Home and Community Based Services (HCBS) Brain Injury (BI), Community Mental Health Supports (CMHS), and Elderly, Blind, and Disabled (EBD)

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General Information

Waiver programs provide additional Health First Colorado (Colorado’s Medicaid Program) benefits to specific populations who meet special eligibility criteria.

Level of care determinations are made annually by the case management agencies (aka Single Entry Points). Members must meet financial, medical, and program criteria to access services under a waiver. The applicant must be at risk of placement in a nursing facility or hospital. To access waiver benefits, members must be willing to receive services in their homes or communities. A member who receives services through a waiver is also eligible for all basic Health First Colorado covered services except nursing facility and long-term hospital care. When a member chooses to receive services under a waiver, the services must be provided by certified Health First Colorado providers.

Each waiver has an enrollment limit. Applicants may apply for more than one waiver, but may only receive services through one waiver at a time.

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Prior Authorization Requests (PARs)

Unless otherwise noted, all HCBS services require prior approval before they can be reimbursed by Health First Colorado. Case management agencies/single entry points complete the Prior Approval and/or Cost Containment requests for their specific programs according to instructions published in the regulations for the Department of Health Care Policy and Financing (the Department).

The telephone numbers are listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.

The following services have additional state approval processes beyond the PAR:

  • Services above the daily cost containment limit
  • Home modifications
  • Mental health counseling (beyond 30 visits);
  • Substance Abuse Counseling (beyond 30 visits)

 

Assistive Technology (beyond medication reminders).Providers may contact the CMA/SEP for the status of the PAR or inquire electronically through the Health First Colorado Online Portal.

The CMAs/SEPs responsibilities include, but not limited to:

  • Informing members and/or legal guardian of the eligibility process.
  • Submitting a copy of the approved Enrollment Form to the County department of human/social services for a Health First Colorado member identification number.
  • Developing the appropriate Prior Approval and/or Cost Containment Record Form of services and projected costs for approval.
  • Submitting the Prior Authorization and/or Cost Containment information to the authorizing agent. A list of authorizing agents can be found by referring to Appendix D, listed under the Appendices drop-down section on the Billing Manuals web page.
  • Assessing the member’s health and social needs.
  • Arranging for face-to-face contact with the member within 10 calendar days of receipt of the referral.
  • Monitoring and evaluating services.
  • Reassessing each member.
  • Demonstrating continued cost effectiveness whenever services increase or decrease.

 

Approval of prior authorization does not guarantee Health First Colorado payment and does not serve as a timely filing waiver. Prior authorization only assures that the approved service is a medical necessity and is considered a benefit of the Health First Colorado. All claims, including those for prior authorized services, must meet eligibility and claim submission requirements (e.g., timely filing, provider information completed appropriately, required attachments included, etc.) before payment can be made.

Prior approvals must be completed thoroughly and accurately. If an error is noted on an approved request, it should be brought to the attention of the member’s case manager for corrections. Procedure codes, quantities, etc., may be changed or entered by the member’s case manager.

The authorizing agent or case management agency/single entry point is responsible for timely submission and distribution of copies of approvals to agencies and providers contracted to provide services.

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PAR Submission

The HCBS-BI, CMHS, and EBD forms are submitted electronically via the Bridge by CMA/SEP case managers. The Bridge directly interfaces with the Colorado interChange System. Access to the Bridge is accomplished via the Medicaid Enterprise User Provisioning System (MEUPS).

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Consumer Directed Attendant Support Services (CDASS)

For members authorized to receive CDASS, case managers will need to enter the data into one of the web-based systems in addition to sending a PAR to the Department’s fiscal agent. Members have the option to receive Financial Management Services (FMS) from one (1) of three (3) FMS vendors:

  • Acumen
  • Palco
  • Public Partnerships, LLC (PPL)

 

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PAR Form Instructional Reference Table

