This website summarizes:
Unanswered stakeholder questions received during Colorado Department of Health Care Policy and Financing’s (HCPF) stakeholder engagement on February 25, 2025 regarding proposed changes to the Health First Colorado appeals process.
Below each item, HCPF has provided an interim response.
Important Note: There are several stages of policy development and implementation. Any responses in this document represent a snapshot of HCPF’s position as of April 4, 2025 and should not be read as final policy determination.
Where can I find policy changes and updates shared in the stakeholder meeting, held on February 25, 2025?
The February 25, 2025 meeting presentation and recording are posted on the event webpage.
Does this change apply to both eligibility and benefit determinations?
Yes, this change applies to both eligibility and benefit determinations.
What resources are available to members or their representatives who are navigating the appeals process?
More information about the appeals process, including contact information for legal assistance referrals, can be found on HCPF’s appeals webpage. The Colorado Office of Administrative Courts, the office that conducts appeal hearings, also has resources available on their website. Their contact information can be found below.
What is the required timeline for members, applicants, or their representatives to request an appeal?
Members, applicants, or their representatives must file an appeal with the Office of Administrative Courts no later than 60 calendar days after the date of the Notice of Action.
How much notice will be given to members or their representatives before a termination, suspension, reduction, transfer, or discharge becomes effective?
With certain exceptions, federal and state regulations require HCPF to send advance notice at least 10 days before the date of action. The date of action is the intended date on which a termination, suspension, reduction, transfer, or discharge becomes effective. It also means the date of the preadmission screening and annual resident review determination.
Where can I find the date of action on a Notice of Action letter?
First, it is important to note that the date of action is different from the Notice of Action letter date. The Notice of Action letter date is the date the Notice of Action was issued and is found on the top of the letter. The date of action is the intended date on which a termination, suspension, reduction, transfer, or discharge becomes effective. Generally, it is the date that the intended action will take place. It also means the date of the preadmission screening and annual resident review determination. The date of action can be found in the body of the notice of action letter in the grey box. It is the date the notice says that eligibility or benefits will be terminated/ended, suspended, or reduced.
How can members or their representatives demonstrate that they received their Notice of Action letter later than the required 10 days prior to the date of action?
The date on which the notice is received is considered to be five days after the date on the notice. Members or their representatives can attest that they did not receive the notice within the five day period by submitting a written statement with their appeal request to the Office of Administrative Courts.
What can members or their representatives do if they are not able to appeal by the deadline due to inadequate noticing, disability, or illness?
Members or their representatives must file an appeal with the Office of Administrative Courts no later than 60 calendar days after the date of the Notice of Action. If a member or their representative does not file a timely appeal, the Court is required to dismiss the appeal. HCPF regulations do not specifically provide for allowance of late appeals.
When should members, applicants, and their representatives anticipate receiving official notices for initial and final decisions after an appeal hearing?
Each case is different, including the specific dates on which members, applicants, and their representatives can expect to receive initial decisions and final agency decisions. The Administrative Law Judge (ALJ) typically completes writing an initial decision within 20 days of the hearing. The initial decision then goes to HCPF for mailing to the member, applicant, any representatives, and any advocate or attorney. Once the initial decision has been mailed, HCPF must wait a minimum of 18 days for either party to file exceptions or request an extension of time. HCPF’s Office of Appeals reviews the initial decision, evidence presented at the hearing, and any exceptions filed - together with the hearing transcript - prior to issuing final agency decisions. Final agency decisions will take longer to issue based on whether exceptions are filed, if there are complex legal or factual issues, or if there are lengthy records from the Office of Administrative Courts.
How does the appeal process and this update apply to members who receive waiver services?
There is no difference between how the appeals process works for individuals appealing waiver services versus other kinds of services.
What steps will HCPF take to ensure that the 90-day requirement to resolve appeals is met?
HCPF continues to identify efficiencies to improve timely resolution of appeals.
What steps will HCPF take to improve noticing timelines for members regarding prior authorized services?
Timing related to the issuance of Notices of Action is based on a number of factors. For example, the Department’s fee-for-service utilization management vendor is required to issue decisions within 10 days of receipt of a complete prior authorization request (PAR). However, factors leading to delays in issuance of PAR notices include incomplete documentation submitted by a requesting provider or lack of information about medical necessity of a requested service. These situations can lead to a pended PAR or an administrative denial. The date of action can be close in time to the issuance of a notice of action, particularly in situations where a member is receiving a prior authorized service and the requesting provider fails to submit a new PAR in advance of the previous prior authorization’s expiration. The Department is continuing to work with providers to improve the timely submission of PARs.
What Health First Colorado appeals data is available publicly?
Generally, Health First Colorado appeals data is not regularly reported publicly. One exception is reporting required by the federal Centers for Medicare and Medicaid Services related to the number of appeals pending for more than 90 days. This CMS reporting requirement, together with other reporting, coincided with the end of the Public Health Emergency and is available on the HCPF website. The number of appeals pending over 90 days is reported on line 8 of each monthly report.
How do I contact the Office of Administrative Courts?
The Office of Administrative Courts can be reached at:
- Address: Office of Administrative Courts, 1525 Sherman St., 4th floor Denver, CO 80203
- Phone: 303-866-5626
- Fax: 303-866-5909 (10 pages or fewer; otherwise, mail your request)
- Email: oac-gs@state.co.us The Office of Administrative Courts customer service hours are Monday through Friday from 8:00 a.m. to 4:30 p.m. except for state holidays.
Is the appeals process the same for private duty nursing denials? Where can I learn more about private duty nursing?
There is no difference between how the appeals process works for individuals appealing private duty nursing services versus other kinds of services. More information about private duty nursing, including private duty nursing resources, policy and regulations, and answers to frequently asked questions, can be found on HCPF’s website.
For more information contact HCPF_Stakeholders@state.co.us.