Previously he had oversight of the various safety net programs, and projects to maximize federal Medicaid revenue. Holidays, weekends, and dates of business closure do not extend the timely filing period. If the provider receives a third-party lump-sum payment for multiple services billed to the Health First Colorado program on separate claim records, the payment amount should be apportioned across the affected claims. Capitated MCOs may have different prior authorization requirements. Victim Assistance Programs do not represent potential TPL. Providers receive notification of re-certification. The Provider has failed to complete Provider revalidation. In March of 2016, the Department began issuing Medical Identification Cards (MICs) with a new look. Unfortunately, pre-COVID workforce shortages have been further exacerbated by the impacts of the pandemic as well as the increase in demand for HCBS services. The Health First Colorado program sends a questionnaire to members who have received services for a diagnosis that may be accident related. A woman cannot be enrolled in PE until the results of the test are known. See the Office of Community Living Stakeholder Engagement page, which includes an updated online calendar of stakeholder engagement meetings. Batch billing systems usually extract information from an automated accounting or patient billing system to create a group of claim transactions. The OLTCs conduct evaluations and needs assessment, care planning with the member, and ongoing case management to monitor the care plan, as well as coordinate service delivery and perform periodic reassessment of member needs. Refer to the Health First Colorado policy on Member Billing. Claims that are duplicates will be denied as such. Providers must be able to show evidence that claims for dual eligible members, where appropriate, have been denied by Medicare prior to submission to the Health First Colorado program. He also leads the creation of strategic plans, programmatic goals and objectives, allocation of business analysts and fiscal resources. Erroneous transactions (e.g., duplicate deposits) are electronically reversed. Cristen has focused her public service efforts on improving health care policy, expanding access to behavioral health, and fighting stigma and systemic barriers to health. Home and Community Based Services (HCBS) Policy Questions, Member Contact Center1-800-221-3943/State Relay: 711. hb```f``f`a``; @1V naPppv& QfzIp]`oC >9Z\c~()K=?((qN.n@ L`#acDa@r30D0031aVf|y)sIJ!dB4#wS(` \E Paper claims may be completed by computer, typewriter, or by hand. The claim must be submitted, even if the result is a denial. Services Room and board. Providers and their staff should familiarize themselves with the manual and refer to it to answer program and billing questions. The provider is responsible for pursuing available third-party resources in a timely manner. The Health First Colorado program adds and deletes codes as they are published in annual revisions of CPT. 303-436-4949. for assistance in English and Spanish, or call . The Providers business closes, or the business is nonoperational. Complete the Medicare fields on electronic and hardcopy crossover claims using the Medicare processing information on the Medicare payment report. Members who insist upon obtaining care outside of the MCO network may be charged for non-covered services. The estimate is 72 to Timely filing for Medicare crossover claims is within 120 days from the date of payment denial. Note: The In-Process section only reports claims that enter a "Suspense" status within eight days of the RA date. If the form is signed by an authorized agent, the provider remains completely responsible for the information on the claim and the conditions under which the claim is submitted. or visit https://www.denverhealthmedicalplan.org to get a Provider Directory. Re-billed zero payment claims are denied as duplicates. Services needed because the individual's health would be endangered if he or she were required to return to Colorado for medical care. The RA also contains a Financial Transactions page that summarizes the provider's weekly financial activity. When required information is not included or is illegible on paper claims, the claims are returned to the provider for correction and/or completion. Title XVIII governs the Medicare Program, and Title XIX establishes the State Option Medical Assistance Program, also known as Health First Colorado. Adding modifier 33 information and updated copay information. Faint printing caused by worn or poor-quality typewriters or printer cartridges cannot be imaged. For members under Medicare A (skilled nursing coverage) in nursing facilities, the member's member payment is applied to the Medicare A coinsurance. Payments, Denials, Adjustments and In Process Claims are reported using distinctive headings. This group meets quarterly on the 1st Thursday of the month from 9:00 a.m. to 4:00 p.m. in February, May, August and November. For help with claim submission via the Provider Web Portal, reference the Provider Web Portal Quick Guides. Rachel ReiterPolicy, Communications and Administration Office Director. According to Title VI of the Civil Rights Act, providers who receive any federal funds through programs such as the Medical Assistance Program, Medicare, CHAMPUS, etc., must provide oral interpretation services (excluding a member's family members) to all limited English proficient members in their practice, including those for whom you do not receive federal funds. Requests for Reconsideration must be filed with the fiscal agent within 60 days of the last action, if initial timely filing has expired. These records must fully substantiate or verify claims submitted for payment and must be furnished on request to the authorizing agency. 