Field Label Completion Format Instructions
PA Number being revised   Conditional
Complete if PAR is a revision. Indicate original PAR number assigned.
Revision Check box
Yes   No
Required
Check the appropriate box.
Client Name Text Required
Enter the member's last name, first name and middle initial.
Example: Adams, Mary A.
Client ID 7 characters, a letter prefix followed by six numbers Required
Enter the member's state identification number. This number consists of a letter prefix followed by six numbers.
Example: A123456
Sex Check box
M    F
Required
Check the appropriate box.
Birthdate 6 numbers
(MM/DD/YY)
Required
Enter the member's birth date using MM/DD/YY format.
Example: January 1, 2015 = 01/01/15.
Requesting Provider # 8 numbers Required
Enter the eight-digit Health First Colorado provider number of the requesting provider.
Client's County Text Required
Enter the member's county of residence
Case Number (Agency Use) Text Optional
Enter up to 12 characters, (numbers, letters, hyphens) which helps identify the claim or member.
Dates Covered
(From/Through)
6 numbers for from date and 6 numbers for through date
(MM/DD/YY)
Required
Enter PAR start date and PAR end date.
Services Description Text Not required
List of approved procedure codes for qualified and demonstration services.
Provider Text Optional (SEP use)
Enter up to 12 characters to identify provider.
Modifier 2 Letters Required
The alphanumeric values in this column are standard and static and cannot be changed.
Max # Units Number Required
Enter the number of units next to the services being requested for reimbursement.
Cost Per Unit Dollar Amount Required
Enter cost per unit of service.
Total $ Authorized Dollar Amount Required
The dollar amount authorized for this service automatically populates.
Comments Text Optional
Enter any additional useful information. For example, if a service is authorized for different dates than in “Dates Covered" field, please include the HCPCS procedure code and date span here.
Total Authorized HCBS Expenditures Dollar Amount Required
Total automatically populates.
Plus Total Authorized Home Health Expenditures
(Sum of Authorized Home Health Services during the HCBS Care Plan Period)
Dollar Amount Required
Enter the total Authorized Home Health expenditures.
Equals Client's Maximum Authorized Cost Dollar Amount Required
The sum of HCBS Expenditures + Home Health Expenditures automatically populates.
Number of Days Covered Number Required
The number of days covered automatically populates.
Average Cost Per Day Dollar Amount Required
The member's maximum authorized cost divided by number of days in the care plan period automatically populates.
CDASS

Effective Date Monthly Allocation Amt.
Date (MM/DD/YY)
Dollar Amount
Required for SCI, BI, CMHS and EBD
Enter CDASS information (All CDASS information must be entered in the FMS web portal).
Immediately prior to HCBS enrollment, this client lived in a long-term care facility Check box
Yes   No
Required
Check the appropriate box.
Case Manager Name Text Required
Enter the name of the Case Manager.
Agency Text Required
Enter the name of the agency.
Phone # 10 Numbers
123-456-7890
Required
Enter the phone number of the Case Manager.
Email Text Required
Enter the email address of the Case Manager.
Date 6 Numbers
(MM/DD/YY)
Required
Enter the date completed.
Case Manager's Supervisor Name Text Required
Enter the name of the Case Manager's Supervisor.
Agency Text Required
Enter the name of the agency.
Phone # 10 Numbers
123-456-7890
Required
Enter the phone number of the Case Manager's Supervisor.
Email Text Required
Enter the email address of the Case Manager's Supervisor.
Date 6 Numbers
(MM/DD/YY)
Required
Enter the date of PAR completion.

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Claim Submission

Refer to the General Provider Information manual for general billing information, including claims submission.

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Persons with a Brain Injury (HCBS-BI)

The Home and Community Based Services Brain Injury (HCBS-BI) waiver program provides a variety of services to qualified members with brain injury as an alternative to inpatient hospital and nursing facility placement. Members meeting program eligibility requirements are certified as medically eligible for HCBS-BI by the case manager.

