Managed Care Programs Billing Manual

• Identifying Health First Colorado Managed Care Enrollment
  • Managed Care Entity Support Services for Providers
• Managed Care Organizations (MCOs)
  • Benefit Availability
    • MCO Benefits
    • Medical Assistance Program Fee-For-Service Only Benefits
• Fee-For-Service Benefits for MCO-Enrolled Members
• Managed Care Organization Benefits by Non-MCO Providers
  • Emergency Care
  • Inquiries
• Community Behavioral Health Services Program
  • Enrollment and Participation
  • Behavioral Health Program Benefits
  • Emergency Care
  • Full Benefit Medicare-Health First Colorado Enrollees
  • Behavioral Health Program Non-Included Services
• Managed Care Programs Revision Log

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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 (FFS) 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. The name and telephone number of the MCE is identified on the eligibility verification response.

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Managed Care Entity Support Services for Providers

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

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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 FFS 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 FFS reimbursement.

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Benefit Availability

MCO Benefits

• Acute Home Health
• Ambulance
• Durable Medical Equipment and Disposable Supplies
• Early and Periodic Screening, Diagnostic and Treatment (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

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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

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Fee-For-Service Benefits for MCO-Enrolled Members

Health First Colorado pays FFS 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.

FFS 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.

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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.

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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.

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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.

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 Community Behavioral Health Services Program

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).

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Behavioral Health Program Benefits

The BHOs are responsible for the cost of the behavioral health services listed in the most recently updated State Behavioral Health Services Billing Manual, for the behavioral health diagnoses listed in Appendix T under the Appendices drop-down section on the Billing Manuals web page.

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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 FFS to the Department of Health Care Policy & Financing's (the Department) fiscal agent.
• All providers must comply with the BHOs billing policies and procedures.

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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.

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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 FFS reimbursement.
• Services in a Residential Treatment Center (RTC). RTC claims are submitted to the Department's fiscal agent for FFS 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

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Managed Care Programs Revisions Log