- Private Duty Nursing
- Provider Qualifications
- Billing Information
- General Prior Authorization Requirements
- Revenue Coding
- Reimbursable Private Duty Nursing Services
- Non-Reimbursable Private Duty Nursing Services
- Special Reimbursement Conditions for PDN Services
- Reimbursable Private Duty Nursing Service Locations
- Other Billing Information
- UB-04 Paper Claim Reference Table
- Timely Filing
- Institutional Provider Certification
- Early and Periodic Screening, Diagnostic and Treatment
- Electronic Visit Verification
- Private Duty Nursing Revisions Log
Return to Billing Manuals Web Page
Private Duty Nursing
The Department of Health Care Policy & Financing (the Department) periodically modifies information in this manual, including but not limited to, provider qualifications, service limits and other information necessary to ensure compliant billing by providers for eligible and enrolled Health First Colorado (Colorado's Medicaid program) members. Providers are responsible for reviewing the manual for updates and changes. Visit the Provider Rates and Fee Schedule web page for daily and annual limits, including any changes.
The Private Duty Nursing (PDN) benefit provides medically necessary nursing services that are more individualized and provide more continuous care than is available under the Home Health benefit or that is routinely provided by the nursing staff of a hospital or skilled nursing facility. The PDN benefit allows eligible and enrolled Health First Colorado members to remain in their home or community-based setting. A plan of care, as ordered by the primary physician or allowed practitioner, is developed by the Home Health Agency. The plan of care is reviewed periodically by the primary physician or other allowed practitioner. The definition of an “allowed practitioner” is provided in the Ordering, Prescribing and Rendering section below.
Provider Qualifications
Providers must be enrolled as a Health First Colorado provider in order to:
- Treat a Health First Colorado member
- Submit claims for payment to Health First Colorado
In order to become a Health First Colorado Home Health Provider, an agency must:
- Hold a current and active Class A Home Care License issued by the State of Colorado,
- Obtain Medicare certification and/or deemed status with an accepted Home Health Accreditation entity: Joint Commission (JC), Community Health Accreditation Program (CHAP) or the Accreditation Commission for Health Care, Inc. (ACHC),
- Be enrolled as a Medicare provider, and
- Be in good standing with the Department, Colorado Department of Public Health and Environment (CDPHE) and Medicare.
Prior to becoming a Health First Colorado Home Health provider, enrolling agencies must first obtain licensure and certification as a Class A Home Care Agency, following all processes required by CDPHE. Once licensed and certified as a Class A Home Care Agency, applicants must submit a completed provider enrollment packet to become Health First Colorado-eligible providers. Visit the Provider Enrollment web page and the Revalidation web page for enrollment information.
All Private Duty Nursing services are subject to post-payment review for medical necessity and regulation compliance.
Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10 Section 8.540), for specific information when providing PDN services.
Billing Information
Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information.
Ordering, Prescribing and Referring (OPR) Providers
Effective July 1, 2022, the Department began enforcing the federal requirement 42 CFR § 455.440, which requires that all claims for Home Health services include the National Provider Identifier (NPI) of the provider who ordered the service and 42 CFR 455.440, that requires the NPI is associated with an actively enrolled with Health First Colorado Provider.
Providers are required to enter the NPI of the ordering provider into the following locations for claim submission. In the Provider Web Portal, this field may be labeled "Referring Provider".
Institutional claims
- The Attending Provider field (#76) or the Other ID fields (#78 or #79) for both paper and electronic claims
- Providers should refer to their applicable UB-04 billing manuals for guidance on how each field is used.
Private Duty Nursing services can be ordered by either a physician or an allowed practitioner. Allowed practitioners are defined in accordance with State law as physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). The ordering provider must also be actively enrolled [Health First Colorado. If these conditions are not met, the claim will be denied.
Visit the OPR Claim Identifier Project web page or refer to Program Rule 10 CCR 2505-10 8.125.8.A for further information.
General Prior Authorization Requirements
All PDN Prior Authorization Requests (PARs) must be submitted via the ColoradoPAR web page. The additional forms necessary for PDN PAR submission are located on the Provider Forms web page or from the authorizing agency. PAR forms must be completed and sent to the authorizing agency before services can be billed. Instructions for completing the PAR form are included in this manual. Refer to Appendix C and Appendix D located on the Billing Manuals web page under the Appendices drop-down for authorizing agency information.