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HCBS-BI Procedure Code Table

Providers may bill the following procedure codes for HCBS-BI services:

HCBS-BI Procedure Code Table
Description Procedure Code + Modifiers Units
Adult Day Services, Tier 1 S5100 U6 1 unit = 15 minutes; maximum of two (2) hours per day
Adult Day Services, Tier 2 S5102 U6 1 unit = 2+ hours
Adult Day Services Transportation (Taxi) A0100 U6, HB 1 unit = (1) one way trip
Assistive Technology T2029 U6 Negotiated by case manager through prior authorization
Behavioral Programming H0025 U6 1 unit= 30 minutes
Brain Injury Transitional Living Program (BI TLP) Acuity Tier 1 T2016 U6 1 unit = 1 day
Brain Injury Transitional Living Program (BI TLP) Acuity Tier 2 T2016 U6, HB 1 unit = 1 day
Brain Injury Transitional Living Program (BI TLP) Acuity Tier 3 T2016 U6, HE 1 unit = 1 day
Brain Injury Transitional Living Program (BI TLP) Acuity Tier 4 T2016 U6, HK 1 unit = 1 day
Brain Injury Transitional Living Program (BI TLP) Acuity Tier 5 T2016 U6, HB, HE 1 unit = 1 day
Consumer Directed Attendant Support Services (CDASS) (Cent/Unit) T2025 U6 1 unit = 15 minutes
CDASS Per Member/Per Month (PM/PM) T2040 U6 1 unit = 1 month
Day Treatment H2018 U6 1 unit = 1 day
Home Delivered Meals S5170 U6 I unit = 1 meal
Home Modifications S5165 U6 1 unit = half of each modification
Independent Living Skills Training (ILST) T2013 U6 1 unit = 15 minutes
Mental Health Counseling, Family H0004 U6, HR 1 unit = 15 minutes
Mental Health Counseling, Group H0004 U6, HQ 1 unit = 15 minutes
Mental Health Counseling, Individual H0004 U6 1 unit = 15 minutes
Non-Medical Transportation (NMT), Taxi A0100 U6 1 unit=one way trip
NMT, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
U6
U6, TT
U6, TN
1 unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Mobility Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
U6, HB
U6, TT, HB
U6, TN, HB
unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
U6
U6, TT
U6, TN
unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Wheelchair Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
U6, HB
U6, TT, HB
U6, TN, HB
1 unit=one way trip
1 unit=one way trip
1 unit=one way trip
Non-Medical Transportation (NMT), Local Public Transit
RTD Local – Monthly Pass
RTD Local – 10 ride book
RTD Local – Day Pass
RTD Local – 3 Hour Pass
RTD Local – Access-A-Ride Single
RTD Local – Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
U6,  TT
U6, TK
U6, TF
U6, TN
U6,SE
U6, TG
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
1 unit = (1) 6 Ride ticket book
Non-Medical Transportation (NMT), Local Public Transit Adult Day
RTD Local – Monthly Pass
RTD Local – 10 ride book
RTD Local – Day Pass
RTD Local – 3 Hour Pass
RTD Local – Access-A-Ride Single
RTD Local – Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
U6, TT, HB
U6, TK, HB
U6, TF, HB
U6,TN, HB
U6, SE, HB
U6, TG, HB
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
1 unit = (1) 6 Ride ticket book
Non-Medical Transportation (NMT), Regional Public Transit
RTD Regional – Monthly Pass
RTD Regional – 10 ride book
RTD Regional – Day Pass
RTD Regional – 3 Hour Pass
RTD Regional – Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
 
U6,CG
U6, TJ
U6, TU
U6, EY
U6, HC
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
Non-Medical Transportation (NMT), Regional Public Transit, Adult Day
RTD Regional – Monthly Pass
RTD Regional – 10 ride book
RTD Regional – Day Pass
RTD Regional – 3 Hour Pass
RTD Regional – Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
 