0 Providers should submit claims to the commercial health insurer for individuals who have supplemental health insurance. This manual describes policies for commercial health insurance coverage, Medicare coverage, and other liability programs such as accident coverage and victim compensation. The number and types of assessments will depend on the position being filled as well as the number of qualified applicants. An Accounts Receivable (AR) account is established when circumstances result in a provider owing money to the Health First Colorado program. The provider also cannot bill members for co-pay/deductibles assessed by the TPL. Financial Analytics. Updated language to be consistent with the newly revised provider participation rule, 8.130, which will be effective January of 2022 (changes made concerning change of ownership, record retention, and inactivation). Such agencies and divisions include but are not limited to: OCL ensures active participation by members, families, advocates, providers, communities, and agencies, sothat necessary coordination and administration is achieved. Members are not responsible for remaining balances after Health First Colorado B crossover processing. Most insurance companies make direct provider payments when the policyholder assigns benefits to the provider. The Specialty Billing Information manuals. Those roles have been in both the executive and legislative branches at the municipal, county, and state level. The services are a benefit when they meet the following requirements: Acute and ambulatory benefit services may be provided under FFS reimbursement and through capitated Managed Care Programs. This directory is for Adams, Arapahoe, Denver, and Jefferson counties. See the Internal Control Number (ICN) Information Sheet for more information. Enter the total of Medicare Coinsurance + Medicare Co-pay amount into the Medicare Coinsurance field. Collection agencies, accounting firms, legal firms, and similar organizations cannot submit claims for direct reimbursement. Providers can also utilize the HIPAA 276/277 Claim Status Request and Response transaction to inquire about claims. To apply for a specific job, follow the instructions in the announcement section titled How to Apply. Denver, CO Type Government Agency Founded 1994 Specialties health care, medicaid, child health plan plus, health first colorado, cicp, and chp+ Locations Primary 1570 Grant Street Denver, CO. Always verify eligibility before rendering services. The Health First Colorado program makes every attempt to maintain up to date TPL information. An estimated 10% of Health First Colorado members have other health insurance resources available to pay for medical expenses. Claims for more than one occurrence of the same procedure on the same date should be billed on one billing line using multiple units of service and increasing the charges accordingly. Except as listed, benefit services provided by registered nurses enrolled as non-physician practitioners must comply with the following requirements: The following list on-premise supervision and non-direct reimbursement exemptions: A copy of the current Provider Participation Agreement can be found on the Provider Revalidation & Enrollment web page. A copy of the Remittance Advice (RA) should not be included with the claim. Added Medicare-only provider types information in Medicare Resources section. Providers should take special care to apply only the policies and procedures appropriate to the specific resource. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. Providers cannot bill members for the difference between commercial health insurance payments and their billed charges when Health First Colorado does not make additional payment. Case Management Agency Meetings and Resources, CO DB101 and Benefits Counseling Presentation, Care and Case Management System-Demonstration of Training Login, Medicaid Subcommittee Recommendations Presentation, HCBS Settings Final Rule - Excerpt of 10 CCR 2505-10 8.484 Regulation, New Assessment and Person-Centered Support Plan Page, CIRS - Critical Incident Reporting Website, Case Management andQuality Performance Division Directory, Complementary and Integrative Health Advisory Committee, Electronic Visit Verification Stakeholder Workgroup, HCBS Final Rule Setting Process - Ways to be Involved, Nursing Facility Provider Fee Advisory Board (PFAB), Office of