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.
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.
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.
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
HCPF RAC Team:
Bart Armstrong, Fraud, Waste & Abuse Division 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 & Medicaid Rules, Laws, & Regulations
House Bills
Colorado RAC Contract & Transmittals
Colorado State Plan Amendments (SPA)
Colorado Revised Statutes
Federal Register (FR)
National Correct Coding Initiatives (NCCI)
Reports and Scorecards
Colorado RAC Reports
Reporting is in development to ensure we have meaningful interactive peer reporting and capture the information as requested by providers and required in HB23-1295.
Department Reports
- Cost-shift Reporting
Medicaid.gov Reports
CMS Reports
- HCFA Rulings
- Coming soon
- RAC Resources
Government Accountability Office Reports
Office of Inspector General Reports
- Fraud Alerts
- Coming soon
- Reports and Recommendations
- Coming soon
Medicaid Fraud Control Unit (MFCU) Reports
- Civil Case Reports
- Coming soon
- Criminal Case Reports
- Coming soon
- Corporate Integrity Agreements
- Coming soon
National RAC State Program Links and Resources
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
RAC 101 And General Provider Training
HMS Training Resources |
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HMS Colorado RAC Training Dates and Registration Links |
*****Recorded training for the HMS Colorado RAC Provider Portal can be accessed on their website under Resources & Informational Documentation***** |
Department Training Resources |
More coming soon |
Provider Type-Specific Training |
Coming soon |
Colorado RAC Stakeholder Engagement
Upcoming Meetings and Documents
May 12, 2023 Stakeholder Meeting | |
August 3, 2023 Stakeholder Meeting | |
November 2, 2023 Stakeholder Meeting | |
February 1, 2024 Stakeholder Meeting | |
May 2, 2024 Stakeholder Meeting | |
Upcoming Dates | |
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Provider Requests and Surveys
RAC Provider Stakeholder Engagement (Questions, Comments & Suggestions) Form |
This form is utilized by the Department to identify Common & Trending:
Use the Questions, Comments & Suggestions Form to provide feedback. |
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. |
Stakeholder Communications
Email Blasts |
Audit Communications |
RAC Program Updates |
Bulletins & Publications |
Coming soon |
HB23-1295 Provider Advisory Board
HB23-1295 RAC Provider Advisory Board Members:
Metro & Rural Hospital Members
- Dr. Derek Braun, MD; Senior Medical Director & Associate Chief Medical Officer, Banner Health
- Shana Steckler, CPC - A; Compliance & Billing Integrity Manager, Denver Health
- Kathryn “Katie” A. Zeller; Director of Denials Management and Payer Audits, UCHealth
- Michelle Gay, CHC; Director of Compliance, San Luis Valley (SLV) Health
Durable Medical Equipment (DME) Member
- Jennifer Willingham; Accounts Receivable Coordinator, Oxygen intake Coordinator, Columbine Medical Equipment
Radiology Member
OPEN SEAT
Independent Physician Member
- Barbara Quissell, MD; Retired, Neonatal experience
HCBS, Long-term care, Skilled Nursing facilities, Home Health & Hospice Members
- Kristin Wildrop; Director of Compliance & Quality Management, Nursing & Therapy Services of Colorado, Inc.
- Jan Arnott, RN; Home Health & Hospice
HCPF Members
- Prismar Perez, Contractor Audit Operations Unit Supervisor (RAC)
- Alex Weichselbaum, Primary & Ancillary Care Section Manager (Policy)
HMS Member
- Chantal Kalisch, Colorado RAC Program Manager
HB23 - 1295 RAC Provider Advisory Board Meetings 2024:
Contact Information
Department Recovery Audit Contract Section
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.
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:
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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. |