A PAR is required for all PDN services. Prior authorization is a request for medically necessary services based on the member's needs. The PAR may be approved for up to six (6) months for a new member and up to one (1) year for ongoing care.
Home Health Agencies (HHAs) shall provide the following when requesting a PAR:
- A current Plan of Care (POC) on CMS Form 485 or form of a similar format that summarizes health conditions, specific care needs and current treatments signed by the physician or allowed practitioner or a documented verbal order.
- Identification of professional disciplines supporting the medical needs of the member in the home and responsible for the delivery of care.
- Documentation submitted shall include sufficient information to demonstrate the medical necessity of Skilled Nursing Services.
If a member’s condition necessitates a change in PDN hours, the HHA shall submit a PAR revision request via the ColoradoPAR web page within 10 business days of a change and prior to the PAR end date. The revision may be an increase or a decrease in requested hours. Discharge notification is also required within 10 business days via a PAR revision request.
In the event a member changes provider agencies, the receiving HHA shall submit a Change of Provider Form and POC to the Utilization Review Contractor (URC) through the ColoradoPAR web page within 10 business days of starting PDN services.
Revenue Codes
The following table identifies the only valid revenue codes for billing PDN to Health First Colorado. Valid revenue codes are not always a Health First Colorado benefit. When valid, non-benefit revenue codes are used, the claim must be completed according to the billing instructions for non-covered charges.
PDN providers billing on the UB-04 claim form for services provided to authorized members must use the appropriate condition code in form locators 18 through 28 (Condition Codes) and use the revenue codes listed below. Claims submitted with revenue codes that are not listed below are denied.
| Service Type | Revenue code | Unit Value |
|---|---|---|
| PDN-RN | 552 | One Hour |
| PDN-LPN | 559 | One Hour |
| PDN-RN (group-per client) | 580 | One Hour |
| PDN-LPN (group-per client) | 581 | One Hour |
| Blended (group-per client) | 582 | One Hour |
The "blended" rate is available on request for a Home Health Agency that provides PDN to multiple clients in group care settings. All PDN provided in those settings is billed at the same rate and revenue code, irrespective of whether the service is provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN).
Reimbursable Private Duty Nursing Services
The licensed and certified Class A Home Care shall not bill Health First Colorado for care provided by staff that have been excluded from participation in federally funded healthcare programs by the United States Department of Health and Human Services (HHS)/Office of Inspector General (OIG). All staff shall be in good standing with the Colorado Department of Regulatory Agencies (DORA) or other governmental regulatory agency:
Registered Nurses (RN) and Licensed Practical Nurses (LPN) must have a current, active license in accordance with the DORA Colorado Nurse Practice Act at § 12-38-111, C.R.S.`
Non-Reimbursable Private Duty Nursing Services
- Supplies used for routine Home Health are not reimbursed separately through the Home Health or Durable Medical Equipment (DME) benefit. Non-routine or member-specific supplies must be reimbursed through the member's DME benefit.
- No skilled services shall be authorized or reimbursed if the skilled hours of service, regardless of funding source, total more than 24 hours per day for members aged 20 or younger and no more than 23 hours per day for members aged 21 or older.
- No services shall be reimbursed if the care is duplicative of care that is being reimbursed under another benefit or funding source, including but not limited to Home Health or other insurance.
- No services shall be reimbursed for dates of service prior to the PAR start date as authorized by the Utilization Review Contractor through the ColoradoPAR web page.
- Reimbursement shall not be allowed at any time when nursing staff is sleeping during the provision of PDN services.
- No individual nurse shall be reimbursed for over 16 hours of care per day, except in a documented emergency situation.
Special Reimbursement Conditions for Private Duty Nursing Services
- PDN services provided to members who are eligible for Medicare and Medicaid or have another third-party insurance and Health First Colorado must be billed to Medicare first. All insurance requirements must be met and exhausted prior to billing PDN services to Health First Colorado.
- A denial must be kept in the member's record and updated annually on the anniversary of the denial.
- The third-party insurance denials must be based on non-coverage and not due to the failure of adhering to the requirements set forth by the insurance agency.
- Health First Colorado will not accept a "no-pay" denial (type of bill 320, condition code 21) from Medicare as a valid denial of Medicare coverage.
- In the event of limited nursing resources for a Home Health Agency (HHA), two (2) HHAs may coordinate care and provide services to the same member as long as there is no duplication of services on the same date(s) of service and each provider obtains a PAR.
