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Colorado Recovery Audit Contractor (RAC) Program

About the Colorado RAC Program

Senate Bill 25-314

HB23-1295 Provider Advisory Board    Colorado RAC Stakeholder Engagement

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.
 

Overpayments

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.

checkered flag image  Report Fraud, Waste and Abuse

Underpayments

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.

Our 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.

Visit the HMS Colorado RAC website for resources and information from the Colorado RAC Vendor.

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:

  • Exit Conference Requests
  • HMS Colorado RAC Provider Portal Questions
  • Address Updates in the HMS RAC Provider Portal
  • Claim/Review Status (Audit) Questions

Email CORAC@HMS.com for requests related to:

  • Providing a Password for a CD or DVD
  • HMS Escalations
     
Medical Records SubmissionInformal Reconsideration Request Submission
HMS – Colorado Recovery Audit Services
5615 High Point Drive
Mail Stop 200-CO
Irving, TX 75038		HMS – Colorado Recovery Audit Services
Informal Reconsideration Request
5615 High Point Drive<
Stop 200-CO
Irving, TX 75038

For questions about HMS letters regarding commercial or other coverage, call HMS Third-Party-Liability (TPL) Provider Relations at 1-877-262-7396.

Meet the Colorado RAC Team

HCPF RAC Team:

Dr. Jeffrey K. Chapman M.D. MMM RAC Audit Medical Director

Alyssa Gilger, Recovery Audit Contract Section Manager

Prismar Perez, Contractor Audit Operations Unit Supervisor

Lydia Clark, Contingency-based Contract Manager & Fiscal Specialist

Jennifer Kaufman, Contract Audit Statistical Data Analyst

Meghan Morhauser, Recovery Audit Contract External Communications Liaison

Lizette Bustillos, Contract Audit Operations Medical Claims Specialist 

Nicole Morton, Recovery Audit Contract Claims Specialist and Operational Coordinator

Christy Lehnerz, Recovery Audit Contract Litigation and Research Specialist

RAC Team Contact Information

Email hcpf_corachcpf@state.co.us 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.

Use the Questions, Comments & Suggestions Form if you:

  • Have feedback, complaints or suggestions regarding the RAC program
  • Have provider training or provider education requests or suggestions
  • Want to submit a test case for HCPF and HMS to review
  • Have areas of Medicaid you believe the RAC should focus on
  • Want to submit agenda items for the next stakeholder meeting
  • Want to submit agenda items for consideration of the RAC provider advisory board
  • Want to communicate anything related to the RAC program to HCPF

Colorado RAC & Medicaid Resources 

Office of the State Auditor RAC Evaluation Updates

National RAC State Program Links and Resources

The Centers for Medicare and Medicaid Services (CMS), under the guidance of Health and Human Services (HHS) and the Office of Inspector General (OIG) have oversight over all the Medicaid programs, nationally. 
CMS has approved RAC topics and the Colorado RAC utilizes the basic topics that CMS gives us guidance to review. However, HCPF & the RAC vendor must tailor each audit to ensure it follows Colorado Medicaid guidelines.

Approved RAC Topics | CMS

HCPF has partnered with other states to create a National Medicaid RAC quarterly Meeting starting in November 2023. We will be updating information as it becomes available.
 

Online Provider Training and Resources

HMS Training ResourcesDepartment Training Resources
Department Billing Training Calendar
HMS Colorado RAC Training Dates and Registration Links