The client's county’s Department of Human/Social Services agency helps to establish client eligibility for Colorado Medical Assistance Program benefits. More information can be found on the Colorado Department of Human Services Web site.

A client’s Colorado Medical Assistance Program eligibility may be made retroactive prior to the application date. Charges for services are the patient’s responsibility until eligibility is established. Claims are denied if the client’s eligibility status is not available through eligibility verification methods.

Fax-Back information is located in the Provider Enrollment Application. The application is available in the Provider Services Enrollment section of the Department's Web site (colorado.gov/hcpf). Completed information may be faxed to the Department’s fiscal agent’s Provider Enrollment Unit at 303-605-4134 or mailed to:

Xerox State Healthcare, Provider Enrollment
PO Box 1100
Denver, CO 80201-1100

Providers may also contact the Department’s fiscal agent's Provider Services Unit at 1-800-237-0757 or 1-800-237-0044 (Toll free) for Fax-Back information.

Load Letters (LL) and Late Bill Override Dates (LBOD) allow providers to submit claims that are outside of the timely filing period. LLs are issued for claims with dates of service (DOS) past 365 days. LBODs are issued for claims with DOS past 120 days, but not exceeding 364 days.

The LBOD process allows providers to submit claims for services rendered past the 120 day timely filing period. Providers may submit LBOD requests on the LL form.

NOTE: The purpose of the Load Letter and Late Bill Override Date is to allow providers to submit claims outside of the timely filing period; however, they are not a guarantee of payment. For CHP+ clients, please contact the HMO listed on the back of the client’s medical card for an LL or LBOD.

A Load Letter can only be issued when the provider has verified the client’s eligibility and receives an Eligibility Status of “Eligible” through the Web Portal (Web Portal), FaxBack, or Automatic Voice Response System (AVRS). The Load Letter Request form is available under Other Forms in the Provider Services Forms section. Upon receiving the request from providers, the Department will generate an LL or LBOD as long as the request meets all of the following criteria:

Client/patient was eligible when services were rendered;
Client/patient was showing as ineligible at the time of claims submission;
Eligibility was recently reinstated retroactively, but the claim is out of timely filing; and
Client is currently showing as eligible.

All Load Letter requests should be faxed to the Department at 303-866-2082, or via encrypted email to loadletterrequests@hcpf.state.co.us. Use Load Letter Request as the subject. Do not use the client’s State ID in the subject line.

Clients with coverage by Medicare and Medicaid are referred to as Medicare-Medicaid enrollees. Providers are reminded that Medicaid is always the payer of last resort, therefore, services for Medicare-Medicaid enrollees must be billed first to Medicare. Providers must be able to show evidence that claims for clients with dual eligibility, where appropriate, have been denied by Medicare prior to submission to the Colorado Medical Assistance Program. Per the Provider Participation Agreement, this evidence must be retained for six years following the Medicare denial. The Colorado Medical Assistance Program requires that the Medicare Standard Paper Remit (SPR) accompany any paper claims submitted for Medicare-Medicaid enrollees.

Feel free to contact the Department’s fiscal agent’s Provider Services Unit at 1-800-237-0757 or 1-800-237-0044 (Toll free) Monday through Friday, 8:00 a.m. to 5:00 p.m. MST with questions.

Presumptive Eligibility (PE) allows children age 18 and under and pregnant women to be enrolled in either Medicaid or CHP+ as presumptively eligible. Medicaid PE for children includes coverage of all Medicaid covered services. However, Medicaid PE for pregnant women only covers outpatient services.

Medicaid PE for pregnant women includes:
• Outpatient Services
• Prenatal Care

Medicaid PE for pregnant women does not include:
• Inpatient care
• Labor and Delivery

Medicaid PE for children includes full Medicaid benefits, and is not limited to:
• Outpatient services
• Inpatient care
• Mental health services
• Prescriptions
• Dental services

The Modified Medical Program provides care for Colorado old age pensioners with limited incomes who do not qualify for the Colorado Medical Assistance Program.

Elderly and disabled Medicare beneficiaries with incomes below the federal poverty level and resources at twice the Supplemental Security Income (SSI) level are eligible for Colorado Medicaid payments of Medicare deductibles and coinsurance. Individuals who qualify are called Qualified Medicare Beneficiaries (QMBs).

