About the Colorado RAC Program
RAC Program Purpose
Under Section 6411(a) of the Affordable Care Act, each state must contract with a contingency-fee-based vendor to review provider claims. The purpose of the review is to reduce improper Health First Colorado (Colorado's Medicaid program) payments through the efficient detection and collection of overpayments, the identification of underpayments and the implementation of actions that will prevent future improper payments. See also CRS Section 25.5-4-301 and 10 CCR 2505-10, Sections 8.050 and 8.076.
In November 2009, President Barack Obama signed Executive Order 13520 which aimed at reducing improper payments by increasing transparency in government and holding agencies accountable for reducing improper payments. A year later, Section 6411 of the Affordable Care Act was enacted, directing each state Medicaid program to establish a program in which it contracts with one or more recovery audit contractors for the purpose of identifying underpayments and overpayments and recouping overpayments.
The purpose of the RAC is to reduce improper payments while also presenting billing education opportunities to providers to improve the accuracy of claims submitted to the Department for reimbursement. Under the RAC, all provider types will be audited. The RAC vendor will audit the following types of claims: Health First Colorado fee-for-service, waiver services, managed care, and Child Health Plan Plus (CHP+) claims. HMS will conduct post-payment claims reviews of provider-submitted Health First Colorado paid claims to determine whether services were actually provided, medically necessary, coded correctly, and properly paid or denied.
Covered services and Health First Colorado benefits are defined throughout the Code of Colorado Regulations (CCR). Overpayments are defined under 10 CCR 2505-10 section 8.076.9 which states "Overpayment means the amount paid to a Provider which is in excess of the amount that is allowable for goods or services furnished under Section 1902 of the Social Security Act and which is required to be refunded under Section 1903 of the Act." Any claims for which documentation is not received upon request shall be deemed to be overpayments subject to recovery regardless of whether or not services were provided. The Department will recover the overpayments, per 10 CCR 2505-10 8.040. Providers are required by Section 1902(a)(27) of the Social Security Act and 10 CCR 2505-10, Section 8.130 to:
- Retain records necessary to disclose the nature and extent of services provided to recipients.
- Maintain records that fully substantiate or verify claims submitted for payment.
- Submit records to federal and state governments upon request.
Underpayments which are discovered by the Colorado RAC are reported to policy and the claims system vendor to adjust any and all claims with specified underpayments to correct via a system mass adjustment. Providers who believe they have been underpaid for services can reach out to the Provider Services Call Center for information on how to correct their claims.
Refer to the Copy, Adjust, or Void a Claim Quick Guide for more information.
The Colorado RAC Vendor
In 2021, the Department awarded Health Management Systems, Inc. (HMS) the contract to act as its Recovery Audit Contractor (RAC). HMS serves as a RAC vendor in several other states around the nation.
Meet the Colorado RAC Team
RAC & Medicaid Rules, Laws, & Regulations
Reports and Scorecards
Colorado RAC Reports
Government Accountability Office Reports
Office of Inspector General Reports
|Reports and Recommendations|
Medicaid Fraud Control Unit (MFCU) Reports
|Civil Case Reports|
|Criminal Case Reports|
|Corporate Integrity Agreements|
National RAC State Program Links and Resources
Online Provider Training and Resources
RAC 101 And General Provider Training
|HMS Training Resources|
More coming soon
|Department Training Resources|
More coming soon
|Provider Type-Specific Training|
Colorado RAC Stakeholder Engagement
Provider Requests and Surveys
|RAC Provider Stakeholder Engagement (Questions, Comments & Suggestions) Form|
|This form is utilized by the Department to identify Common & Trending:
|Provider Request to Participate in RAC Advisory Board Form|
This form is utilized by providers to request to be on the Colorado RAC Advisory Board & to upload their CVs/resumes.
|Provider Request to Participate in the Inpatient Rebilling System Testing Pilot|
This form is utilized by Providers to request to take part in testing the Claims system after rebilling programming has been completed.
|Provider Request To Be Added To The Department's RAC Email Contact List|
This form is utilized by the Department to send email blasts, flyers, and any communications to Providers. This will ensure quick and efficient information is being communicated while any updates to the website or content are being made.
Provider Advisory Board
Department Recovery Audit Contract Section
Email firstname.lastname@example.org for requests related to:
- Payment Plans
- Offset Requests
- Financial Questions
Emails for specific requests will be updated in the next 3-6 months with an email blast sent. The website will be updated once the information is received.
Health Management Systems (HMS) Contacts
|HMS Colorado RAC Provider Services Team|
Call (877) 640-3419, available M-F 8:00 a.m. to 5 p.m. (MST) for requests related to:
Email CORAC@HMS.com for requests related to:
|HMS Mailing Addresses|
|(if you are not using the HMS Colorado RAC Provider Portal to upload documents electronically)
For questions about HMS letters regarding commercial or other coverage, call HMS Third-Party-Liability (TPL) Provider Relations at 1-877-262-7396.