U6, CG, HB
U6, TJ, HB
U6, TU, HB
U6, EY, HB
U6, HC, HB
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
Peer Mentorship H2015 U1, SC 1 unit = 15 minutes
Personal Care T1019 U6 1 unit = 15 minutes
Personal Care, Relative T1019 U6, HR 1 unit = 15 minutes
Personal Emergency Response System (PERs) Install/Purchase S5160 U6 Negotiated by case manager through prior authorization.
PERs, Monitoring S5161 U6 Negotiated by case manager through prior authorization.
Respite Care, In Home S5150 U6 1 unit = 15 minutes
Respite Care, Nursing Facility (NF) H0045 U6 1 unit = 1 day
Substance Abuse Counseling, Family T1006 U6 1 unit = 1 hour
Substance Abuse Counseling, Group H0047 U6, HQ 1 unit = 1 hour
Substance Abuse Counseling, Individual H0047 U6, HF 1 unit = 1 hour
Supportive Living Program (SLP) Acuity Tier 1 T2033 U6 1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 2 T2033 U6, HB 1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 3 T2033 U6, HE 1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 4 T2033 U6, HK 1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 5 T2033 U6, HB, HE 1 unit = 1 day
Supportive Living Program (SLP) Acuity Tier 6 T2033 U6, HB, HK 1 unit = 1 day
Transition Setup - Coordination T2038 U6 1 unit = 15 minutes
Transition Setup - Items Purchased A9900 U6 One-time payment

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Paper Claim Reference Table

The following paper form reference table gives required and/or conditional fields for the paper CMS 1500 claim form for BI claims:

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Not required  
5. Patient's Address Not Required  
6. Client Relationship to Insured Not Required  
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Not Required  
9a. Other Insured's Policy or Group Number Not Required  
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Not Required  
10a-c. Is patient's condition related to? Not Required  
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Not Required  
11a. Insured's Date of Birth, Sex Not Required  
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Not Required  
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Not Required  
15. Other Date Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional  
18. Hospitalization Dates Related to Current Service Not Required  
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges
Not Required  
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.

HCBS
HCBS may use R69
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional HCBS
Leave blank
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Practitioner claims must be consecutive days.
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
11 Office
12 Home
NOTE:
Use POS Code 12 (Home) for Alternative Care Facility, Adult Day Program, or Respite in the Facility
24C. EMG Not Required  
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

HCBS
Refer to the HCBS-BI procedure code table..
24D. Modifier Conditional Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

HCBS
Refer to the HCBS-BI procedure code table.
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.
24G. Days or Units General Instructions A unit represents the number of times the described procedure or service was rendered.

Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.

Home & Community Based Services
Combine units of services for a single procedure code for the billed time period on one detail line. Dates of service do not have to be reported separately. Example: If forty units of personal care services were provided on various days throughout the month of January, bill the personal care procedure code with a From Date of 01/03/XX and a To Date of 01/31/XX and 40 units.
24H. EPSDT/Family Plan Not Required  
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Not Required  
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #
Conditional Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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Community Mental Health Supports (CMHS), and Persons who are Elderly, Blind, and Disabled (EBD)

The HCBS-CMHS and EBD waiver programs provide a variety of services to the Elderly, Blind and Disabled (EBD), and Community Mental Health Supports (HCBS-CMHS), formally known as Persons with Major Mental Illness (MI), as an alternative to nursing facility, and inpatient hospitals to qualified members. Members meeting program eligibility requirements are certified by the case management agency/single entry point as medically eligible for these HCBS waiver programs. These three waivers offer all of the following services:

