Verifying Member Eligibility
- Log in to the Provider Web Portal.
- Click the Eligibility tab.
- Click the Eligibility Verification link.
- Enter search criteria, then click "Submit."
- Click "Expand All" to view Benefit Details, Coverage, Co-pay Amount and Review the search results.
- Managed Care Assignment Details.
The screenshots below show Coverage Details, Benefit Details, and Managed Care Assignment Details:
Verifying Child Health Plan Plus (CHP+) Coverage
All CHP+ eligible members will be automatically enrolled into a CHP+ Managed Care Organization (MCO). If a CHP+ member’s eligibility start date occurs prior to the member’s enrollment with a CHP+ Managed Care Organization (MCO), claims must be billed directly to Gainwell. Once the member is assigned a managed care organization, the claims must be billed to that MCO.
See the example below. The Benefit Details Effective Date is prior to the CHP+ Managed Care Assignment Details Effective Date. Any services provided from May 1 to July 14, 2021 should be billed to Gainwell.
Verifying Co-Pay Amount
- Verify member co-pay requirements by referring to the "Copay Amount" column under the Benefit Details section.
Members may not be required to pay a co-pay for every visit, so it is important that providers check the co-pay amount every time they see a Health First Colorado member.
If a member has already reached their 5% co-pay maximum for a given month, the Copay Amount field will display $0 for a member when they are max-met or exempt, the base co-pay amount when a co-pay is due, and 'Non-Covered' when the coverage code is inactive for the member's associated coverage during the benefit plan effective dates.
The Pharmacy Coverage Code Description (CCD) will be used in conjunction with the 'Brand Name Prescription Drug' and 'Generic Prescription Drug' CCD's. If a value of 'Covered' for Pharmacy services is received the base co-pay due will reside in values next to 'Brand Name Prescription Drug' and/or 'Generic Prescription Drug'.
Scroll to the bottom of the page to see Managed Care Assignment Details.
Verifying Remaining Service Units - PT/OT
- If applicable, check the member's available units of physical/occupational therapy (PT/OT) services under the Limit Details section.
This remaining benefit amount is calculated by counting all the paid units of service for PT/OT a member has incurred in the previous rolling 365 days. Once the soft limit of 48 units has been reached, an approved Prior Authorization Request (PAR) is required to exceed it.
The counting function will calculate PT/OT units regardless of whether they were paid with a PAR on file. This means that after a PAR for PT/OT is exhausted members will not automatically have another 48 units of PT/OT available without a PAR. A full 365 days must elapse before the member has another 48 units of PT/OT available without requiring a PAR.
Refer to the Benefit Limitation Frequently Asked Questions, located on the Outpatient PT/OT Benefits web page, for more information.
Verifying Remaining Service Units - Behavioral Health
- If applicable, check the member's available units of short-term behavioral health services under the Limit Details section.
"5807 LIMIT MET FOR BH SERVICES" references the system audit that will post when the service unit limit is exceeded.
This used benefit amount is calculated by subtracting all the paid units of service for short-term behavioral health a member has incurred within the current state fiscal year from the limit. Once the unit limit has been reached for the state fiscal year, a PAR cannot be used to exceed it.
Additional visits beyond the unit limit during a state fiscal year may be eligible for reimbursement by the Regional Accountable Entity in accordance with their provider credentialing and utilization management policies and procedures. At the beginning of the next state fiscal year, the total units for that fiscal year will be available.
- Scroll to the Managed Care Assignment Details section, then click the [+] sign.
Click the plus [+] sign next to Managed Care Assignment Details.
The coverage information will include the name or type of coverage and the Effective and End dates of that coverage. Additional information returned in the eligibility response may display the following details panels:
- Managed Care Details displayed when the member is assigned to a managed care plan and shows all of the plans the member is assigned to including their effective dates of coverage.
- Lock-in Details displayed when a member is locked-in or restricted to a specific provider known as a 'lock-in plan'. To authorize services delivered for a member by a provider other than the designated Lock-in Plan Provider, claims must include the referring provider's National Provider Identifier (NPI). The Lock-in Details panel provides the Lock-in Provider's DBA Name and Provider Phone information.
- Level of Care Details displayed when a member resides in a nursing home and reports their level of care within that facility.