Community Living Update Webinars, Participant Directed Programs Policy Collaborative (PDPPC), County Contacts for Department of Human/Social Services Offices, Colorado Developmental Disabilities Council, University of Colorado School of Medicine JFK Partners, Sign up to receive Office of Community Living Communications, Long-Term Services and Supports Programs Page, File a complaint about Health Facilities to the Colorado Department of Public Health and Environment, Developmental Disability and Delay Determinations FAQ, Request for Developmental Disability Determination Form, Developmental Disability Determination Decision Form, Developmental Delay Determination Decision Form, Informational Memo - IM 19-054 -Developmental Disability and Delay Determinations Frequently Asked Questions, Developmental Disability and Delay Determinations FAQ Sheet, Informational Memo - IM 18-49 - The Role of Psychological Testing in Accessing Medicaid Services FAQ, FAQ - The Role of Psychological Testing in Accessing Medicaid Services, Developmental Disability Determination Definition Fact Sheet, Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities, Nursing Facility Supplemental Behavioral Services, Pre-Admission Screening and Resident Review (PASRR) Program andForms, Programs for All-Inclusive Care for the Elderly (PACE), ACC Phase II - Member Messaging Resource Center, Health First Colorado Buy-In Programs Page, Buy-In for Working Adults with Disabilities, Consumer Directed Attendant Support Services (CDASS), Local Contact Agencies for Options Counseling, Resources for Case Managers and Providers, Waiting Lists and Enrollments for persons with Intellectual and Developmental Disabilities, Testing Experience and Functional Tools (TEFT) Project, Person- and Family-Centered Care Implementation Grant, Long-Term Services and Supports Benefits and Services Glossary, Community Mental Health Supports Waiver (CMHS), Complementary and Integrative Health Waiver (CIH), Children with Life-Limiting Illness Waiver (CLLI), Children's Extensive Support Waiver (CES), Children's Habilitation Residential Program Waiver (CHRP), Children's Home and Community Based Services Waiver (CHCBS). Health Policy Office/ Medicaid Director Schneider, B. Providers must submit crossover information for railroad retirees. Calculation of the crossover payment is described below. The IRS requires that Health First Colorado payments made in the name of an individual practitioner be reported under the individual's SSN. There is no coverage for Health First Colorado-only benefits (e.g. Employed individuals who have commercial health insurance through employment or union membership. {9O 8>OAh@%CEa]MgLNNp!|U%v7?\zovWP6 Timely filing for Medicare crossover claims is within 120 days from the date of payment or denial. All positions at the Department of Health Care Policy &Financing (HCPF) are security sensitive and require that candidates undergo a criminal record background check as a condition of employment. Kim Bimestefer was appointed by Governor John Hickenlooper to serve as Executive Director for the Department of Health Care Policy and Financing in January 2018. Her background managing Medicaid patients was strengthened during her time as the National Director of Case Management for Anthem/CareMore, a nationally known integrated delivery system. A copy of the explanation of benefits (EOB) is not required with electronic submission, however the Medicare EOB date must be included on the claim. Individuals eligible for Medicare coverage because of age or disability. Charlotte Crist became Director of the Departments Cost Control and Quality Improvement Office in June 2022. If claim filing requirements are not met because of circumstances beyond the control of the provider, the provider can contact the fiscal agent. Providers may append Modifier 33 to an Evaluation & Management (E&M) office visit only if the primary purpose of the E&M office visit is the delivery of a USPSTF grade A or B service, and not if it is simply a component part of a different billed service. Steinbrecher joined the Department in 2011 as a Division Director for Claims Systems and Operations where he has managed multiple programs and IT projects. When a member presents a PE card after the expiration date, always verify eligibility. Interactive claim submission through the Provider Web Portal is a real-time exchange of information between the provider and the Health First Colorado program. Following the procedures and guidelines for program participation established by the Department. Keeping provider enrollment information current with the fiscal agent. To use this method of determining claim status, the provider must be able to transmit compliant HIPAA transactions, or use a clearinghouse or switch vendor to transmit the data for them. Providers may limit the number of Health First Colorado members associated with their practice agency or facility if the policies and methods of applying limitations are non-discriminatory. A denied claim should be resubmitted electronically as a new claim once corrections have been made. If