  • Alternative Care Facility - Alternative Care Services means, but is not limited to, a package of personal care and homemaker services provided in a state-certified alternative care facility including: assistance with bathing, skin, hair, nail and mouth care, shaving, dressing, feeding, ambulation, transfers, and positioning, bladder & bowel care, medication reminding, accompanying, routine housecleaning, meal preparation, bed making, laundry and shopping. Reimbursement shall be per unit, with one unit equaling one day of care.
  • Adult Day Services (Basic)– Services delivered on a tiered basis.
    • Tier I - Services provided virtually or in-person in an outpatient setting to include parks or other community-based locations. Meal provision not required if services are not provided in person or over the lunch hour. Service can be provided up to three hours per day.
    • Tier II - Services provided between three (3) – five (5)  hours per day as approved by the case manager and in the context of the member’s health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a “full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual’s plan of care would be provided as component parts of this service if such services are not being provided in the participant’s home.
  • Tier III - Services provided over a full day as approved by the case manager and in the context of the member’s health, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a “full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual’s plan of care would be provided as component parts of this service if such services are not being provided in the participant’s home. Tier I Adult Day Services cannot be provided in conjunction with this service.
  • Adult Day Services (Specialized)– Services provided between three (3) – five (5) or more hours per day on a regularly scheduled basis, for one or more days per week. Services provided in an outpatient setting, encompassing both health and social services needed to assure the optimal functioning of the individual. Meals provided as part of these services shall not constitute a “full nutritional regimen" (3 meals per day). Physical, occupational and speech therapies indicated in the individual’s plan of care would be provided as component parts of this service if such services are not being provided in the participant’s home. Tier I Adult Day Services cannot be provided in conjunction with this service.
  • Electronic Monitoring/Personal Emergency Response Systems – An electronic device, which enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable “help" button to allow for mobility. The system is connected to the person’s phone and programmed to signal a response center once a “help" button is activated. Monitoring of the device is included in the PERS service. The response center is staffed by trained professionals.
  • Homemaker – Services consisting of general household activities (meal preparation and routine household care) provided by a trained homemaker. Provided when the individual regularly responsible for these activities is temporarily absent or unable to manage the home and care for him or herself or others in the home.
  • Home Modifications are specific modifications, adaptations or improvements in an eligible member's existing home setting which, based on the member’s medical condition are necessary to ensure the health, welfare and safety of the member, enable the member to function with greater independence in the home, are required because of the member's illness, impairment or disability, as documented on the ULTC-100.2 form and the care plan and prevents institutionalization of the member. There shall be a lifetime cap of $14,000.00 per member.
  • Personal Care – Assistance with eating, bathing, dressing, personal hygiene, activities of daily living. These services may include assistance with preparation of meals, but does not include the cost of the meals themselves. When specified in the service plan, this service may also include such housekeeping chores as bed making, dusting and vacuuming. Services are incidental to the care provided, or are essential to the health and welfare of the individual, rather than the individual’s family. Payment will not be made for services provided to a minor by the child’s parent (or step parent), or to an individual by the person’s spouse.
  • Relative Personal Care – Personal Care providers may be members of the individual’s family. The number of Health First Colorado personal care units for provided by any single member of the member’s family shall not exceed the equivalent of 444 personal care units per annual certification. Payment will not be made for services provided to an individual by an individual’s spouse employed by a Personal Care agency.
  • Respite care means services provided to an eligible member on a short-term basis because of the absence or need for relief of those persons normally providing the care. The unit of reimbursement shall be a unit of one day for care provided in a Nursing Facility or Alternative Care Facility. Individual respite providers shall bill according to an hourly rate or daily institutional Nursing Facility rate, whichever is less.
  • Non-Medical Transportation – Service offered in order to enable individuals served on the waiver to gain access to waiver and other community services, activities and resources, specified by the service plan. This service is offered in addition to medical transportation required under 42 CFR 431.53 and transportation services under the State Plan, defined at 42 CFR 440.170 (a) (if applicable), and shall not replace them.
    Non-Medical Transportation will be limited to two (2) round-trips per week. Trips to and from adult day programs are not subject to this cap.
  • Consumer Directed Attendant Support Services (CDASS) – CDASS is a service delivery option that offers HCBS-EBD, HCBS-CMHS, and HCBS-BI members the opportunity to direct personal care, homemaker and health maintenance tasks. Members may also designate an authorized representative to direct these activities on their behalf.
  • Medication Reminders – Medication reminders are devices, controls, or appliances which enable an individual at high risk of institutionalization to increase their abilities to perform activities of daily living, such as medication administration. Medication reminders shall include devices or items that remind or signal the member to take prescribed medications. Medication reminders may include other devices necessary for the proper functioning of such items, and may also include durable and non-durable medical equipment not available as a State plan benefit.
  • Home Delivered Meals – Includes nutritional counseling, planning, preparation, and delivery of meals. Must demonstrate need for the service in Service Plan: demonstrated need for nutritional counseling, meal planning, and preparation; dietary restrictions or specific nutritional needs; unable to prepare their own meals; limited or no outside assistance; inability to access and prepare nutritious meals demonstrates a need-related risk to health, safety or institutionalization. Home Delivered Meals are limited to two (2) meals per day up to 14 meals per week, up to 365 days post-transition.
  • Life Skills Training – Individualized training, provided in member’s residence, the community, or group living situations, that is designed and directed with member to develop and maintain the ability to independently sustain himself/herself in the community. Must demonstrate need for the service in Service Plan: need for training to sustain self in the community; skills for which training is needed and that without poses a risk to the health, safety, or ability to live in the community; without training individual could not develop the skills needed; with training ability to acquire these skills within 365 days. Life Skills Training is limited to up to 24 units per day with no more than 160 units per week, up to 365 days post-transition.
  • Peer Mentorship – Provided by peers to promote self-advocacy and encourage community living by instructing and advising on issues and topics related to community living, describing real-world experiences as examples, and modeling successful community living and problem-solving. Must demonstrate the need for the service in Service Plan: need for soft skills, insight, or guidance from a peer; without service may experience a health, safety, or institutional risk; no other services or resources available to meet the need. Peer Mentorship is limited to 24 units per day for 365 days post-transition.
  • Transition Setup – Coordination and coverage of one-time, non-recurring expenses to establish a basic household upon transition from nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or Regional Center to a community living arrangement not operated by the state. [Note: This is not available for transition to provider-owned settings (e.g., ACF, Host Home, Group Home, or SLP. This is not available in a community to community transition.] Units limited to 40, up to 30 days post-transition.

