Known Issues and Updates | Department of Health Care Policy and Financing

ATTENTION: Claims billed with a HCPCS 2026 procedure code may suspend for EOB 0000 - "This claim/service is pending for program review," effective January 1, 2026. The Colorado interChange is being updated with the 2026 HCPCS billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual 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 and 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.

ATTENTION: A standardized file naming convention for X12 files has been implemented for all Trading Partners. A Trading Partner is an entity that submits batch X12 transactions on behalf of a Provider. Providers should contact their Trading Partner to confirm they are using the new X12 file naming standards and that the vendor has adjusted their system to retrieve reports before they expire. Refer to the X12 File Naming Standards Quick Guide for details on X12 file naming standards and format changes to response files.

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. Provider's whose TIN does not match the IRS data will receive a letter notifying that their contract has been put on hold until the TIN is verified. Refer to the Update Legal Name and Tax Identification Quick Guide for 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'

Checks written to refund payment should be made out to "Colorado Department of Health Care Policy and Financing" and mailed to:

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

It is highly recommended to submit refunds electronically as that will automatically set up an Accounts Receivable (AR) balance. Reference the Provider Web Portal Quick Guide - Copy, Adjust, or Void a Claim, available on the Quick Guides web page, to learn how to copy, adjust or void a claim in the Provider Web Portal.

Checks made out to Gainwell Technologies will be returned. "Colorado Department of Health Care Policy and Financing" is the only pay-to name that will be accepted.

Provider Web Portal

How to Look Up a Prior Authorization Request (PAR) on the Provider Web Portal

Home & Community-Based Services (HCBS) providers can view a member's Prior Authorization Request (PAR) status and details in the Provider Web Portal with the prior authorization number. Providers should choose the "Care Management" option from the home page and select "View Authorization Services". Providers will be required to enter the member identification number and approved prior authorization number into the Provider Web Portal.

Note: Providers should be receiving prior authorization numbers from the case managers.

Other provider types (not HCBS) can look up a prior authorization status without the number, as long as the billing provider ID matches. PARs that are visible in the Provider Web Portal are also finalized in the Colorado interChange.

For more information on viewing PARs on the Provider 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 Browsers May Cause Provider Web Portal Errors

Providers should not use older versions of browsers when accessing the Provider Web Portal. Providers should ensure they have downloaded the most recent version of supported web browser. Refer to the Website Requirements web page of the Provider Web Portal to see a list of supported web browsers.

Provider Web Portal Login Reminders

Timeouts Due to User Inactivity

The Provider Web Portal allows up to 15 minutes of inactivity. If left idle for 15 minutes, the system will automatically log the user out. To regain access, the user may immediately return to the login page and enter the credentials.

Unlock a User Account

A user may become temporarily locked out. This is commonly due to multiple attempts using wrong password. The account will automatically unlock after approximately 15 minutes, at which point the user may attempt to log in again using the correct credentials.

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 Claims in Suspended Status

Claims in Suspended Status

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

Explanation: 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. Physician Administered Drugs (PADs) require a National Drug Code (NDC) assignment and may take up to 90 days before implementation.

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 365 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 member is currently not eligible.

Estimated Time for Processing: This claim will be recycled after 15 calendar days. If after 15 days the member is still not eligible for the Date of Service (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." 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 five (5) days for final approval. Providers should not submit duplicate update requests.

2026 Medicare Part A and Part B Deductible Amounts

The Medicare annual deductible amounts have changed for 2026. Medicare Part A increased from $1,676 to $1,736. Medicare Part B increased from $257 to $283.

Known Issues and Resolved Issues

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

All Provider Types

Tracking ID Missing a Digit in 271 and 277 Response and Acknowledgement File Names in the Electronic Data Interchange (EDI)

Some Trading Partners using automated scripts to retrieve EDI response and acknowledgement files may not be able to process 271 and 277 files. The issue is due to a missing one-digit prefix in the tracking ID portion of the file name. The tracking ID currently contains nine (9) digits; however the correct file name format requires nine (9) digits plus one-digit prefix.

Trading Partners may manually download 271 and 277 files while the issue is being addressed.

A resolution is in process.

Resolved 11/12/25: Some Provider Web Portal Users were Receiving an Error During Eligibility Verification

Some providers performing member Eligibility Verification in the Provider Web Portal received an error message when the search contains a date range. This occurred for members with multiple, non-overlapping aid code records within the date range searched. Providers searched by a single date instead of a date range to avoid this error message.

