Billing FAQs

Billing FAQs

This page references the Colorado Medical Assistance Program which includes Health First Colorado (Colorado's Medicaid program), Child Health Plan Plus (CHP) and other long-term care programs.

Back to Provider Information


Accounts Receivable (AR) Balances

1. Who should be contacted to find out about an AR balance?
Call the Provider Services Call Center at 1 (844) 235-2387 (toll-free) for information related to AR balances. Hours of operation are Monday, Tuesday, and Thursday from 7:00 a.m. to 5:00 p.m. MST as well as Wednesday and Friday from 10 a.m. to 5 p.m. MST

Back to Top

2. What creates an AR balance?
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

Back to Top

3. What are the steps to take to when the AR balance is paid in full (have a canceled check), but a balance still appears on the RA?

Allow 30 days for processing.

If the AR balance remains after that period, please call the Provider Services Call Center at 1 (844) 235-2387 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, RA date in which receivable was established.

Back to Top


Common Billing Questions

4. Who should be contacted for billing or Electronic Data Interchange (EDI) questions?

Please call the Provider Services Call Center at 1 (844) 235-2387 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 (e.g., change of address, tax IDs)
  • EDI batch billing or report retrieval questions

The Provider Services Call Center is available Monday, Tuesday, and Thursday from 7:00 a.m. to 5:00 p.m. MST as well as Wednesday and Friday from 10 a.m. to 5 p.m. MST.

Back to Top

5. If Medicare claims don't automatically crossover to Medicaid, what steps does a provider need to take?

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 RA 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.

Back to Top

6. How long should a provider retain member records?

Retain member 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.

Back to Top

7. What should a provider do if the PHP (Pre-paid Health Plan) denies the claim for "Not a benefit"?

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

Back to Top

8. How does a provider bill the Colorado Medical Assistance Program when there is a contractual write-off with other insurance?

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.

Back to Top

9. Where can CHP+ information be obtained?

CHP+ information may be accessed by visiting the Child Health Plan Plus (CHP+) web page.

Back to Top

10. How can the Colorado Medicaid fee schedule be accessed?

The current fee schedule and the instructions for reading the fee schedule may be accessed by visiting the Provider Rates & Fee Schedule web page. 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.

Back to Top

11. How are newborn charges covered?

If the newborn and the mother are both still in the hospital, bill using the mother's Colorado Medical Assistance Program member ID along with all of the mother's information (i.e., date of birth and name).

Use the -UK modifier. The -UK modifier on the CMS 1500 paper claim form identifies the claim as belonging to the baby.

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

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 Colorado Medical Assistance Program ID number.

Back to Top

12.1 To whom does the birth of a baby need to be reported to?

The birth of babies of women on Medicaid need to be reported to the assigned county or Medical Assistance (MA) site case worker in the member’s county of residence.

Back to Top

12.2 What can Providers do to report the birth of a baby in an emergency situation? 

An online form provides a secure means of submitting the newborn’s information to the Department.  For emergent requests, the newborn’s information will be added to its mother’s case within two business days from its receipt.  A confirmation of receipt of the form is provided through the online process.

Back to Top

12.3 Can a provider bill a Medicaid member for the cost or the cost remaining after payment by Medicaid, Medicare, or a private insurer?

No, Medicaid members cannot be billed for any service covered by Medicaid. More information is available in the Statement Regarding Billing of Medicaid Members

Back to Top


Electronic Funds Transfer (EFT)

13. Is EFT a requirement?
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)
 
 
14. What needs to be done to have EFT established?
Providers can establish an EFT through the new Provider Web Portal. For information on setting up an EFT, please review the information in this Provider Web Portal Quick Guide.
 
 
15. How long does it take to set up/update EFT?
  • Once the update is submitted via the enrollment portal, a specialist will review the submission.
  • Once the update has been processed by DXC, an additional two weeks is needed to establish EFT.
  • Paper checks will be sent until EFT has been established.

Back to Top

16. Does a new EFT document need to be submitted for a change in bank information?
Yes. Each time bank information changes, a new EFT document must be submitted. Processing EFT information takes about a month. While EFT information is in process, providers will receive paper checks (warrants).
 
 
17. What steps need to be taken for EFT deposits that don't show in an account? 
If after the bank has been contacted and the deposit has not been received within seven days from the paid date, please call the Provider Services Call Center at 1 (844) 235-2387 to verify the account information on file.  Please provide the following information over the phone 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 RA Date)
  • Dollar Amount
  • If this the first EFT payment from the Colorado Medical Assistance Program
  • Additional Information to help research the problem
 

Electronic Reports

18. How are Accept/Reject and Provider Claim Reports retrieved electronically?
These reports can be retrieved through the File and Report Service option within the Web Portal. See the Provider Information web page for the Web Portal section for more information.
 
