Managed Care Programs Billing Manual

Return to Billing Manuals Web Page

 

Some Health First Colorado, Colorado's Medicaid Program, members obtain Health First Colorado through enrollment in a Health First Colorado's Managed Care Organizations (MCO). Health First Colorado offers the following Managed Care Entity (MCE) options:

  • Managed Care Organizations (MCOs)
    • Denver Health Medicaid Choice
    • Rocky Mountain Health Plans Prime
  • Community Behavioral Health Services Program

 

Identifying Health First Colorado Managed Care Enrollment

Providers must always verify eligibility information, including managed care participation, before providing services. Failure to verify eligibility information increases the risk of not receiving payment for rendered services. Fee-for-service claims for members who are enrolled in a Health First Colorado MCE will be denied.

Providers must comply with the requirements of Managed Care Entities.

For MCEs, service providers must be enrolled in the MCE network or have authorization to provide non-exempt services (see information below under Managed Care Entities). The name and telephone number of the MCE is identified on the eligibility verification response.

Back to Top

Managed Care Entity Support Services for Providers

Questions about the policies and billing procedures for a specific MCE should be directed to that MCE.

Back to Top

Managed Care Organizations (MCOs)

Health First Colorado contracts with MCOs to provide benefits to Medical Assistance Program members enrolled in the MCO. MCO-enrolled members must obtain available services from the MCO with which they have been assigned. Available services may differ across each MCO as each MCO enrolls different member groups.

MCO enrolled members are entitled to the same Health First Colorado benefits as members who are not enrolled in managed care.

  • Managed Care Organizations provide most of the Health First Colorado benefits to enrolled members, for physical health conditions.
  • Benefits that the MCO does not cover may be provided through Fee-for-Service reimbursement, provided it is a covered Health First Colorado benefit.
  • Certain MCO covered benefits may have coverage limitations, such medical necessity or a set number of services. When such an MCO benefit is exhausted, additional medically necessary services are provided through Fee-for-Service reimbursement.

 

Back to Top

Benefit Availability

MCO Benefits

  • Acute Home Health
  • Ambulance
  • Durable Medical Equipment and Disposable Supplies
  • EPSDT
  • Family Planning Services
  • Inpatient Hospital
  • Laboratory and X-ray
  • Medical Services
  • Outpatient Hospital
  • Physical and Occupational Therapy
  • Physician Services
  • Podiatry
  • Prescription Drugs
  • Vision Services
  • NOTE: Adult vision benefits are only available through an MCO

Back to Top

Medical Assistance Program Fee-for-Service Only Benefits

  • Dental Care*
  • Home and Community Based Services
  • Hospice Services
  • Long Term Care (Nursing facilities or Community-based care)
  • Long Term Home Health
  • Non-Emergency Transportation
  • Private Duty Nursing

Back to Top

Fee-for-Service Benefits for MCO-Enrolled Members

Health First Colorado pays Fee-for-Service claims for MCO-enrolled members under the following circumstances:

  1. When a Health First Colorado benefit is not provided by the MCO, the benefit may be referenced in the MCO contract and referred to as a wrap-around" benefit, or
  2. When the member has exhausted MCO benefits and requires additional medically necessary Health First Colorado benefit services.

Fee-for-Service claims for services provided to MCO enrolled members must have the following attachments:

  • A benefits exhausted statement (explanation of benefits) for MCO exhausted benefits.
  • A statement from the MCO indicating the service is not a provided MCO benefit. If the MCO routinely does not provide a specific service (e.g. nursing facility, physical therapy, etc.), the non-benefit statement is optional. Benefit coverage may vary from one (1) MCO to another.

 

Back to Top

Managed Care Organization Benefits by Non-MCO Providers

Health First Colorado will not pay claims for services provided to an MCO enrolled member that are available through the MCO. Providers should always contact the member's MCO before providing services to determine the extent of benefits available through the MCO. Direct any questions about MCO covered benefits and billing instructions to the MCO listed on the eligibility verification response.

Back to Top

Emergency Care

Emergency care and out-of-area URGENT care provided by a non-MCO provider is the responsibility of the MCO. The non-MCO provider must comply with all MCO notification requirements.

  1. The non-MCO provider must contact the MCO within 48 hours of providing services.
  2. The non-MCO provider must contact the MCO for authorization before providing non-emergency services.
  3. The MCO may not pay for services determined to be non-emergent.

 

Back to Top

Inquiries

Inquiries about MCO payments or denials should be directed to the MCO.

Inquiries about claims submitted to the fiscal agent, Gainwell Technologies for exhausted MCO benefits or non-covered MCO services should be directed to the fiscal agent.

Back to Top

Enrollment and Participation

With the exception of some select populations/individuals, essentially all Health First Colorado members are automatically enrolled in the Community Behavioral Health Program. Exceptions can found in the Code of Colorado Regulations (10 CCR 2505-10 8.212).

Back to Top

Behavioral Health Program Benefits

The BHOs are responsible for the cost of the behavioral health services listed in the most recently updated Uniform Service Coding Standards (USCS) Manual, for the behavioral health diagnoses listed in Appendix T under the Appendices drop-down section on the Billing Manuals web page.

Back to Top

Emergency Care

  • All providers who render emergency mental health services must bill the BHO. All providers who render emergency substance use disorder services on a CMS 1500 must bill the BHO.
    • This includes emergency department evaluation and management codes 99281-99285.
  • All providers who render emergency substance use disorder services on a UB-04 must bill Fee-for-Service to the Department's fiscal agent.
  • All providers provider must comply with the BHOs billing policies and procedures.

Back to Top

Full Benefit Medicare-Health First Colorado Enrollees

  • Full Benefit Medicare-Health First Colorado Enrollees may obtain Medicare-covered services from either BHO or non-BHO providers. The fiscal agent accepts and processes submitted Medicare crossover claims.
  • If the behavioral health service is covered by Health First Colorado only, the Full Benefit Medicare-Health First Colorado Enrollee must obtain the service from the BHO.

Back to Top

Behavioral Health Program Non-included Services

  • Behavioral health-related prescription drugs. Claims for prescription drugs are submitted to the Department's fiscal agent under the Fee-for-Service Reimbursement Program or to the MCO for MCO-enrolled members.
  • Nursing facility residential care. Nursing facility claims are submitted to the Department's fiscal agent for Fee-for-Service reimbursement.
  • Services in a Residential Treatment Center (RTC). RTC claims are submitted to the Department's fiscal agent for Fee-for-Service reimbursement.
  • Claims submitted to the Department's fiscal agent, Gainwell Technologies should be addressed to:
    Gainwell Technologies
    Claims Submission
    P.O. Box 30
    Denver, CO 80201

Back to Top

 

Health First Colorado Managed Care Programs Revisions Log

Revision Date Addition/Changes Made by
12/10/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive. HPE (now DXC)
12/27/2016 Updates based Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
5/22/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
2/9/2018 Update terminology and references HCPF
7/10/2019 Updated Appendices' links and verbiage DXC
2/28/2020 Converted to web page HCPF
4/20/2021 Removal of PACE, updated to DXC Gainwell HCPF
10/05/2022 Removed Call Center phone number and linked to the Provider Help web page. HCPF