Issue resolved 11/12/25.

Resolved 10/1/25: Some Providers Were Not Seeing Additional Taxonomies During Maintenance

Some providers that have additional taxonomies were not seeing the taxonomies listed in the Additional Taxonomies section of the Specialty and Contact Information Changes panel when completing a Maintenance Request in the Provider Web Portal.

No action is needed from providers.

Issue resolved 10/1/25.

Resolved 10/1/25: Provider Web Portal Registration Instruction Letters

Many providers received a letter on 9/3/25 containing registration instructions for creating a Provider Web Portal account. If the Provider Web Portal account is already created, please disregard the letter.

Providers that need to create a Provider Web Portal account for the first time may follow the directions to complete this action. We apologize for any confusion.

Issue resolved 10/1/25.

Resolved 9/30/25: "Unknown Error" Message when Editing Service Address in Provider Web Portal

Some providers were encountering an “Unknown Error” message when attempting to add or update information in the Service Address Information panel of the Provider Web Portal. The issue has been resolved. We apologize for the inconvenience.

Ambulatory Surgical Centers (ASC)

No Known Issues for this provider type.

Anesthesia

No Known Issues for this provider type.

Audiology

No Known Issues for this provider type.

Behavioral Health

Resolved 1/14/26: Some Claims for Short Term Behavioral Health Services were Denying for Explanation of Benefits (EOB) 2029

Some claims for Short Term Behavioral Health services for procedure codes 90791, 90832, 90834, 90837, 90846, 90847 were denying for EOB 2029 - “The Services Must Be Billed to the Members RAE.”

Affected claims were reprocessed on 9/3/24.

Issue resolved 1/14/26.

Resolved 10/2/25: Some Professional Claims Submitted by Provider Type (PT) 37 and PT 25 were Denying Incorrectly for Explanation of Benefits (EOB) 2861

Some professional claims submitted by PT 37 (Licensed Psychologist) and PT 25 (Non-Physician Practitioner) for services billed with procedures codes 90837, 90832, 90834, 90846 or 90847 with Dates of Service (DOS) 7/1/2025 - 9/30/2025 were denying incorrectly for Explanation of Benefits (EOB) 2861 - “No Rate on File for the Date(s) of Service.”

Affected claims were reprocessed on 10/03/2025.

Issue resolved 10/02/2025.

Resolved 9/26/25: Professional or Institutional Claims for Some Essential Safety Net Providers (ESNP) Provider Types Were Denying for Explanation of Benefits (EOB) 0182

Professional or Institutional claims for some Essential Safety Net Providers (ESNP) provider types were denying on or after 9/5/2025 for Explanation of Benefits (EOB) 0182 – “Billing Provider Type and/or Specialty is not allowable for the service billed.”

Affected claims will be reprocessed.

Issue resolved 9/26/25.

Birthing Center (Free-standing)

No Known Issues for this provider type.

Case Managers

Pre Prior Authorization (PPA) Certification Dates in the Bridge out of Sync

Case Managers may encounter a message in the Bridge stating that the “PPA Cert Dates” are out of sync with the matching Service Plan when saving a Waiver-to-Waiver Revision. Case Managers may use the following workaround to submit the PPA:
1.    Modify the line item by end dating, then click Save.
2.    Go to Base Information, change the end date and check limits. (A B049 error message to end date the Inventory of Needs will appear.)
3.    Refresh the PPA and check limits. If there are no errors in the Message panel then submit the PPA.

A resolution is in process.

Comprehensive Safety Net Providers

Resolved 9/5/2025: Claims for Comprehensive Safety Net Provider Services were Denying for Explanation of Benefits (EOB) 1040

Claims for Comprehensive Safety Net Provider Services with Date of Service (DOS) on or after 7/1/2024 were denying for Explanation of Benefits (EOB) 1040 – “Contract Could Not Be Determined.”

Affected claims were reprocessed 9/19/25.

Issue resolved 9/5/2025.

Durable Medical Equipment (DME)/Supply

Resolved 1/7/26: Some CGM Claims May Have Paid at an Unexpected Rate

Some professional claims for Continuous Glucose Monitors (CGMs) with a Date of Service (DOS) on or after 11/1/2025 may have paid at an unexpected rate when billed with procedure codes A4238, A4239, A9277, A9276, A9277 or E2103, with no modifier or with a modifier of U1, U2 or U3.

