for Physician-Administered Drugs (PADs). A provider’s office (clinic) will not be reimbursed for a PAD when another pharmacy or professional/professional crossover claim line has already been paid for the same drug’s specified National Drug Code (NDC) range within seven (7) days of the date of service. If a duplicate is detected, the line will be denied and providers will receive Explanation of Benefits (EOB) 1817 - "Duplicate claim. NDC previously paid."

Affected claims were reprocessed on 07/21/23.

Changes implemented on July 12, 2023.

Resolved 01/18/23: COVID-19 Vaccine Claims with Procedure Codes 0044A and 90471 were Denying for Explanation of Benefits (EOB) 7809 and/or EOB 1381

Affected claims were reprocessed on 01/19/23.

Issue resolved 01/18/23.

Resolved 10/03/22: Physician Services: Claims for Physician Administered Drugs (PAD) Denying on New J Codes

Claims that require a prior authorization (PA) were denying on new codes that were effective October 1, 2022: J0178, J0202, J0219, J0221, J0490, J0491, J1303, J2796, J3032, J3241.

An error occurred which did not adequately allow PA submission for the new codes. This error has been rectified as of Monday, October 3, 2022.

Retroactive PAs for dates of service October 1, 2022, to October 6, 2022, may be accepted for the PAD PA required codes that were effective October 1, 2022. Approved PA numbers may be found in Atrezzo.

Claims billed and denied for dates of service October 1, 2022, to October 12, 2022, were reprocessed on October 25, 2022.

Issue resolved 10/03/22.

Claims should adjudicate appropriately.

Issue resolved 08/24/22.

Resolved 1/14/22: Physician-Administered Drug (PAD) Claims Denying for Explanations of Benefits (EOB) 0192

Some PAD claims for the following procedure codes with dates of service on or after 1/1/2022 were denying for EOB 0192 –“ Prior Authorization (PA) is required for this service. An approved PA was not found.”

Impacted procedure codes: J0517, J0585, J0586, J0587, J0588, J0897, J1300, J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599, J1745, J2182, J2323, J2350, J2357, J2786, and J3380.

Providers are reminded that these drugs will be subject to PA requirements effective January 18, 2022. Refer to the January 2022 Provider Bulletin (B220472) for more information

Affected claims were reprocessed 1/14/22.

Issue resolved 1/14/22

Resolved 11/18/21: Physician-Administered Drug (PAD) Claims for Multiple Procedure Codes Denying for Explanation of Benefits (EOB) 1381
Some Physician-Administered Drug (PAD) claims for the listed procedure codes with dates of service on or after 10/1/2021 were denying for EOB 1381 – “No billing rule for procedure.”

J0517	J0585	J0586	J0587
J0588	J0897	J1300	J1459
J1556	J1557	J1561	J1566
J1568	J1569	J1572	J1599
J1745	J2182	J2323	J2350
J2357	J2786	J3380

Affected claims were reprocessed 12/3/21. Additional affected claims were identified on 1/19/21 and were reprocessed 1/28/22.

Issue resolved 11/18/21

Resolved 10/27/21: Women’s Health Claims for Procedure Code S4993 Denying for Explanation of Benefits (EOB) 0101
Some claims for procedure code S4993 were denying for EOB 0101 - "This is a duplicate service." when billed with multiple line items or multiple claims using modifiers FP or FP, U1.

Affected claims were reprocessed 10/27/21.

Issue resolved 10/27/21

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

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

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

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"

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 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

Nursing Facility

Affected claims were reprocessed 07/28/23

Issue resolved 07/28/23

Resolved 06/28/23: PETI/PAR Error Message

Some providers were receiving an incorrect error message when they tried to submit for Post Eligibility Treatment of Income (PETI) Prior Authorization Request (PAR), “Data validation failure. PROV invalid for FIN payer. Rend PROV invalid for BEN Plan.”

Affected claims were reprocessed on 06/28/23.

Issue resolved 06/28/23.

Resolved 01/18/23: COVID-19 Vaccine Claims with Procedure Codes 0044A and 90471 were Denying for Explanation of Benefits (EOB) 7809 and/or EOB 1381

Affected claims were reprocessed on 01/19/23.