Benefits available to non-citizens are limited to care and services necessary to treat immediate emergency conditions including labor and delivery.

For additional information on eligibility, please see the Medicaid Programs Fact Sheet in the Partners & Researchers Program Fact Sheets section of the Department's Web site.

These reports can be retrieved through the File and Report Service option within the Web Portal. See the Provider Services Web Portal section of the Department’s Web site for more information.

Contact the Department’s fiscal agent’s EDI Services Unit at 1-800-237-0757 or 1-800-237-0044 (Toll free) Monday through Friday, 8:00 a.m. to 5:00 p.m. MST.

Submit an Application for EDI enrollment, or submit an EDI Update Form if a trading partner ID # has already been approved and assigned to your agency. Both forms are located in the Provider Services EDI Support section of the Department’s Web site.

Enter the receiving trading partner ID # in the receiving TP ID box next to each report.

Note: When a billing agent is authorized to receive reports, the reports may not be directed to an additional trading partner ID for retrieval.

All reports are available electronically for 60 days. Once a report is purged, the provider must request a paper copy.

The Department’s fiscal agent does not provide copies of Provider Claim Reports (Remittance Statements) free of charge to providers who:
• Currently bill or retrieve reports electronically or
• Are requesting Provider Claim Reports over 30 days old

There are two options to obtain a duplicate copy of a PCR.
Option One (1):
The Department’s fiscal agent will send an encrypted email with the duplicate copy PCR attached. The charge for this service is $2.00 per page.
Option Two (2):
The Department’s fiscal agent will mail the duplicate copy PCR via FedEx. The charge for this service is a flat rate cost of $2.61 per page for a business address or $2.86 per page for a residential address.

Contact the Department’s fiscal agent at 1-800-234-0757 to request the number of pages per report and mail a check to:
Xerox State Healthcare
P.O. Box 30
Denver, CO 80201-0030
Make check payable to Xerox State Healthcare, LLC. Note the provider number, week of the PCR, mailing address, and to whose attention the mailing should be sent. Allow seven (7) days for processing after receipt of request, and additional time for return mail.

The specification manuals can be downloaded from the Provider Services Specifications section of the Department's Web site.

The Department requires EFT for the following:

• All in-state and border provider groups, clinics, and facilities
• Individual providers who are not affiliated with a group, excluding Physician Assistants and Non-Physician Practitioners (RNs)
• EFT is required to receive the X12N 835 (claim payment/claim report)

The Electronic Funds Transfer (EFT) form labeled "Authorization Agreement for Automatic Deposits", located in the Provider Services Enrollment section for Providers already enrolled in the Colorado Medical Assistance Program must be completed.

Click on Electronic Funds Transfer and print the form.

Attach an updated or current W-9 to the completed EFT form.

The form can either be faxed to the Department’s fiscal agent’s Provider Enrollment Unit at 303-534-0439 or mailed to:

Xerox State Healthcare, Provider Enrollment
P.O. Box 1100
Denver, CO 80201-1100

Allow 30 days for processing EFT requests

• After 30 days, check with the bank to verify that EFT has been set up.
• Paper checks will be sent until EFT has been established.

Yes. Each time bank information changes, a new EFT document must be submitted as well as a new W-9. Processing EFT information takes about a month. While EFT information is in process, providers will receive paper checks (warrants).

If after the bank has been contacted and the deposit has not been received within 30 days from the paid date, send an email to HCPFAR@hcpf.state.co.us for specific account number information.  Please provide the following information in the email in order to expedite the process:

• Billing Provider Number
• Billing Provider Name
• Billing Provider Address
• Contact Name
• Contact Telephone Number
• Contact Email Address
• Date of Missing EFT (Reference to PCR Date)
• Dollar Amount
• If this the first EFT payment from the Colorado Medical Assistance Program
• Additional Information to help research the problem

If it has been 30 days since the date of the payment: 
Call the fiscal agent’s Provider Services Unit at 1-800-237-0757 or 1-800-237-0044 (Toll free).

• The customer service representative can submit a check trace.
• Ask the representative for the warrant number for your reference.