 
19. How can duplicate copies of RAs be obtained?
Call the Provider Services Call Center at 1 (844) 235-2387 to obtain an electronic copy of an RA prior to March 1, 2017. All other RAs are posted to the Provider Web Portal.
 
Back to Top

Eligibility

20. Who determines a member's eligibility?

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

Back to Top

21. What is delayed/retroactive eligibility?

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

Back to Top

22. What are Load Letters and Late Bill Override Dates?

Load Letters (LL) allow providers to submit claims that are outside of the timely filing period. Providers may submit requests on the LL form. Providers have 120 days from the date of the load letter to submit the claim with the attached form for review by the fiscal agent.

 
NOTE: The purpose of the Load Letter is to allow providers to submit claims outside of the timely filing period if the member was retroactively enrolled; however, it is not a guarantee of payment. If the member was enrolled on the date of service but failed to inform the provider of that existing coverage, the certification for Delayed Eligibility Notification can be used.
 
For CHP+ members, please contact the HMO listed on the back of the member’s medical card for a Load Letter.
 
The Load Letter Request form is available under Other Forms in the Forms section. Upon receiving the request from providers, the Department will generate a Load Letter as long as the request meets all criteria.
 
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 member’s State ID in the subject line.
 

23. What is Dual Eligibility?

Members 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 members 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.

Please call the Provider Services Call Center at 1 (844) 235-2387 (toll-free) Monday through Friday, 8:00 a.m. to 5:00 p.m. MST with questions.
 

24. What is Presumptive Eligibility (PE)?

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

Back to Top

25. What is the Modified Medical Program?

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

Back to Top

26. What are Qualified Medicare Beneficiaries?

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).

Back to Top

27.1. Are non-citizens eligible for Medicaid benefits?

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.

Back to Top

27.2 What is a newborn’s eligibility when the mother gives birth while on Medicaid?

A baby born to a woman on Medicaid at the time of the newborn’s birth is guaranteed continuous eligibility through the baby’s first birthday.

Back to Top


HIPAA

28. What are the provider responsibilities under HIPAA?

Please refer to the Provider Information HIPAA web page. 

Back to Top


Notification of Non-Payment

 
30. What is an IRS 147 C Letter, and why is it requested?
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.
 
 
31.  When does the provider bill using the group provider number vs. the individual's provider number?
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.

Back to Top


Paper Checks/ Warrants

32. What steps need to be taken when a check payment is not received?
If it has been 30 days since the date of the payment, please call the Provider Services Call Center at 1 (844) 235-2387 (toll-free).
 
The customer service representative can submit a check trace to the Department’s financial team. The financial team will then determine if the check/EFT was cashed and the next appropriate course of action. If appropriate, they will initiate a “stop pay” on the previous check and reissue the payment. For more information, see FAQ #34 (“How can a check be reissued?”).
 
Ask the customer service representative for the warrant number for your reference.

Back to Top

33. How can a copy of a cashed check be obtained?
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 checks 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.
 
Include the following details with 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.
 
34. How can a check be reissued?
If the check trace research verifies that the check was not cashed or was not found, please call the Provider Services Call Center at 1 (844) 235-2387 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 Provider Web Portal. If you recently updated your address and suspect that you did not receive your check due to the change in address, follow the steps listed under FAQ #32 (“What steps need to be taken when a check payment is not received?”).
 
To reissue a lost, damaged or stolen check, the Department’s accounting team will first verify that the check has not been cashed and then will send the provider a “Lost Check Affidavit,” in accordance with the Office of the State Controller’s policy on reissuing lost checks.  Once the signed affidavit is returned, the accounting team will cancel the lost check and reissue in the Colorado interChange system.
 
 
35. What if Provider Enrollment is not notified of an address change?
Checks may have been returned to the Department’s fiscal agent. Providers who have the capability should update their information through the Provider Web Portal.

 
 
36. Is there a better way to receive Colorado Medical Assistance Program payments?
The safest, 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.
 
Back to Top

Software Vendor

37. Where can a software vendor interested in programming a practice management system get a copy of the Colorado Medical Assistance Program Specification Manual(s)?

The specification manuals can be downloaded from the Provider Information Specifications section.

Back to Top


Web Portal

38. What is the Web Portal?
The Colorado Medical Assistance Program Secure Web Portal (Web Portal) is a secured website that is accessible from the Secured Site option via the Department of Health Care Policy and Financing’s (the Department) website 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 Remittance Advices (RAs). 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 a day 7 days a week from any computer with 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, member and provider data can be managed, and inquiries can be made on the status of a Prior Authorization Request (PAR) and 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.