- PDN services may be provided by a single nurse to an individual or to multiple individuals in a non-institutional group setting. The nurse:member ratio shall not exceed what is permissible for one licensed nurse to safely care for each member simultaneously, based on member acuity and the availability of additional support in the home
Reimbursable Private Duty Nursing Service Locations
The PDN program reimburses for medically necessary skilled nursing services that are provided as more individual and continuous care than is available under the Home Health benefit or routinely provided by the nursing staff of a hospital or skilled nursing facility. This allows members to remain in their home or community-based setting and receive PDN services.
Health First Colorado members may receive Home Health services outside of their place of residence when:
- The PDN services can be provided safely and adequately in a location other than the member's residence,
- PDN services and interventions will be at least equally effective in a location other than the member's residence,
- It is clinically appropriate for the PDN services to be provided in a location other than the member's residence,
- It is not primarily for the convenience of the member, member's family, physician or other care provider,
- It is not provided in a nursing facility, hospital or other facility.
Other Billing Information
- Health First Colorado will reimburse two (2) agency staff for caring for a member when it is necessary to safely provide care due to the complexity of tasks, member weight, etc., and when it has been prior authorized and documented in the plan of care.
- Skilled Nursing services provided as a PDN benefit shall be reimbursed in units of one (1) hour at the lesser of the provider’s usual and customary charge or the maximum Medicaid allowable rates established by the Department.
- The agency must retain the member's PDN Medical records for at least seven (7) years unless State or Health First Colorado regulations require that the records be maintained for more than seven (7) years.
UB-04 Paper Claim Reference Table
The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBC UB-04 Reference Manual.
All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.
The UB-04 Certification document must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, located on the Billing Manuals web page under the Appendices drop-down.
Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form.
Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.
Bill with a date span (From and To dates of service) only if the service was provided every consecutive day within the span. The From and To dates must be in the same month.
The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to Health First Colorado for Private Duty Nursing services.
| Form Locator and Labels | Completion Format | Instructions | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. Billing Provider Name, Address, Telephone Number | Text | Required
Abbreviate the state using standard post office abbreviations. Enter the telephone number. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 2. Pay-to Name, Address, City, State | Text | Required only if different from FL 1.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3a. Patient Control Number | Up to 20 characters: Letters, numbers or hyphens | Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3b. Medical Record Number | 17 digits | Optional Enter the number assigned to the member to assist in retrieval of medical records. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 4. Type of Bill | 3 digits | Required
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 5. Federal Tax Number | None | Submitted information is not entered into the claim processing system. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 6. Statement covers period From/Through | From: 6 digits MMDDYY Through: 6 digits MMDDYY | Required Private Duty Nursing "From" date is the actual start date of services. "From" date cannot be prior to the start date reported on the initial prior authorization, if applicable, or is the first date of an interim bill. "Through" date is the actual discharge date, or final date of an interim bill. "From" and "Through" dates cannot exceed a calendar month (e.g., bill 01/15/10 thru 01/31/10 and 02/01/10 thru 02/15/10, not 01/15/10 thru 02/15/10). Dates must match the prior authorization if applicable. If member is admitted and discharged the same date, that date must appear in both fields. Detail dates of service must be within the "Statement Covers Period" dates. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 8a. Patient Identifier | Text | Enter the Health First Colorado ID number for the member. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 8b. Patient Name | Up to 25 characters, letters and spaces | Required Enter the member's last name, first name and middle initial. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9a. Patient Address - Street | Characters Letters and numbers | Required Enter the member's street/post office box as determined at the time of admission. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9b. Patient Address - City | Text | Required Enter the member's city as determined at the time of admission | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9c. Patient Address - State | Text | Required Enter the member's state as determined at the time of admission. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9d. Patient Address - ZIP | Digits | Required Enter the member's zip code as determined at the time of admission. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9e. Patient Address - Country Code | Digits | Optional | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 10. Birthdate | 8 digits (MMDDCCYY) | Required Example: 01012010 for January 1, 2010. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 11. Patient Sex | 1 letter | Required Enter an M (male) or F (female) to indicate the member's sex. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 12. Admission Date | 6 digits | Required Enter the date care originally started from any funding source (e.g., Medicare, Health First Colorado, Third Party Resource, etc.). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 13. Admission Hour | 6 digits | Not required | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14. Admission Type | 1 digit | Not Required | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 15. Source of Admission | 1 digit | Required Complete if the member has been admitted or readmitted during the billing period. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 16. Discharge Hour | 2 digits | Not Required | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17. Patient Discharge Status | 2 digits | Required
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 18-28. Conditions Codes | 2 digits | Conditional Use condition code A1 to bill PDN hours greater than 16 for children. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 29. Accident State | 2 digits | Optional | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 31 - 34. Occurrence Code/Date | 2 digits and 6 digits | Required use occurrence code 27 and enter the Plan of care start date. Enter the date using MMDDYY format. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 35-36. Occurrence Span Code From/ Through | Digits | Leave blank | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 38. Responsible Party Name/Address | None | Leave blank | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 39 - 41. Value Codes and Amounts | 2 characters and up to 9 digits | Conditional