the commercial health insurance benefit is the same or more than the Health First Colorado benefit allowance, no additional payment will be made. The Office of Community Living (OCL) was created by Governor Hickenlooper through an Executive Order in July 2012. CMQP Division Director - Amanda Lofgren Amanda.Lofgren@state.co.us Procedure codes are dependent on the type of service and claim type. 303 . Committees, Boards and Collaboration. Providers are advised to bill their usual and customary charges. Providers always have at least 365 days from the DOS to submit a claim. Whether the Co-pay amount is deducted can be seen in the remittance advice that accompanies each payment. Only delegates with a valid, current business reason should have Provider Web Portal access. Procedures that may be performed both for medical reasons and for cosmetic reasons. Providers should submit claims to the Health First Colorado program when the member is Health First Colorado eligible. An X12N 999 Functional Acknowledgement is generated when a file that has passed the header and trailer check passes through X12 validation. If eligibility is denied, PE expires at the end of the 60 days. OLTC agencies arrange services for Home and Community Based Services members and evaluate options for members at home who are seeking nursing facility care. Whether you seek health care, provide health care, or care about health care, we are here to serve you. Batch may be submitted using batch submission software that must be developed by the provider or purchased from a certified software vendor, or by utilizing the HIPAA 837 transaction. This document provides a link to the Pharmacy billing instructions. The direct care workforce is the backbone of the HCBS system. All benefit services are subject to applicable reimbursement policies including: Other health care services may include other EPSDT benefits if the need for such services is identified. This manual provides general information about Health First Colorado to assist enrolled providers with submitting claims for services rendered to Health First Colorado members. Enrolled providers must have and maintain licensure and certification required by Health First Colorado regulations. Appeals submitted to the Office of Administrative Courts must be received within 30 days from the mailing date of the last notice of action. Labor and delivery are not covered during the PE period. Tests for non-citizens that are not marked as "Emergency" will not be paid. Important: Organ transplants are not a covered benefit for non-citizens. This program offers a variety of opportunities and possibilities for interns to gain both academic and professional experience, build your resume and make connections. Claims that appear in the Claims Paid section of the RA should be adjusted electronically. The claim must be submitted, even if the result is a denial. We're the Colorado Department of Health Care Policy & Financing. In general, Health First Colorado benefits are comprehensive and provide care in most medical disciplines. Submitting claims correctly to the fiscal agent. Adela Flores-BrennanMedicaid Director and Health Policy Office Director. This document contains program-specific benefit, procedural, and billing information for providers billing on the CMS 1500 paper claim form. Sign up to receive HCPF newsletters. A delegate is a person who has been given access to perform certain Provider Web Portal functions on the providers behalf. Prior authorization is not a timely filing waiver. A signed Trading Partner Agreement with the clearinghouse, if used, or with the Health First Colorado program if sending the transaction directly from an office. The Department contracts with the fiscal agent for the processing of Health First Colorado claims. What is the Office of Community Living? If Medicare's payment equals or is more than the Health First Colorado allowed benefit, crossover claims are paid zero. Providers agree to accept Health First Colorado payment as payment in full for benefit services. All claims are processed to provide a weekly RA to providers. Address the specific technical requirements completely on your application. This manual contains Health First Colorado information specific to provider types, including paper claims and electronic claims. Health First Colorado benefits for Medicare QMB-Only members are limited to the Medicare coinsurance and deductibles for all Medicare-covered services. h[oJ&A5mxp`K,G The Claims Processing unit is authorized to evaluate and validate alternative information resources when the provider can show the following conditions: Billing and claim preparation errors are not recognized as beyond the provider's control. If a claim has been underpaid, the fiscal agent must receive a claim adjustment within the applicable timely filing period. Providers may not bill Health First Colorado members for missed appointments, telephone calls, completion of claim submission forms, or medication refill approvals. Waiting for prior authorization or correspondence from the Department or the fiscal agent is not an