Benefit Coverage Standards
Benefit Coverage Standards must be evidence-based and guided by best practices in treatment as well are coverage and payment decisions. Colorado Medicaid may also use external vendors and tools developed by third parties to assist in determining medical necessity and administering Medicaid State Plan benefits.
What is Benefit Coverage Standard?
A document that defines and limits the appropriate amount, duration, and scope of a covered service by stating:
- Our determination of whether a service is proven to be effective based upon published clinical evidence or generally accepted standards of practice;
- Whether a given service is medically necessary and a covered benefit; and
- Services determined to be experimental, investigational, unproven, or not medically necessary are typically not covered.
Benefit Coverage Standards may include the following subsections:
Brief Coverage Statement: An explanation of the Benefit Coverage Standard topic and if pertinent, medical information regarding the condition to be treated in accordance with the Benefit Coverage Standard.
Services Addressed in Other Coverage Standards: A description of other related Benefit Coverage Standards.
Eligible Providers: An explanation of which providers may render the services described within the Benefit Coverage Standard according to state laws and licensure requirements.
Eligible Places of Service: A description of where the services may be rendered to Medicaid clients and where the Colorado Medicaid claim system, MMIS, permits providers to bill as places of service on the claim form.
Eligible Clients: An explanation of which Medicaid clients are eligible to receive services described within the Benefit Coverage Standard.
Covered Services and Limitations: An outline of what services or clinical indications are covered, and what specific limitations are placed upon those covered services or indications.
Non-Covered Services and General Limitations: An outline of what is not covered, and general limitation placed upon the Benefit Coverage Standard.
Requirements: An explanation of requirements needed to properly bill for the services described within the Benefit Coverage Standard such as prior authorization requirements or documentation requirements.
Billing Guidelines: A referral to the appropriate billing manual for the services described within the Benefit Coverage Standard or an explanation of how to bill for these services if an appropriate billing manual does not exist.
Definitions: An explanation of terms within the Benefit Coverage Standard that have been defined within the document.
References: An outline of all sources researched and used for the Benefit Coverage Standard. This section should detail the titles, authors, publication or website access dates, and website address, if applicable.