The HCBS-EBD program offers the following additional services:

  • In-Home Support Services (IHSS) – IHSS includes health maintenance activities, support for activities of daily living or instrumental activities of daily living, personal care service and homemaker services. Additionally, IHSS providers are required to provide the core independent living skills. This service is only available for EBD, SCI and CHCBS members.

 

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HCBS-CMHS Procedure Code Table

Providers may bill the following procedure codes for HCBS-CMHS services:

HCBS-CMHS Procedure Code Table
Description Procedure Code + Modifiers Units
Adult Day Services, Basic Tier 1 S5100 UA 1 unit = 15 minutes; maximum of 3 hours per day
Adult Day Services, Basic Tier 2 S5105 UA 1 unit = 3-5 hours
Adult Day Services, Basic Tier 3 S5105 UA 1 unit = 3-5 hours
Adult Day Services, Specialized S5105 UA, TF 1 unit = 3-5 hours
Adult day Services Transportation (Taxi) A0100 UA, HB 1 unit = (1) one way trip
Alternative Care Facility T2031 UA 1 unit =1 day
Consumer Directed Attendant Support Services (CDASS) (Cent/Unit) T2025 UA Negotiated by case manager through prior authorization.
CDASS Per Member/Per Month (PM/PM) T2040 UA Negotiated by case manager through prior authorization.
Home Delivered Meals S5170 UA 1 unit = 1 meal
Home Modifications S5165 UA 1 unit =1 modification
Homemaker S5130 UA 1 unit = 15 minutes
Life Skills Training H2014 UA I unit = 15 minutes
Medication Reminder, Install/Purchase T2029 UA 1 unit = 1 purchase
Medication Reminder, Monitoring S5185 UA 1 unit per month
Non-Medical Transportation (NMT), Taxi A0100 UA 1 unit=one way trip
NMT, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
UA
UA, TT
UA, TN
1 unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Mobility Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
UA, HB
UA, TT, HB
UA, TN, HB
unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
UA
UA, TT
UA, TN
unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Wheelchair Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
UA, HB
UA, TT, HB
UA, TN, HB
1 unit=one way trip
1 unit=one way trip
1 unit=one way trip
Non-Medical Transportation (NMT), Local Public Transit
RTD Local – Monthly Pass
RTD Local – 10 ride book
RTD Local – Day Pass
RTD Local – 3 Hour Pass
RTD Local – Access-A-Ride Single
RTD Local – Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
UA,  TT
UA, TK
UA, TF
UA, TN
UA,SE
UA, TG
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
1 unit = (1) 6 Ride ticket book
Non-Medical Transportation (NMT), Local Public Transit Adult Day
RTD Local – Monthly Pass
RTD Local – 10 ride book
RTD Local – Day Pass
RTD Local – 3 Hour Pass
RTD Local – Access-A-Ride Single
RTD Local – Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
UA, TT, HB
UA, TK, HB
UA, TF, HB
UA,TN, HB
UA, SE, HB
UA, TG, HB
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
1 unit = (1) 6 Ride ticket book
Non-Medical Transportation (NMT), Regional Public Transit
RTD Regional – Monthly Pass
RTD Regional – 10 ride book
RTD Regional – Day Pass
RTD Regional – 3 Hour Pass
RTD Regional – Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
 