acceptable reason for late filing. If the Medicare Administrative Contractor is not the designated MAC, providers must submit crossover information. Under FFS reimbursement, the Health First Colorado program prior authorizes: FFS prior authorization approval assures the provider that the service is medically necessary and a Health First Colorado benefit. The non-physician practitioner must look to the billing provider for reimbursement. Claims denied because of billing errors, incorrect eligibility information, etc., may be rebilled with additional or corrected information at any time during the applicable timely filing period. If needed, the provider may contact the Provider Services Call Center for assistance. His focus in the last 17 years has been in economic security and public assistance, including oversight of Medicaid and public assistance program eligibility for the City and County of Denver. Providers must maintain records that fully disclose the nature and extent of services provided. The following are examples of invalid TPL reasons for submitting Health First Colorado claims: When commercial health insurance coverage is identified after claims are paid, providers receive notification of the intent to recover payment and instructions for submitting claims to the commercial health insurer. See the Provider Web Portal information in the Billing section of this manual. See the, Sign up for the Long-Term Services & Supports Stakeholders communication list, Office of Community Living Stakeholder Engagement, View full list of other newsletters offered by the Department, View HCPF Memo Series Communications Page, View Long-Term Services and Supports Programs page. Rebilled claims appear on the RA as a new claim with a new ICN. The Health First Colorado program uses the CMS HCPCS to identify services provided to Health First Colorado members. Be sure to fill out your application completely to address the minimum and the preferred qualifications. Commercial health insurers often offer greater benefits than Health First Colorado. With few exceptions, Health First Colorado claims must be submitted electronically. These claims are transmitted through the Provider Web Portal). Administers other medical assistance programs such as Child Health Plan Plus (CHP+) and the Colorado Indigent Care Program (CICP). The Department also receives Child Health Insurance Program (Title XXI) funding from the federal government for the Childrens Basic Health Plan, marketed as Child Health Plan Plus or CHP+. She brings extensive experience leading Medicare population health programs (MSSP, CPC+) and brings insight from her leadership positions with Blue Cross, Geisinger, CareMore, and Kaiser Permanente. Using the information in manuals and bulletins helps eliminate program and billing misunderstandings that can result in payment delays, incorrect payments, and payment denials, regarding covered services, member eligibility, and billing procedures. Examples include: Reconsideration is available only when extenuating circumstances or mitigating factors prevent compliance with filing requirements. New fields are defined below: Refer to the Provider Web Portal Quick Guide - Reading Your Remittance Advice (RA) Dated on or After 1/9/2019 for examples and more information. This means that we work to make our members healthier while getting the most for every dollar that is spent. Individuals who qualify for benefits under the Medicare Catastrophic Coverage Act are called Qualified Medicare Beneficiaries (QMBs). Electronic re-bills (resubmissions of previously denied or paid claims) and adjustment requests must be filed with the fiscal agent and received within the timely filing period. Medicare adjustments may show the crossover message, but automatic crossover processing is not possible. Emergency Response Guide; Emergency Management Paper claims must be the red-ink forms and cannot be photocopied. Cristen Bates serves as the Office Director for Colorado Medicaid and CHP+ Behavioral Health Initiatives and Coverage, and the Deputy Medicaid Director at HCPF. Each medical record entry must be signed and dated by the person ordering and providing the service. Paper adjustments must be accompanied by the Medicare SPR and adjustment documentation. Refer to Appendix D and Appendix E on the Billing Manuals web page under Appendices for address, phone and fax number information. All Health First Colorado eligible pregnant women may receive EPSDT outreach and case management services. Failure to abide by applicable Colorado and United States laws. Except when holidays create a one to two-day delay, providers should receive their warrant by the beginning of the following week. If the supplemental health insurer denies benefits, the provider may submit a crossover claim with documentation of the commercial health insurance denial. Testing is conducted to verify the integrity of the format, not the integrity of the data, however, in order to simulate a production environment, EDI requests that providers send real transmission data.
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