Send an email to HCPFAR@hcpf.state.co.us to request copies of cashed checks and provide the following information in order to expedite your request:

• Billing Provider Number
• Billing Provider Name
• Billing Provider Address
• Contact Name
• Contact Telephone Number
• Contact Email Address
• Warrant Number
• Warrant Date
• Warrant Amount
• Multiple warrants on one request are acceptable but please include all warrant information for each warrant you are requesting.

The following is the charge per warrant requested:

• Warrant Date Prior to July 1, 2003 - $9.00 per warrant requested
• Warrant Date After June 30, 2003 - $1.00 per warrant requested

Make check payable to the Department of Health Care Policy and Financing and mail to:

Department of Health Care Policy and Financing
Accounting Department
1570 Grant Street
Denver, CO 80203-1714

Both the request and check may be mailed to the address above.

 If the check trace research verifies that the check was not cashed or was not found, send an email to HCPFAR@hcpf.state.co.us to request a check to be reissued. Please provide the following information in order to expedite your request:

• Billing Provider Number
• Billing Provider Name
• Billing Provider Address
• Contact Name
• Contact Telephone Number
• Contact Email Address
• Warrant Number
• Warrant Date
• Warrant Amount
• Fax Number
• Multiple warrants on one request are acceptable but please include all warrant information for each warrant you are requesting.

Some providers may update their information (e.g., address, telephone number, email address) through the Web Portal’s (MMIS) Provider Data Maintenance area. Once the information is entered, verify it the following day.

Checks may have been returned to the Department’s fiscal agent. Providers who have the capability should update their information through the Web Portal. Changes made through the Web Portal are effective within 24 hours.

Providers who are unable to update address information through the Web Portal may submit a Provider Enrollment Update Form, located in the Provider Services Forms section of the Department’s Web site, or send updated information on the provider’s letterhead to Provider Enrollment (PO Box 1100; Denver, CO 80201-1100). Changes sent by mail may take up to two weeks to process.

Once a check is returned to the fiscal agent, claims will deny until the information is updated.
If the Web Portal is used for updates, notify the Department’s fiscal agent’s Provider Services Unit on the next business day (at least 24 hours) after the update is completed.

When the claims are re-billed, another payment/check will be issued and mailed to the corrected address.

The safest, best, fastest, and easiest way to receive Medical Assistance Program payments is through EFT.

(See Electronic Funds Transfer (EFT) Questions to learn how to set up EFT.) EFT permanently solves paper check (warrant) problems!

Call the Department’s fiscal agent’s Provider Services Unit at 1-800-237-0757 or 1-800-237-0044 (Toll free) for information related to AR balances.

There are several reasons that an AR balance may be created.

An AR is created when claims are reversed and the amount due was not received from the provider.

An AR is created if a completed audit finds that a provider was paid in error and the Colorado Medical Assistance Program forwards a financial transaction requesting that the funds be recovered from the provider’s next payment.

An AR is created if the recovery request is not satisfied with funds from the next payment.

Allow 30 days for processing.

If the AR balance remains after that period, email HCPFAR@hcpf.state.co.us and provide the following information to expedite the request:

• Billing Provider Number
• Billing Provider Name
• Billing Provider Address
• Contact Name
• Contact Telephone Number
• Contact Email Address
• Check Account Name
• Check Number
• Check Date
• Check Amount
• If possible, PCR date in which receivable was established.

Claims processed by the Department’s fiscal agent, Xerox State Healthcare, to a provider number that is not active in the Colorado Financial Reporting System (COFRS) results in incomplete payment.

This usually occurs when the rendering provider number is used in the billing provider number field on the claim(s). It can also occur when there is a question about a Tax Identification Number (TIN). In addition, if there has been no payment to a provider in the last 18 months, COFRS purges the account.

If a Notification of Non-Payment form is received, follow the instructions and fax the information directly to 303-866-3669, attention “Accounting”. Keep all of the forms as one packet and fax them together. Do not separate the forms.

This could be due to a business type or name conflict between the provider information in the Medicaid Management Information System (MMIS) and the billing provider number information in COFRS.