Issue resolved 01/18/23.

Occupational Therapist

Resolved 04/12/23: Claims Denying for Outpatient Speech Therapy, Physical Therapy and Occupational Therapy Provided via Telehealth for Explanation of Benefits (EOB) 3054 – “EVV Record Required and Not Found”

Claims submitted after April 1, 2023, for Electronic Visit Verification (EVV) Implementation for Outpatient Speech Therapy, Physical Therapy and Occupational Therapy providers were denying incorrectly for Explanation of Benefits (EOB) 3054 – “EVV Record Required and Not Found”.

Affected claims were reprocessed on 4/14/23.

Issue resolved 4/12/23

In the December 2022 Provider Bulletin (B2200487) located on the Bulletins web page, the Department stated that EVV would be required for outpatient therapies provided via telehealth beginning April 1, 2023. This change in policy has not occurred. The policy will continue with an exemption for EVV. Contact hcpf_evv@state.co.us with any EVV questions.

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"

This issue has been resolved for adjusted claims, and these adjustments were reprocessed by Gainwell Technologies.

Pediatric Behavioral Therapy Providers

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 07/12/23: Prevention of Duplicate Injectables within Seven Days of Billing

Affected claims were reprocessed on 07/21/23.

Changes implemented on July 12, 2023.

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.

Physical Therapist

Affected claims were reprocessed on 4/14/23.

Issue resolved 4/12/23

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"

This issue has been resolved for adjusted claims, and these adjustments were reprocessed by Gainwell Technologies.

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

Affected claims were reprocessed on 08/17/23.

Issue resolved 08/16/23.

Affected claims were reprocessed 07/28/23

Issue resolved 07/28/23

Resolved 07/12/23: Prevention of Duplicate Injectables within Seven Days of Billing

Affected claims were reprocessed on 07/21/23.

Changes implemented on July 12, 2023.

Resolved 01/18/23: COVID-19 Vaccine Claims with Procedure Codes 0044A and 90471 were Denying for Explanation of Benefits (EOB) 7809 and/or EOB 1381

Affected claims were reprocessed on 01/19/23.

Issue resolved 01/18/23.

Resolved 10/03/22: Physician Services: Claims for Physician Administered Drugs (PAD) Denying on New J Codes

Claims that require a prior authorization (PA) were denying on new codes that were effective October 1, 2022: J0178, J0202, J0219, J0221, J0490, J0491, J1303, J2796, J3032, J3241.

An error occurred which did not adequately allow PA submission for the new codes. This error has been rectified as of Monday, October 3, 2022.

Issue resolved 10/03/22.

Claims should adjudicate appropriately.

Issue resolved 08/24/22.

Resolved 10/28/22: Claims for Physician Administered Drugs (PAD) Denying for Explanation of Benefits (EOBs) 0192 and 3053

Some claims that were billed with a Physician Administered Drug (PAD) may have denied with EOBs 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" and EOB 3053: "Prior Authorization (PA) is required for inpatient services. An approved PA was not found matching the provider, member, and service information on the claim."

Affected claims were reprocessed were on 11/02/22.

Issue resolved 10/28/22.

Resolved 1/14/22: Physician-Administered Drug (PAD) Claims Denying for Explanations of Benefits (EOB) 0192

Impacted procedure codes: J0517, J0585, J0586, J0587, J0588, J0897, J1300, J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1599, J1745, J2182, J2323, J2350, J2357, J2786, and J3380.

Providers are reminded that these drugs will be subject to PA requirements effective January 18, 2022. Refer to the January 2022 Provider Bulletin (B220472) for more information

Affected claims were reprocessed 1/14/22.

Issue resolved 1/14/22

J0517	J0585	J0586	J0587
J0588	J0897	J1300	J1459
J1556	J1557	J1561	J1566
J1568	J1569	J1572	J1599
J1745	J2182	J2323	J2350
J2357	J2786	J3380

Affected claims were reprocessed 12/3/21.Additional affected claims were identified on 1/19/21 and were reprocessed 1/28/22.

Issue resolved 11/18/21

Issue resolved 10/27/21

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

Providers may resubmit affected claims.

