ColoradoPAR: Health First Colorado Prior Authorization Request Program

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• PDN Information
• Inpatient Hospital Review Program
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• LibrarySecondary Medical Necessity SUD Reviews

Provider Announcements

The DME Provider Survey is Now Open! 

HCPF and Acentra are pleased to announce the DME Provider Survey is now open for all providers who work with Acentra as well as use their Atrezzo® provider portal.

The DME Provider Survey opened on September 13, 2023 and will remain available until October 24, 2023. The DME Provider Survey is your opportunity to provide feedback regarding Acentra’s services in processing PARs, customer service, provider education, and timeliness.

You may contact Kepro Customer Service at 720-689-6340 or send an email to COproviderissue@kepro.com for any questions regarding PARs or the Atrezzo system. 

HCPF will continue to auto-authorize the below durable medical equipment (DME) codes that were instituted due to the public health emergency to increase efficiency with hospital discharges:

Nursing Services Prior Authorization Request (PAR) Step-Down Process

Private Duty Nursing (PDN) Prior Authorization Requests (PAR) Update for Providers

Private Duty Nursing

Effective March 17, 2023, the Department of Health Care Policy and Financing (HCPF) announced the temporary administrative approval process will end April 2, 2023. Please see Informational Memo (IM) 23-010 for additional information about the ending of the temporary approval process and provider responsibilities during this time. Please reach out to homehealth@state.co.us with questions.

2023 HCPCS Codes

When trying to submit a Fee for Service PAR that will contain a 2023 HCPC code, providers have two options to proceed with a PAR request before the Department releases those codes, which are:

• A PAR can be submitted with the old, or a best-match code, including a note in the PAR stating a HCPC code modification request will be submitted at a later date. Then, once the codes are released by the Department, please submit that PAR modification with the updated 2023 HCPC code(s).
  • Example: Continuous Glucose Monitor (CGM) and/or CGM supplies - Please submit the PAR with the current CGM codes with a note stating you will update the PAR once the new HCPC codes are released. Once the new HCPC codes are released, request a PAR modification with a note stating you are modifying the PAR to the 2023 HCPC code.
• A Retro PAR can be submitted once the codes have been released by the Department. When submitting retroactively, please include a note explaining the reason for the delay.

If you have any additional issues or questions about PARs or billing for K0553 and K0554, please contact the UM inbox at HCPF_UM@state.co.us.

Atrezzo® System Enhancements

From provider feedback, Kepro released Atrezzo portal enhancements to improve the end user experience in late January. The UM Create Case Wizard enhancement is now live and designed to improve provider experience and decrease provider burden when submitting your Health First Colorado PARs to Kepro for review. Kepro has provided a pre-recorded training to review those updates on your own time. If you have any questions regarding the training or the new portal enhancements, please email Kepro at coproviderissue@kepro.com.

Attention Inpatient Providers: IHRP 2.0 

Attention Hospital Staff: Senate Bill 18-266 requires Health First Colorado (Colorado’s Medicaid program) to implement an evidence-based hospital review program to ensure appropriate utilization of hospital services. The hospital review program created by SB 18-266, known as the Inpatient Hospital Review Program (IHRP) was paused at the beginning of the COVID-19 Pandemic and Public Health Emergency. Help is needed in identifying the staff who need to learn about the next generation Inpatient Hospital Review Program - IHRP 2.0. 

Enter information in the Inpatient Hospital Review Program (IHRP) 2.0 Stakeholder Engagement Contact Form if wanting to be involved in the Stakeholder Engagement Opportunities for IHRP 2.0, which will begin in early December 2022. Those who have identified interest in participating in further stakeholder engagement opportunities for IHRP 2.0 will receive additional email communication and calendar invitations for stakeholder events.  Forward this email to those that you believe should be involved from your hospital. Contact the ColoradoPAR Program Utilization Management Team at hcpf_um@state.co.us with any questions.

Private Duty Nursing Announcement

The Department of Health Care Policy and Financing (the Department) is informing all Private Duty Nursing (PDN) providers that effective November 23, 2022, the Department announced an extension to the temporary administrative approval process for PDN through at least February 28, 2023. This means all requested PDN services are authorized through February 28th.

Private Duty Nursing Training continues in collaboration with the utilization review contractor Kepro. If your agency has not been scheduled for training, please email COproviderissue@kepro.com to be scheduled. 

Agencies are invited to work with the Department on a resubmission plan for cases with a denial prior to the administrative approval. Please reach out to homehealth@state.co.us with questions.

For the most up to date information on the Private Duty Nursing Program including announcements, FAQs, recorded webinars, etc. please go to Private Duty Nursing page or use the green PDN button at the top of this page.

Private Duty Nursing (PDN) Adult Prior Authorization Reviews (PARs)

Providers will be able to submit PARs exceeding the 16 hours per day limit for members aged 21 and older beginning August 12, 2022 contingent upon MSB approval of the emergency PDN PAR Rule.  

• Providers may request a maximum of 23 hours per day for adult members.
• PARs will be reviewed for medical necessity on a case-by-case basis.
• The PDN Tool, the Plan of Care (POC), the Physician order and all supporting documentation remains required for all PDN PARs. 
• New PAR: For adult members who do not have an active PAR in place, a new PAR should be submitted. Please note, as of 9/1/2022, PARs are required for all PDN services.
• For members who currently have an active PDN PAR: 
  • Requests for increase of hours on PARs already in place should be submitted as a PAR Revision, also called a PAR Modification, to the current PAR.
    • The start date should be updated to 08/12/22 but no changes should be made to the PAR’s original end date. 
    • Requests to back date the PAR prior to 08/12/22 will be denied. 
    • Please do not submit a new PAR, as this would overlap with the existing PAR and therefore increase the likelihood the claim will deny for duplication of services. 
  • The Physician order, POC, the PDN tool and any additional documentation must appropriately reflect the hours requested. If the documentation from the original PAR does not reflect the hours requested in the PAR Revision request, please ensure you submit the updated documents. Failure to upload these documents may result in the PAR being pended for additional information. 
  • Because this is a PAR Revision, an updated physician order is not required if the date span on the PAR Revision include a start date of 8/12 through the original PAR end date.  

For more information on how to properly submit these cases as a PAR Revision, please contact Kepro at coproviderissue@kepro.com.  

For questions about the PAR process or to escalate questions, please contact the UM Team at hcpf_um@state.co.us. 

For questions about the PDN Rule and/or PDN Benefit or Policy, please contact the Office of Community Living PDN Benefit Management Team at HCPF_HCBS_Questions@state.co.us.