UA,CG
UA, TJ
UA, TU
UA, EY
UA, HC
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
Non-Medical Transportation (NMT), Regional Public Transit, Adult Day
RTD Regional – Monthly Pass
RTD Regional – 10 ride book
RTD Regional – Day Pass
RTD Regional – 3 Hour Pass
RTD Regional – Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
 
UA, CG, HB
UA, TJ, HB
UA, TU, HB
UA, EY, HB
UA, HC, HB
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
Peer Mentorship H2015 UA 1 unit = 15 minutes
Personal Care T1019 UA 1 unit = 15 minutes
Personal Care, Relative T1019 UA, HR 1 unit = 15 minutes
Personal Emergency Response System (PERs) Install/Purchase S5160 UA 1 unit = purchase and installation
PERs, Monitoring S5161 UA 1 unit = 1 month of service
Respite Care, Alternative Care Facility (ACF) S5151 UA 1 unit = 1 day
Respite Care, Nursing Facility (NF) H0045 UA 1 unit =1 day
Transition Setup - Coordination T2038 UA 1 unit = 15 minutes
Transition Setup - Items Purchased A9900 UA One-time payment

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HCBS-EBD Procedure Code Table

Providers may bill the following procedure codes for HCBS-EBD services:

HCBS-EBD Procedure Code Table
Description Procedure Code + Modifiers Units
Adult Day Services, Basic Tier 1 S5100 U1 1 unit = 15 minutes; maximum of 3 hours per day
Adult Day Services, Basic, Tier 2 S5105 U1 1 unit = 3-5 hours
Adult Day Services, Basic, Tier 3 S5105 U1 1 unit = 3-5 hours
Adult Day Services, Specialized S5105 U1, TF 1 unit = 3-5 hours
Adult Day Services Transportation A0100 U1, HB 1 unit = (1) one way trip
Alternative Care Facility T2031 U1 1 unit =1 day
Community Transition Services, Coordinator T2038 U1 1 unit = 1 transition
Community Transition Services, Items Purchased A9900 U1 1 unit = purchase
Consumer Directed Attendant Support Services (CDASS) (Cent/Unit) T2025 U1 Negotiated by case manager through prior authorization.
CDASS Per Member/Per Month (PM/PM) T2040 U1 Negotiated by case manager through prior authorization.
Home Delivered Meals S5170 U1 1 unit = 1 meal
Home Modifications S5165 U1 1 unit =1 modification
Homemaker S5130 U1 1 unit = 15 minutes
IHSS Health Maintenance Activities H0038 U1 1 unit = 15 minutes
IHSS Personal Care Service T1019 U1, KX 1 unit = 15 minutes
IHSS Relative Personal Care T1019 U1, HR, KX 1 unit = 15 minutes
IHSS Homemaker Service S5130 U1, KX 1 unit = 15 minutes
Life Skills Training H2014 U1 1 unit = 15 minutes
Medication Reminder, Install/Purchase T2029 U1 1 unit = 1 purchase
Medication Reminder, Monitoring S5185 U1 1 unit per month
Non-Medical Transportation (NMT), Taxi A0100 U1 1 unit=one way trip
NMT, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
U1
U1, TT
U1, TN
1 unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Mobility Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
U1, HB
U1, TT, HB
U1, TN, HB
unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
U1
U1, TT
U1, TN
unit=one way trip
1 unit=one way trip
1 unit=one way trip
NMT, Wheelchair Van, To and From Adult Day
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
U1, HB
U1, TT, HB
U1, TN, HB
1 unit=one way trip
1 unit=one way trip
1 unit=one way trip
Non-Medical Transportation (NMT), Local Public Transit
RTD Local – Monthly Pass
RTD Local – 10 ride book
RTD Local – Day Pass
RTD Local – 3 Hour Pass
RTD Local – Access-A-Ride Single
RTD Local – Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
U1,  TT
U1, TK
U1, TF
U1, TN
U1,SE
U1, TG
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
1 unit = (1) 6 Ride ticket book
Non-Medical Transportation (NMT), Local Public Transit Adult Day
RTD Local – Monthly Pass
RTD Local – 10 ride book
RTD Local – Day Pass
RTD Local – 3 Hour Pass
RTD Local – Access-A-Ride Single
RTD Local – Access-A-Ride Book
A0110
A0110
A0110
A0110
A0110
A0110
U1, TT, HB
U1, TK, HB
U1, TF, HB
U1,TN, HB
U1, SE, HB
U1, TG, HB
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
1 unit = (1) 6 Ride ticket book
Non-Medical Transportation (NMT), Regional Public Transit
RTD Regional – Monthly Pass
RTD Regional – 10 ride book
RTD Regional – Day Pass
RTD Regional – 3 Hour Pass
RTD Regional – Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
 