Affected claims were reprocessed 1/9/26.

Issue resolved 1/7/26.

Resolved 11/5/25: Professional Claims for Some Supply Services were Denying for EOB 3958

Professional claims for Supply services with procedure codes A4238 and A4239 and a Date of Service (DOS) of 10/31/25 were denying for Explanation of Benefits (EOB) 3958 – “NO REIMB RULE FOR PROC.”

Affected claims will be reprocessed.

Issue resolved 11/5/25.

Resolved 9/29/25: Professional Claims Submitted by Durable Medical Equipment (DME)/Supply Providers for Specific Procedure Codes were Denying

Professional claims with Durable Medical Equipment (DME)/Supply procedure codes E1032, E1033 and E1034 and a Date of Service (DOS) on or after 4/1/25 were denying for Explanation of Benefits (EOB) 7826 - "Procedure code is not allowed to be submitted more than once per date of service."

Affected claims were reprocessed 10/6/25.

Issue resolved 9/29/25.

Resolved 10/24/25: Professional Claims for Supply Providers with Certain Procedure Codes and a Modifier of BO were Denying

Professional claims with a Date of Service (DOS) on or after 3/1/2025 were denying for Explanation of Benefits (EOB) 7802 – “The non-payment modifier is not appropriate with the billed procedure code” when billed with the following procedure codes and a modifier of BO: B4102, B4103, B4104, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162 and B9999.

Affected claims were reprocessed 10/24/25.

Issue resolved for procedure codes B4160 and B4161 10/1/25. Issue resolved for all other procedure codes 10/24/25.

Essential Safety Net Providers (ESNP)

Resolved 11/6/25: Professional Claims Submitted by Some Providers with an Essential Safety Net Providers (ESNP) Designation were Denying Incorrectly

Professional claims submitted by some providers with an Essential Safety Net Providers (ESNP) designation for procedure codes: 90791, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 99245 with Dates of Services (DOS) on or after 7/1/24 were denying for Explanation of Benefits (EOB) 3530 – “There is no rate on file for the date of service. Charges cannot be processed."

Affected claims were reprocessed 11/10/25.

Issue resolved 11/6/25.

Federally Qualified Health Center (FQHC)

Some Institutional Claims with Revenue Code 900 Denied Incorrectly

Some Federally Qualified Health Center (FQHC) and Rural Health Center (RHC) institutional claims for behavioral health services with revenue code 900 and a Date of Service (DOS) on or after 7/1/2025 denied incorrectly for Explanation of Benefits (EOB) 2028 – “BH REV 900 REQUIRES BH PROC.”

Affected claims will be reprocessed.

A resolution is in process.

Some Institutional Claims Previously Billed were Reprocessed Incorrectly

Some Federally Qualified Health Center (FQHC) and Rural Health Center (RHC) institutional claims for physical health services with Revenue Code 521 or 529 and with Dates of Service (DOS) prior to 1/1/2025 were reprocessed incorrectly.

Affected claims will be reprocessed.

A resolution is in process.

Resolved 11/19/25: Administrative Codes on Some Professional Claims for the RSV Vaccine were Denying Incorrectly

Some professional claims with procedure code 90382 and a Date of Service (DOS) on or after 7/1/25 were denying for Explanation of Benefits (EOB) 2861 – “No Rate on File for the Date(s) of Service.”

Professional claims with procedure code 96380 were denying for EOB 7800 – “The procedure code billed on claim is missing the primary/base service procedure(s).”

Affected claims were reprocessed 11/21/25.

Issue resolved 11/19/25.

Resolved 9/4/25: Institutional Claims Billed with Revenue Code 900 were Denying for Explanation of Benefits (EOBs) 2028, 2030 or 2031

Institutional claims with a Date of Service (DOS) on or after 1/1/25 that were billed with Revenue Code 900 were denying for the following Explanation of Benefits (EOBs): EOB 2028 – “Behavioral Health Revenue 900 Requires Behavioral Health Procedure;” EOB 2030 – “Client Services Covered by PIHP” and EOB 2031 – “Client Services Covered by RMHP.” EOBs 2030 and 2031 are exclusive to claims for members that are enrolled in Prepaid Inpatient Health Plan (PIHP) and Rocky Mountain Health Plan (RMHP).

Affected claims were reprocessed 9/12/25.

Issue resolved 9/4/25.

