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Policy Statement: Billing for Members who Receive Retroactive Health First Colorado Eligibility

Purpose

To outline the Department of Health Care Policy & Financing's (the Department’s) policy on billing for services rendered to a member who does not have Health First Colorado (Colorado’s Medicaid program) eligibility on the date of service, but who subsequently receives retroactive Health First Colorado covering the date of service.

 

Background

The Department has received questions from both Health First Colorado members and providers regarding how provider billing should be handled for services rendered to non-eligible members who are later made Health First Colorado-eligible. Federal and state regulations prohibit charging Health First Colorado members for covered services, beyond any applicable co-payment. In Colorado, these regulations apply to both participating (Health First Colorado-enrolled) providers and non-participating providers. Refer to the Policy Statement: Billing Health First Colorado Members for Services for more information about billing Health First Colorado members.

 

Current Billing Policy for All Providers

 

Retroactive Health First Colorado - Policy for Participating (Enrolled) Providers

  • Providers must check a member's Health First Colorado eligibility on the Date of Service (DOS). Providers may collect fees for services rendered if the member is not Health First Colorado eligible.
  • The following applies if the member subsequently receives retroactive Health First Colorado eligibility that covers the DOS:
    • The Health First Colorado member does not notify the provider of retroactive Health First Colorado eligibility:
      • Nothing happens.
    • The Health First Colorado member does notify the provider of retroactive Health First Colorado eligibility:
      • The participating provider should return any collected fees to the member, minus any required co-pay(s), and bill Health First Colorado for covered services. Providers may obtain a Timely Filing waiver letter from the Department policy staff if the claim is out of timely filing (currently 365 days).
    • Bill normally if the covered service does not require a Prior Authorization Request (PAR).
    • If the covered service does require a PAR, the Department may direct its Utilization Management (UM) contractor to process a retroactive PAR if the provider submits all required documentation. This does not guarantee the PAR will be approved or the claim paid.

 

Retroactive Health First Colorado - Policy for Non-Participating Providers

  • Non-participating providers do not have access to Health First Colorado eligibility information but should ask if a member has insurance coverage before providing services. The provider may collect fees for service(s) rendered if no Health First Colorado coverage is reported.
  • The following applies if the member subsequently receives retroactive Health First Colorado eligibility that covers the DOS:
    • The Health First Colorado member does not notify provider of Health First Colorado eligibility:
      • Nothing happens.
    • The Health First Colorado member does notify the provider of retroactive Health First Colorado eligibility:
      • The provider ideally returns any collected fees to the member and agrees to bill Health First Colorado for covered services. The provider must enroll in Health First Colorado before submitting a claim. Policies outlined above for participating providers apply if the provider enrolls with Health First Colorado.
      • Refund of fees to the member is not required if the provider does not want to enroll in Health First Colorado.

Providers should contact the Provider Services Call Center for additional information about this policy.

Health First Colorado members should contact the Member Contact Center at 1-800-221-3943 with questions about this policy.