The client's county of residence establishes client eligibility for Colorado Medical Assistance Program benefits.

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.

The fiscal agent, ACS, and the Department’s Client Contact Center are unable to provide you with a guarantee number used to assure client eligibility and coverage. You can verify eligibility through one of the electronic methods, and if the client is eligible for the date span provided, you will receive an eligibility guarantee number.

Electronic methods include:

1. Colorado Medical Assistance Program Web Portal (Batch or Interactive): X12N 270 - Eligibility Inquiry

Batch eligibility verifications may be made through other vendors such as WebMD, Envoy, Passport Health, etc.

Maintain copies of all eligibility and coverage information in the client's file for billing and audit purposes.

2. Fax-Back: 1-800-493-0920 Toll free

Fax-Back is a phone number that can be used to have an eligibility report automatically sent to the provider's fax machine.  The recorded voice prompts the caller for information and responds to the caller.  One date of service can be verified at a time.  If the client is ineligible, the voice informs the caller of ineligibility and no fax is sent. Only one fax number can be associated with a provider number.
FaxBack Eligibility Instructions and corresponding prompts can be found on the Provider Services Billing Manuals and the Manuals pages of the Provider Services section of the Department’s Web site.

3. Colorado Medicaid Eligibility Response System (CMERS)/Automatic Voice Response System (AVRS)

The AVRS was implemented on August 5, 2010 and has enhanced the Colorado Medical Assistance Program Eligibility Response System (CMERS).  The system is an automated voice response system and allows callers to retrieve client eligibility, claim status, and warrant information.  In addition, more than three eligibility inquiries can be made per call.  Providers are also able to check claim status by Provider ID/National Provider Identifier (NPI) with Client ID and Date of Service, or by Transaction Control Number (TCN).  One date of service can be verified at a time.
Colorado Medicaid Eligibility Response System (CMERS)/Automatic Voice Response System (AVRS) Instructions and corresponding prompts can be found on the Provider Services Billing Manuals and on the Manuals pages of the Provider Services section of the Department’s Web site.

Both FaxBack and AVRS provide an eligibility guarantee number. Providers should keep the eligibility guarantee number with the client's file.

Always verify eligibility before rendering services.
 

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.  Completed information may be faxed to ACS Provider Enrollment at 303-534-0439 or mailed to:

ACS Provider Enrollment
PO Box 1100
Denver, CO 80201-1100
Providers may also contact ACS Provider Services at 1-800-237-0757 or 1-800-237-0044 (Toll free) for Fax-Back information.
 

Load Letter’s (LL) and Late Bill Override Dates (LBOD) allows 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 do not exceed 364 days.

Clients with coverage by Medicare and Medicaid have dual eligibility. Providers are reminded that Medicaid is always the payer of last resort, therefore, services for dual-eligible clients must be billed first to Medicare. Providers must be able to show evidence that claims for dual eligible clients, 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 dual-eligible clients.

Feel free to contact ACS Provider Services 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, but are 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 Web Portal FAQs for more information.
 

You may contact ACS EDI Services at 1-800-237-0757 or 1-800-237-0044 (Toll free) Monday through Friday, 8:00 A.M. to 5:00 P.M. Mountain Time.
 

The Trading Partner Administrator assigns the File and Report Service (FRS) role to the user.  The user selects the File and Report Service option from the Web Portal main menu.
1. Click View/Download Reports.
2. Look for “077016 Provider Claim Report” in the Report Types. Either click Search or enter a date range and then click Search.
3. When “077016 Provider Claim Report” is not listed as a report type, click Search without selecting any criteria.
4. Reports selection should display in the lower half of the page.
5. Select the report,

• On the right side of the window, select view or download.
• If view is selected, the reports can also be printed.

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 charge for this service is $2.00 per page. You may contact ACS Provider Services to request the number of pages per report and mail a check to:

Colorado Medical Assistance Program Correspondence
P.O. Box 30
Denver, CO 80201-0030

Make check payable to ACS. 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 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

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

The State 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 (RN)
• EFT is required to receive the X12N 835 (Claim payment/Claim report)
   

You must complete 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.
1.     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 ACS Provider Enrollment at 303-534-0439 or mailed to:
ACS Provider Enrollment
P.O. Box 1100
Denver, CO 80201-1100

Allow 30 days for processing your EFT request.

• After 30 days, check with your bank to verify that EFT has been set up. 
• You will receive paper checks until EFT has started.

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

If after you have contacted your bank and they have not received the deposit 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 your 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
• Is this your first EFT payment from the Colorado Medical Assistance Program?
• Additional Information to help research problem

If it has been 30 days since the payment date of the check:
You may call ACS Provider Services 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 is 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
You may also mail both the request and check 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 is 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 you enter your information, you should verify it the following day.

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

If you are unable to update your information through the Web Portal, submit a Provider Enrollment Update Form located in the Provider Services Forms section ofthe Department’s Web site or send updated information on your letterhead to Provider Enrollment (PO Box 1100; Denver, CO 80201-1100). Changes sent by mail may take up to two weeks.
Once a check is returned to the fiscal agent, your claims will deny until you update your information.
If the Web Portal is used for updates, you should notify ACS Provider Services 24 hrs after the update is completed that your information is correct.
When you re-bill the claims, another payment/check will be issued and mailed to the corrected address.

Future checks cannot be canceled. Please refer to the Q & A above.

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 Provider Services at 1-800-237-0757 or 1-800-237-0044 (Toll free) for information related to AR balances.

There are several reasons for an AR balance. They include: 

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 your 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 fiscal agent 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 you have not received payment in the last 18 months, you were purged out of COFRS.
When you receive these forms, you should 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 is 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 your provider number is linked to your SSN, and you want your payments reported on your SSN, you do not need a new provider number.
• 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.

You may have submitted a W-9 form that 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 your last payment from the Colorado Medical Assistance Program, you must complete and submit a new W-9 to receive payment. Send the completed W-9 to:

ACS 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 ACS EDI Services 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 the ACS 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)

You should 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, you are responsible for submitting crossover claims, electronically or on paper.

If you submit the crossover claim on paper you must submit a copy of the Medicare Standard Paper Remit (SPR) with the paper claim.  Be sure to retain the original SPR for audit purposes.

You must 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.
You must maintain records that fully disclose the nature and the extent of services provided and that substantiate submitted claim information. Upon request, you must furnish information about payments claimed for Colorado Medical Assistance Program services.
 

LBOD stands for Late Bill Override Date. The provider uses the LBOD to document compliance with timely filing requirements. Only use the LBOD if you are 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 you are using that to support your LBOD date. You can use a LBOD 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
 

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

You will choose one of six numeric Delay Reason Codes. In the “Notes” section on the Claim Information tab, write a general description of why you are using the numeric value.

 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 ACS 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.

.

You may access the current fee schedule and the instructions for reading the fee schedule 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, you can 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.

How 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 and Provider Claim Reports (PCRs). There is no need to dial into a system and the response time through the Web Portal is faster. You are able to access the Web Portal from any computer that has internet access, 24 hours 7 days a week.

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, you can store historical claims, manage client and provider data, and check the status of a Prior Authorization Request (PAR). The Web Portal prevents you from storing the information on your own PCs 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, PAR Requests for Medical, Dental and Supply, PAR Responses and PAR 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:

ACS 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.