Home & Community-Based Services (HCBS)

Some Professional Claims for Home and Community-Based Service (HCBS) Providers May Have Been Denied for Explanation of Benefits (EOB) 4758

Some Home and Community-Based Service Providers (HCBS) with an approved Prior Authorization (PA) for members eligible for Community First Colorado (CFC) Benefit Plan services may have had professional claims denied for Explanation of Benefits (EOB) 4758 – “Billing Provider Type/Specialty Restriction on Procedure Coverage Rule.”

Providers may contact the member’s Case Manager to determine if the CFC Benefit Plan should be added.

Resolved 12/01/25: Prior Authorization Request (PAR) must be on File

Professional claims for Home and Community-Based Services (HCBS) must have an approved Prior Authorization Request (PAR) on file. Extensions were granted to allow providers to get timely payment and continue delivering services to members. The grace period has ended and claims were denying for one of the following Explanation of Benefits (EOB) numbers if an approved matching PAR is not on file.

0192
0503
5110
0504

Providers should obtain PAR information from Case Managers. If the provider has the PAR number, additional information can be viewed in the Provider Web Portal.

Claims were reprocessed 12/11/25.

Issue resolved 12/01/25.

Resolved 11/20/25: Claims Billed with Procedure Code T1017 were Denying for Explanation of Benefits (EOBs) 2030 and 2031

Professional claims billed with procedure code T1017 and received on or after 9/5/2025 were denying for Explanation of Benefits (EOB) 2030 – “The Services Must Be Billed to Denver Health Medicaid Choice Plan” or EOB 2031 – “The Services Must Be Billed to Rocky Mountain Health Plan Prime.”

Affected claims were reprocessed 11/25/25.

Issue resolved 11/20/25.

Resolved 11/13/25: Some Home and Community-Based Services (HCBS) Providers were Unable to Add Facility Identifications (IDs) for Specialties in the Provider Web Portal

Some Home and Community-Based Services (HCBS) providers were unable to add Facility IDs for specialties while completing Maintenance Updates in the Provider Web Portal. The Facility ID could not be added for a specialty that had a taxonomy matching another specialty for the provider.

Issue resolved 11/13/25.

Home Health

Resolved 11/19/25: Administrative Codes on Some Professional Claims for the RSV Vaccine were Denying Incorrectly

Professional claims with procedure code 96380 were denying for EOB 7800 – “The procedure code billed on claim is missing the primary/base service procedure(s).”

Affected claims were reprocessed 11/21/25.

Issue resolved 11/19/25.

Hospice

Resolved 9/3/25: Rates Updated for Hospice Claims Effective October 11, 2024 (FFY 24-25)

The FFY 24-25 Hospice Fee Schedule was posted under the Hospice section on the Provider Rates and Fee Schedule web page and claims reimbursement will reflect these rates for Dates of Services (DOS) effective October 11, 2024 through September 30, 2025.

Affected claims were reprocessed 9/4/25.

Issue resolved 9/3/25.

Hospital - General

Resolved 12/17/25: Institutional Claims for Outpatient Hospital Services were Paying at an Incorrect Rate

Institutional claims for outpatient hospital services with a Date of Service (DOS) of July 1, 2025 or later were paying at an incorrect rate due to the Enhanced Ambulatory Patient Grouper (EAPG) version in place.

Affected claims will be reprocessed.

Issue resolved 12/17/25.

Resolved 9/5/25: Outpatient Claims Billed with Hospital Specialty Drug Appendix Z Codes without Modifier SE Were Denying Incorrectly for EOB 6505

Institutional Outpatient Claims Billed with Hospital Specialty Drug Appendix Z Codes J9229, Q2054, J0567, Q2056, J9348, J1413, Q2042, J2326, Q2053, J1303, J0218, Q2041, J3399, J7352, J0225, J9286, J3393, J3394 without Modifier SE Were Denying Incorrectly for Explanation of Benefits (EOB) 6505 - "Paid Inpatient Claim Not Found for Specialty Drugs."

Affected claims were reprocessed on 9/5/25.

Issue resolved 9/5/25.

Hospital - Mental

No Known Issues for this provider type.

Immunization

Resolved 12/23/25: Some Professional Claims for Immunization Procedure Codes were Denying for EOB 1030

Some professional claims billed with immunization procedure codes and a Date of Service (DOS) on or after 1/1/25 were denying 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.”

Affected claims were reprocessed 12/29/25.

Issue resolved 12/23/25.