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 42. Revenue Code | 4 digits | Required Enter the revenue code that identifies the specific accommodation or ancillary service provided. List revenue codes in ascending order. A revenue code must appear only once per date of service. If more than one of the same service is provided on the same day, combine the units and charges on one line accordingly. Enter the appropriate Revenue code. Private Duty Nursing services cannot be provided to Nursing Facility residents. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 43. Revenue code Description | Text | Required Enter the revenue code description or abbreviated description. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 44. HCPCS/Rates/ HIPPS Rate Codes | 5 digits | Required for the following:
When billing HCPCS codes, the appropriate revenue code must also be billed. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 45. Service Date | 6 digits | Conditional Enter the date of service using MMDDYY format for each detail line completed. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 46. Service Units | 3 digits | Required Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 47. Total Charges | 9 digits | Required Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total on line 23 is required for all charges. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 48. Non-covered Charges | Up to 9 digits | Conditional Enter incurred charges that are not payable by Health First Colorado. Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges.) Each column requires a grand total. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 50. Payer Name | 1 letter and text | Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 51. Health Plan ID | 8 digits | Required Enter the provider's Health Plan ID for each payer name. Enter the NPI number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 52. Release of Information | N/A | Submitted information is not entered into the claim processing system. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 53. Assignment of Benefits | N/A | Submitted information is not entered into the claim processing system. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 54. Prior Payments | Up to 9 digits | Conditional Complete when there are Medicare or third-party payments. Enter third party and/or Medicare payments. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 55. Estimated Amount Due | Up to 9 digits | Conditional Complete when there are Medicare or third-party payments. Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount. Medicare Crossovers Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 56. National Provider Identifier (NPI) | 10 digits | Required Enter the billing provider's 10-digit National Provider Identifier (NPI). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 57. Other Provider ID | Optional Submitted information is not entered into the claim processing system. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 58. Insured's Name | Up to 30 characters | Required Enter the member's name on the Health First Colorado line. Other Insurance/Medicare Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 60. Insured's Unique ID | Up to 20 characters | Required Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 61. Insurance Group Name | 14 letters | Conditional Complete when there is third party coverage. Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 62. Insurance Group Number | 17 digits | Conditional Complete when there is third party coverage. Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 63. Treatment Authorization Code | Up to 18 characters | Conditional Complete when the service requires a PAR. Enter the authorization number in this FL if a PAR is required and has been approved for services. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 64. Document Control Number | none | Enter Previous ICN in field 64a | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 65. Employer Name | Text | Conditional Complete when there is third party coverage. Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 66. Diagnosis Version Qualifier | Submitted information is not entered into the claim processing system. Enter applicable ICD indicator to identify which version of ICD codes is being reported. 0ICD-10-CM (DOS 10/1/15 and after) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 67. Principal Diagnosis Code | Up to 6 digits | Required Enter the exact diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 67A. - 67Q. - Other Diagnosis | 6 digits | Optional Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code. Enter applicable ICD indicator to identify which version of ICD codes is being reported. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 69. Admitting Diagnosis Code | 6 digits | Not Required Enter the diagnosis code as stated by the physician at the time of admission. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 70. Patient Reason Diagnosis | Submitted information is not entered into the claim processing system. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 71. PPS Code | Submitted information is not entered into the claim processing system. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 72. External Cause of Injury code (E-Code) | 6 digits | Optional Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E". | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 74. Principal Procedure Code/Date | 7 characters and 6 digits | Not Required | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 74A. Other Procedure Code/Date | 7 characters and 6 digits | Not Required | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 76. Attending NPI - Required | NPI - 10 digits | Health First Colorado ID Required NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number. (If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.) Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado. QUAL - Enter "1D" for Health First Colorado Enter the attending physician's last and first name. This form locator must be completed for all services. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 77. Operating NPI | Optional Submitted information is not entered into the claim processing system. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 78 - 79. Other ID | NPI - 10 digits | Required Complete when attending physician is not the PCP or to identify additional physicians. Ordering, Prescribing or Referring NPI NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility or PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted. The attending physician's last and first name are optional. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 80. Remarks | Text | Enter specific additional information necessary to process the claim or fulfill reporting requirements. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 81. Code - QUAL/CODE/VALUE (a-d) | Qualifier: 2 digits Taxonomy Code: 10 digits | Optional Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a. Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system. Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Private Duty Nursing Claim Example
Note: Medicare crossover claims are valid only with Medicare claims for visits rather than episodes. Low Utilization Payment Adjustment (LUPA) payments, not episode case mix payment.