Issues resolved 3/2/21

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"

This issue has been resolved for adjusted claims, and these adjustments were reprocessed by Gainwell Technologies.

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

Rural Health Clinic

Affected claims were reprocessed on 08/17/23.

Issue resolved 08/16/23.

Affected claims were reprocessed 07/28/23

Issue resolved 07/28/23

Resolved 01/18/23: COVID-19 Vaccine Claims with Procedure Codes 0044A and 90471 were Denying for Explanation of Benefits (EOB) 7809 and/or EOB 1381

Affected claims were reprocessed on 01/19/23.

Issue resolved 01/18/23.

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

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

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

Providers may resubmit affected claims.

Issue resolved 3/2/21

Speech Therapy

Affected claims were reprocessed on 4/14/23.

Issue resolved 4/12/23

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 2/1/23: Non-Emergent Medical Transportation (NEMT) Claims With Procedure Codes and Modifier 76 Were Denying for Explanation of Benefits (EOB) 7817
Some claims for NEMT with procedure codes A0425, A0120, A0100, A0130, A0434, A0090, A0110, A0200, A0428, S0209, A0180, A0433, A0426, A0080, A0190, A0210, A0021, A0430, T2001, A0422, A0140, T2005, T2049, with modifier 76, for multiple trips, were denying for EOB 7817 "payment modifier is not appropriate with the procedure code billed."

Claims were reprocessed on 2/3/23.

Issue resolved 2/1/23

Resolved 2/1/23: Non-Emergent Medical Transportation (NEMT) Claims With Procedure Code A0427 and Modifier 76 Were Denying for Explanation of Benefits (EOB) 7817
Some claims for NEMT with procedure code A0427 and using modifier 76 were denying for EOB 7817 - The payment modifier is not appropriate with the procedure code billed.

Claims were reprocessed on 2/3/23.

Issue resolved 2/1/23

Resolved 1/6/22: Non-Emergent Medical Transportation (NEMT) Claims for Procedure Code A0120 Denying for Explanation of Benefits (EOB) 1512

Some NEMT claims for procedure code A0120 with dates of service on or after 12/1/2021 were denying for EOB 1512 – “The procedure code/modifier combination is not payable for the date of service.”

Affected denied claims were reprocessed 1/13/22.

Issue resolved 1/6/22

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

Vision Services

Resolved 2/6/23: Optometrist Codes

Effective 1/14/23, the following Current Procedural Terminology (CPT) codes are available to Provider Type 07 - Optometrist:

10060, 10120, 11102, 11103, 11200, 11201, 11310, 11440, 11900, 65430, 65435, 65436, 65778, 65855, 66761, 66762, 66821, 67515, 67800, 67801, 67805, 67820, 67825, 67840, 67921, 67930, 68020, 68200, 68760, 68761, 68841

Affected claims were reprocessed on 2/10/23.

Issue resolved 2/6/23.

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

Women's Health

Rate Updates for Procedure Code 99203 with Modifiers FP and FP+GT

The rates for the Evaluation and Management (E&M) Current Procedural Terminology (CPT) code 99203, when billed with the Family Planning modifier (FP) or FP + GT (telemedicine modifier) were loaded into the Colorado interChange incorrectly.

The rates have been corrected on the FY 19-20, FY 20-21 and FY 21-22 Health First fee schedules. Claims submitted for 99203 (FP) or 99203 (FP+GT) with dates of service on or following March 28, 2020, were reprocessed on April 4, 2020, for the additional payment.

The corrected rate amounts, per fiscal year, for 99203 (FP) and 99203 (FP + GT) are listed below:

Family Planning Rates and Modifiers
99203	FP	FP+GT	Note
FY 21-22	$122.77	$127.84	2.5% increase applied to FY 20-21 rate
FY 20-21	$119.78	$124.73	1.0% decrease applied to FY 19-20 rate
FY 19-20	$120.99	$125.94	Base rate

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.

Issue resolved 10/27/21

99401	99402	99403
99404	99406	99407
G8431	G8510	G9006
T1017

Claims were reprocessed 2/5/21.

Issue resolved 2/3/21

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