Benefit Plans and Billing Instructions
See the table below for a complete list of all possible benefit plans along with billing instructions and co-pay notes. Benefit plans for which providers should bill Gainwell directly are marked in green below. Benefit plans for which providers should bill the listed Managed Care (MC) Organization are marked in purple below.
|MC Benefit Plan||Billing||Co-pay|
|Denver Health Medicaid Choice||Providers should bill Denver Health directly, not Gainwell for medical claims. Mental health is billed to the RAE.
Span must show "Active."
|Most services, such as office visits, medications and hospital stays have a co-pay. Services for pregnant women, children 18 and under, American Indians and Alaska Natives do not require a co-pay.|
|Denver Health and Hospital Authority - Primary Care Medical Provider||Providers should not bill the PCMP and instead should bill Gainwell directly for medical claims. Mental health is billed to the RAE.||Not applicable|
|Rocky Mountain Health Plans Prime||Providers should bill Rocky Mountain Health Plans Prime directly, not Gainwell. Mental health should be billed to Colorado Access.||Contact Rocky Mountain Health Plans Prime for co-pay details.|
|Accountable Care Collaborative||Providers should not bill the ACC, PCMP or RAE and instead should bill Gainwell Technologies directly (unless the services are for mental health).
Note: ACC will only appear for dates of service prior to 7/1/18.
|Administrative Service Organization - Dental||Providers should bill DentaQuest directly, not Gainwell.||Contact DentaQuest for co-pay details.|
|Child Health Plan Plus or Child Health Plan Plus - Dental||If a CHP+ member’s eligibility start date occurs prior to the member’s enrollment with a CHP+ Managed Care Organization (MCO), claims must be billed directly to Gainwell. Once the member is assigned a managed care organization, the claims must be billed to that MCO.||Some CHP+ clients may also have to pay a co-pay to their health care provider at the time of service. There is no co-pay for preventative care, such as prenatal care and check-ups. Other services may require a co-pay based on member income. Native Americans and Alaskan Natives do not have to pay co-pay amounts.|
|Primary Care Medical Provider||Providers should not bill the RAE or PCMP and instead should bill Gainwell directly for medical claims. Mental health should be billed to the RAE.||Not applicable|
|Program For All-Inclusive Care For The Elderly||Providers should bill the Program of All-Inclusive Care for the Elderly (PACE) directly, not Gainwell.||There are no co-pay amounts or out-of-pocket expenses for services covered under this program.|
|Regional Accountable Entity [formerly known as Behavioral Health Organizations (BHOs) and Regional Care Collaborative Organizations (RCCOs)]||Providers should bill the RAE for mental health services (behavioral therapy is an exception). Medical claims should be billed to Gainwell directly, unless they have Denver Health PHIP or Rocky Mountain Prime.||There are no co-pay amounts for Health First Colorado behavioral health services. However, if the member has other insurance, they must use that insurance first before using Health First Colorado benefits.|
|Rocky Mountain Health Plans||Providers should bill Rocky Mountain Health Plans for mental health services (behavioral therapy is an exception). Medical claims should be billed to Gainwell directly.||There are no co-pay amounts for Health First Colorado behavioral health services. However, if the member has other insurance, they must use that insurance first before using Health First Colorado benefits.|
|Colorado Access Behavioral Health for Denver Health Medical Choice||Providers should bill Colorado Access for mental health services (behavioral therapy is an exception). Medical claims should be billed to Denver Health Medical Choice.||There are no co-pay amounts for Health First Colorado behavioral health services. However, if the member has other insurance, they must use that insurance first before using Health First Colorado benefits.|
Verifying Third-Party Liability Coverage
- To see Third Party Liability (TPL) coverage (including Medicare), return to the Eligibility Verification page.
Scroll to the bottom of the page and click Other Insurance Detail Information.
This is where other insurance coverage (including Medicare coverage) is displayed:
Add additional TPL information as needed.
Refer to the Adding and Updating Additional TPL Information Provider Web Portal Quick Guide for step-by-step instructions on how to add TPL information for a member with TPL coverage that isn't already listed.
Need More Help?
Please visit the Quick Guides web page to find all the Provider Web Portal Quick Guides.