Resolved 11/19/25: Administrative Codes on Some Professional Claims for the RSV Vaccine were Denying Incorrectly

Professional claims with procedure code 96380 were denying for EOB 7800 – “The procedure code billed on claim is missing the primary/base service procedure(s).”

Affected claims were reprocessed 11/21/25.

Issue resolved 11/19/25.

Independent Laboratory

No Known Issues for this provider type.

Indian Health Services

No Known Issues for this provider type.

Lactation

No Known Issues for this provider type.

Non-Physician Practitioner

Resolved 10/2/25: Some Professional Claims Submitted by Provider Type (PT) 37 and PT 25 were Denying Incorrectly for Explanation of Benefits (EOB) 2861

Affected claims were reprocessed on 10/03/2025.

Issue resolved 10/02/2025.

Nursing Facility

No Known Issues for this provider type.

Occupational Therapist

Resolved 11/17/25: Some Claims for Physical or Occupational Therapy Services were Denying for Invalid Referring Provider

Professional claims for Physical Therapy/Occupational Therapy (PT/OT) services with a Date of Service (DOS) on or after 7/1/2024 and billed by Certified Nurse Midwives (CNMs) were denying for Explanation of Benefits (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 12/2/25.

Issue resolved 11/17/25.

Pediatric Behavioral Therapy Providers

Prepayment Reviews may be Required for Some Pediatric Behavioral Therapy (PBT) Providers

Beginning 2/1/26, the Department of Health Care and Finance (the Department) will conduct prepayment reviews of some Pediatric Behavioral Therapy (PBT) providers.

Reviews will focus on specific PBT coding. Review parameters will be posted publicly once finalized. Individual providers that are asked to participate in prepayment reviews will receive a direct notice from the Department prior to 2/1/26 that outlines the scope of the review and provides general instructions.

Personal Care

No Known Issues for this provider type.

Pharmacist

Resolved 11/19/25: Administrative Codes on Some Professional Claims for the RSV Vaccine were Denying Incorrectly

Professional claims with procedure code 96380 were denying for EOB 7800 – “The procedure code billed on claim is missing the primary/base service procedure(s).”

Affected claims were reprocessed 11/21/25.

Issue resolved 11/19/25.

Pharmacy

Resolved 1/7/26: Some CGM Claims May Have Paid at an Unexpected Rate

Affected claims were reprocessed 1/9/26.

Issue resolved 1/7/26.

Resolved 11/19/25: Administrative Codes on Some Professional Claims for the RSV Vaccine were Denying Incorrectly

Professional claims with procedure code 96380 were denying for EOB 7800 – “The procedure code billed on claim is missing the primary/base service procedure(s).”

Affected claims were reprocessed 11/21/25.

Issue resolved 11/19/25.

Physical Therapist

Affected claims were reprocessed 12/2/25.

Issue resolved 11/17/25.

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.

Physician Services/Clinics

Resolved 11/19/25: Administrative Codes on Some Professional Claims for the RSV Vaccine were Denying Incorrectly

Professional claims with procedure code 96380 were denying for EOB 7800 – “The procedure code billed on claim is missing the primary/base service procedure(s).”

Affected claims were reprocessed 11/21/25.

Issue resolved 11/19/25.

Resolved 9/25/25: Clinics Billing for Hospital Observations on Professional Claims Forms (CMS1500) were Denying Incorrectly for EOB 0182 - "Billing Provider Type and/or Specialty is not allowable for the service billed"

Claims billed by clinics for Hospital Observation with procedure code 99221 for clinic services with Date of Service (DOS) on or after 7/1/24 were denying incorrectly for Explanation of Benefits (EOB) EOB 0182 - "Billing Provider Type and/or Specialty is not allowable for the service billed."

Affected claims were reprocessed on 10/7/25.

Issue resolved 9/25/25.

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.

Rural Health Clinic

Affected claims will be reprocessed.

A resolution is in process.

Some Institutional Claims Previously Billed were Reprocessed Incorrectly

Affected claims will be reprocessed.

A resolution is in process.

Resolved 11/19/25: Administrative Codes on Some Professional Claims for the RSV Vaccine were Denying Incorrectly

Professional claims with procedure code 96380 were denying for EOB 7800 – “The procedure code billed on claim is missing the primary/base service procedure(s).”

Affected claims were reprocessed 11/21/25.

Issue resolved 11/19/25.

Resolved 9/4/25: Institutional Claims Billed with Revenue Code 900 were Denying for Explanation of Benefits (EOBs) 2028, 2030 or 2031

Affected claims were reprocessed 9/12/25.