Timely Filing
Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.
Institutional Provider Certification
The Institutional Certification Form is located on the Provider Forms web page under the Claim Forms and Attachments drop-down.
This document is an addendum to the UB-04 claim form and is required per 42 C.F.R. 445.18 (a)(1-2) to be attached to paper claims submitted on the UB-04.
Early and Periodic Screening, Diagnostic and Treatment
Private Duty Nursing benefits are provided in accordance with Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements as listed in 8.280.4.E: “Other EPSDT Benefits” 8.280.4.E reads as follows:
Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:
- All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
- For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
- The service provides a safe environment or situation for the child.
- The service is not for the convenience of the caregiver.
- The service is medically necessary.
- The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
- The service is the least costly.
Providers can ask for these additional services by following the PAR process as outlined for this benefit.
Visit the EPSDT web page for more information regarding EPSDT.
Contact Gina Robinson at Gina.Robinson@state.co.us with questions about EPSDT.
Electronic Visit Verification
Federal guidance requires Electronic Visit Verification (EVV) for Home and Community Based Services (HCBS) that include an element of Personal Care Services and State Plan Home Health Care Services. Colorado requires the use of EVV for several other services that are similar in nature and delivery to the federally mandated services. These additional services are included to enhance care coordination, promote quality outcomes for members, and to streamline requirements for providers.
All Private Duty Nursing services require EVV.
Visit the EVV web page or refer to the EVV Program Manual for further information regarding the EVV program.
Contact EVV@state.co.us with EVV questions.
Private Duty Nursing Revisions Log
| Revision Date | Section/Action | Made by |
|---|---|---|
| 12/01/2016 | Manual revised for interChange implementation. Form annual revisions prior to 12/01/2016 Please refer to Archive. | HPE (now DXC) |
| 12/27/2016 | Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx | HPE (now DXC) |
| 1/10/2017 | Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsx | HPE (now DXC) |
| 1/19/2017 | Updates based on Colorado iC Stage II 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) |
| 3/8/2017 | Added Type of Bill 32x to row 4 of the Private Duty Nursing Claim example table. | HCPF |
| 3/13/2017 | Updated the Type of Bill section in the Paper Claims Table to reflect the NUBC manual. | HCPF |
| 3/14/2017 | Updated the type of bill in the paper claim example. | HCPF |
| 5/26/2017 | Updates based on Fiscal Agent name change from HPE to DXC | DXC |
| 6/15/2018 | Updated timely filing information and removed references to LBOD, removed general billing information already available in the General Provider Information manual. | DXC |
| 6/13/2019 | Updated Appendices' links and verbiage. Updated Institutional Provider Certification form information. | DXC |
| 12/9/2019 | Converted to web page. | HCPF |
| 8/7/2020 | Updated item 81 of the Paper Claim Reference Table for taxonomy code billing. | DXC |
| 9/17/2021 | Updated Billing manual with existing guidance regarding EPSDT and EVV. | HCPF |
| 7/22/2022 | Changed definition of PDN program to read continuous instead of intermittent. | HCPF |
| 9/11/2023 | Added Ordering, Prescribing, Referring (OPR) Policy. Updated Field #78-79 on claim reference table. | HCPF |
| 7/25/2024 | Updated introduction information, provider qualifications, revised PAR requirements, and added revenue coding chart. Also added sections on reimbursable services, non-reimbursable services, special reimbursement conditions, service locations and other billing information. | HCPF |