• A provider number may only bill using one TIN. However, one Employer Identification Number (EIN) may have multiple provider numbers.
• A provider enrolled with an individual Social Security Number (SSN) as well as an EIN, would have two provider numbers.
• If the provider number is linked to a SSN, and the purpose is to have payments reported on that SSN, a new provider number is not necessary.
• A single Medical Assistance Program provider number cannot be assigned to both an SSN and EIN.
• The billing provider number must correspond to either your SSN or EIN.

Note: The billing provider number is the one receiving payments and the corresponding TIN is reported to the Internal Revenue Service (IRS).

The Colorado Medical Assistance Program utilizes this important business letter to confirm the legal name of the business identified with a corresponding TIN. We request this information to verify that we are reporting payments correctly to the IRS and to verify that you are enrolled correctly.

It could be that the W-9 form that was submitted was completed incorrectly, with both a SSN and an EIN, or with a legal name that does not match the TIN on file. The form must be completed correctly to set up provider payments and to comply with federal tax laws.

If it has been longer than 18 months since the provider’s last payment from the Colorado Medical Assistance Program, a new W-9 must be completed and submitted to receive payment because the Colorado Financial Reporting System (COFRS) purges the account. Send the completed W-9 to:

Xerox State Healthcare, Provider Enrollment
P.O. Box 1100
Denver, CO 80201-1100

When the claim requires a rendering or attending physician’s number, the individual doctor’s provider number must be used in these fields when:

1. The group is the “pay-to” provider; or
2. The individual does not want payments reported against his or her SSN.

Please contact the Xerox State Healthcare EDI Services Unit at 1-800-237-0757 or 1-800-237-0044 Monday through Friday, 8:00 a.m.to 5:00 p.m. MST for the following:

• Electronic claim submission enrollment
• Electronic Accept/Reject report retrieval
• Electronic Remittance Statement retrieval

Please contact Xerox State Healthcare Provider Services Unit at 1-800-237-0757 or 1-800-237-0044 Monday through Friday, 8:00 A.M. to 5:00 P.M. MST for the following:

• Billing questions
• Claims adjudication and payment questions
• Questions regarding eligibility information
• Enrollment for new Colorado Medical Assistance Program providers
• Provider enrollment changes (i.e., change of address, tax IDs)

Allow 30 days for the Colorado Medical Assistance Program to process the crossover claim. If automatic crossover does not appear on the Colorado Medical Assistance Program PCR within 30 days of the Medicare processing date, it is the provider’s responsibility to submit crossover claims, electronically or on paper.

If the crossover claim is submitted on paper, a copy of the Medicare Standard Paper Remit (SPR) must be attached. Be sure to retain the original SPR for audit purposes.

Retain client records for at least six years, or longer if required by regulation or a specific contract between the provider and the Colorado Medical Assistance Program.

Records must fully disclose the nature and the extent of services provided, and substantiate submitted claim information. Upon request, information about payments claimed for Colorado Medical Assistance Program services must be furnished.

LBOD stands for Late Bill Override Date. The provider uses the LBOD to document compliance with timely filing requirements. Only use the LBOD if filing a claim with dates of service older than 120 days. Providers must keep LBOD documentation on file. For example, keep a copy of the Web Portal rejection if that supports an LBOD date. An LBOD can be used on either an electronic claim or paper claim. The original claim must have been filed within the original Colorado Medical Assistance Program timely filing period. The LBOD cannot be greater than 60 days from the last date of adverse action (denial or return).

UB-04 - Occurrence code 53 and the date are required in FL 31-34
Colorado 1500 - Indicate “LBOD” and the date in box 30 - Remarks
2006 ADA Dental - Indicate “LBOD” and the date in box 35 - Remarks

A Delay Reason Code is needed in addition to the LBOD on HIPAA compliant 837 electronic transactions.

Choose one of six numeric Delay Reason Codes. In the “Notes” section on the Claim Information tab, write a general description of why the numeric value is being used.

Delay Reason Codes
1 Proof of Eligibility Unknown or Unavailable
3 Authorization Delays
7 Third Party Processing Delay
8 Delay in Eligibility Determination
9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
11 Other

For more information on how to submit electronic claims, please refer to the appropriate companion guide in the Provider Services Specifications section of the Department’s Web site.