Issue resolved 9/4/25.

Speech Therapy

Resolved 12/23/25: Inaccurate Portal Display for Speech Therapy Units

The Provider Web Portal was displaying inaccurate units available for speech therapy services. Claims were being processed correctly but the totals displayed in the Provider Web Portal were inaccurate.

Providers may contact Acentra to begin the prior authorization process even if all units have not been utilized.

Issue resolved 12/23/25.

Resolved 12/04/25: Some Professional Claims for Speech Therapy Services are Denying for EOB 2305

Some professional claims for Speech Therapy services with a Date of Service (DOS) on or after 08/01/2025 and billed with Procedure Code 92526 with modifiers GN + 97 are 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 were reprocessed 12/09/25.

Issue resolved 12/04/25.

Substance Use Disorder

Resolved 1/15/26: Some Substance Use Disorder (SUD) Providers were Incorrectly Disenrolled

Some Substance Use Disorder (SUD) providers were incorrectly disenrolled from Health First Colorado (Colorado’s Medicaid program).

Specialty 477 for Substance Use Disorder Clinics is no longer a valid specialty for Provider Type 64 - Substance Use Disorder (SUD) Continuum after December 31, 2025. Refer to the specific specialties on the Find Your Provider Type web page. Enrollments for Provider Type 64 with no other specialty attached by December 31, 2025 were terminated.
Contact hcpf_bhbenefits@state.co.us with any questions.

Issue resolved 1/15/26.

Resolved 12/16/25: Some Professional Claims for Substance Use Disorder (SUD) Continuum Services were Denying for Explanation of Benefits (EOB) 1082

Professional claims for Substance Use Disorder (SUD) Continuum services with procedure code H0010 and a modifier of HF were denying for Explanation of Benefits (EOB) 1082 – “Billing Provider Type and/or Specialty is not allowable for the service billed.”

Issue resolved 12/16/25.

Resolved 11/14/25: SUD Providers Were Unable to Add an “Unique Taxonomy”

Substance Use Disorder (SUD) providers were unable to add an “unique taxonomy” when adding “additional specialties” to a provider profile during maintenance.

Issue resolved 11/14/25.

Transportation - Non-Emergent Medical Transportation

ATTENTION: Non-Emergent Medical Transportation providers that did not comply before the deadline may not revalidate. The moratorium for Non-Emergent Medical Transportation new enrollments was approved by the Centers for Medicare & Medicaid Services (CMS) and will be in effect until at least March 31, 2026.

Members Requiring Non-Emergent Transportation (NEMT) Services

Members who require non-emergent transportation to and from medical appointments in the Denver area can call Transdev Health Solutions at (303) 398-2155 or (720) 279-3830 to schedule a ride. Members outside the Denver area can contact a provider from the Non-Emergent Medical Transportation (NEMT) Service Area list.

Credentialing Certificate Reminder for Non-Emergent Medical Transportation (NEMT) Providers

All Non-Emergent Medical Transportation (NEMT) providers are reminded to obtain a valid credentialing certificate issued by Transdev (formerly IntelliRide). Follow the steps outlined in the Special Provider Bulletin - Non-Emergent Medical Transportation (NEMT) - Reference: B2400515. Providers must then revalidate with Health First Colorado (Colorado's Medicaid program).

Claims are now being suspended for any NEMT provider who has not revalidated. Claims may also be suspended for review for other reasons. Refer to Special Provider Bulletin - Non-Emergent Medical Transportation (NEMT) (B2400515 - 11/24) for reasons claims may suspend.

The moratorium of six (6) months on new enrollments approved by the Centers for Medicare & Medicaid Services (CMS) for Non-Emergent Medical Transportation (NEMT) has been extended and will be in effect until at least March 31, 2026.

Resolved 12/18/25: Claims for Rural County Members were Denying for EOB 5527

Professional Non-Emergency Medical Transportation (NEMT) claims billed on behalf of members in rural counties were denying for Explanation of Benefits (EOB) 5527 – “Invalid or Missing Documentation for Non-Emergency Medical Transportation (NEMT) Service Limit” when the NEMT limit of 52 was exceeded.

Affected claims were reprocessed 12/19/25.

Issue was resolved 12/18/25.

Vision Services

No Known Issues for this provider type.

Women's Health

Affected claims were reprocessed 12/2/25.

Issue resolved 11/17/25.

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