Submit a paper claim to the Colorado Medical Assistance Program’s fiscal agent with a copy of the PHP denial.

Common reasons include the following:

• Sterilization claims - Claim must be billed on paper with the completed Med-178 form.
• Hysterectomy claims - Claim must be billed on paper with the completed Acknowledgment/Certification Statement for a hysterectomy form.
• Supply claims - You must indicate that you are billing the invoiced price. Submit the claim electronically using the “UB” modifier.

Providers must bill their usual and customary charge to the Colorado Medical Assistance Program. The TOTAL CHARGES are the provider's usual and customary charges.

The NET CHARGE (TOTAL CHARGES less THIRD PARTY PAID) is the payment actually received plus the contractual write-off amount.

If the THIRD PARTY PAID amount is less than the Colorado Medical Assistance Program allowable amount, the Colorado Medical Assistance Program will pay the difference up to the Colorado Medical Assistance Program allowable amount toward the other insurance copay amount.

If the THIRD PARTY PAID amount is greater than the Colorado Medical Assistance Program allowable amount, the Medical Assistance Program makes no payment.

CHP+ information may be accessed by visiting the Department’s Web site at colorado.gov/hcpf.

The current fee schedule and the instructions for reading the fee schedule may be accessed by visiting the Provider Services Home page of the Department's Web site. Code information includes: procedure code, system parameter, price begin date, price end date, factor code, relative value, gender, min age, max age, post-op days, and if a PAR is required.

If the baby and the mother are both still in the hospital, bill using the mother's Medical Assistance Program client ID number. If the baby is still hospitalized after the mother is discharged or if the baby is transferred to another hospital, the baby's charges must be billed using the baby's Medical Assistance Program ID number.

To submit claims using the mother's Colorado Medical Assistance Program client ID number:
Use the mother's Medical Assistance Program client ID number along with all of the mother's information (i.e., date of birth and name).

Use the -UK modifier. The -UK modifier on the Colorado 1500 paper claim form identifies the claim as the baby's.

Note: The use of the mother's Medical Assistance Program client ID number and the UK modifier only applies to charges billed on the Colorado 1500 for clients in the Fee-for-Service or Primary Care Physician Program. This does not apply to clients covered under Medical Assistance Program contracted HMOs.

The Colorado Medical Assistance Program Secure Web Portal (Web Portal) is a secured Web site that is accessible from the Secured Site option via the Department of Health Care Policy and Financing’s (the Department) Web site at colorado.gov/hcpf. The Web Portal is used to submit and retrieve transactions and/or reports, including Accept/Reject Reports, Prior Authorization Letters, and Provider Claim Reports (PCRs). There is no need to dial into a system, and the response time through the Web Portal is faster. The Web Portal is available 24 hours 7 days a week from any computer that has internet access.

The Web Portal offers a centralized database, which could mean fewer data inconsistencies. The Web Portal is accessed through secure internet connections, and information stored in the database is secure and available only to the specified trading partner. Among other functions, historical claims can be stored, client and provider data can be managed, and inquiries can be made on the status of a Prior Authorization Request (PAR) and on claims submitted on paper. The Web Portal prevents information from being stored on personal computers or waiting for a response from other sources.

The Web Portal currently offers: Interactive Eligibility Inquiries, Batch Eligibility Inquiries, Claim Status Inquiries, Professional, Institutional and Dental claim submission, and PAR status inquiries. Additional services include: Provider Specialty Lookup, which is useful for searching for Medical Assistance Program Providers for referral purposes, and a Dashboard on the Main Menu page for system and transaction status information.

Download and complete an EDI Enrollment form located in the Provider Services EDI Support section of the Department’s Web site. Return the completed form to:

Xerox State Healthcare, EDI Services
P.O. Box 1100
Denver, CO 80201-1100

The Department will follow-up on the enrollment process and send the necessary username and password for the Trading Partner Administrator (TPA) to access the Web Portal.

Note: The TPA is responsible for assigning additional usernames and passwords to other users within their practice or facility.

Providers who have submitted the enrollment packet to the Department’s fiscal agent’s EDI Services Unit, but have not received a response, should contact the EDI Services Unit at 1-800-237-0757 or 1-800-237-0044 (Toll free).