U1,CG
U1, TJ
U1, TU
U1, EY
U1, HC
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
Non-Medical Transportation (NMT), Regional Public Transit, Adult Day
RTD Regional – Monthly Pass
RTD Regional – 10 ride book
RTD Regional – Day Pass
RTD Regional – 3 Hour Pass
RTD Regional – Access-A-Ride Single
A0110
A0110
A0110
A0110
A0110
 
U1, CG, HB
U1, TJ, HB
U1, TU, HB
U1, EY, HB
U1, HC, HB
1 unit=(1) Monthly Pass
1 unit= (1) 10 Ride ticket book
1 unit= (1) Day Pass
1 unit = (1) 3 Hour Pass
1 unit = (1) Single Ticket
Peer Mentorship H2015 U1  1 unit = 15 minutes
Personal Care T1019 U1 1 unit = 15 minutes
Personal Care, Relative T1019 U1, HR 1 unit = 15 minutes
Personal Emergency Response System (PERs) Install/Purchase S5160 U1 1 unit = purchase and installation
PERs, Monitoring S5161 U1 1 unit =1 month of service
Respite Care, Alternative Care Facility (ACF) S5151 U1 1 unit = 1 day
Respite Care, In Home S5150 U1 1 unit = 15 minutes
Respite Care Nursing Facility (NF) H0045 U1 1 unit = 1 day
Transition Setup - Coordination T2038 U1 1 unit = 15 minutes
Transition Setup - Items Purchased A9900 U1 One-time payment

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HCBS-CMHS and EBD Paper Claim Reference Table

The following paper form reference table gives required and/or conditional fields for the paper CMS 1500 claim form for HCBS-CMHS and HCBS-EBD claims:

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Not required  
5. Patient's Address Not Required  
6. Client Relationship to Insured Not Required  
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Not Required  
9a. Other Insured's Policy or Group Number Not Required  
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Not Required  
10a-c. Is patient's condition related to? Not Required  
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Not Required  
11a. Insured's Date of Birth, Sex Not Required  
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Not Required  
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Not Required  
15. Other Date Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional  
18. Hospitalization Dates Related to Current Service Not Required  
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges
Not Required  
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.

HCBS
HCBS may use R69
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Not Required  
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Practitioner claims must be consecutive days.
Single Date of Service: Enter the six digit date of service in the "From" field. Completion of the "To field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
12 Home
NOTE:
Use POS Code 12 (Home) for Alternative Care Facility, Adult Day Program, or Respite in the Facility
24C. EMG Not Required  
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

HCBS
Refer to the HCBS-EBD or HCBS-CMHS procedure code tables.
24D. Modifier Conditional Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

HCBS
Refer to the HCBS-EBD or HCBS-CMHS procedure code tables.
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.
24G. Days or Units General Instructions A unit represents the number of times the described procedure or service was rendered.

Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.

Home & Community Based Services
Combine units of services for a single procedure code for the billed time period on one detail line. Dates of service do not have to be reported separately. Example: If forty units of personal care services were provided on various days throughout the month of January, bill the personal care procedure code with a From Date of 01/03/XX and a To Date of 01/31/XX and 40 units.
24H. EPSDT/Family Plan Not Required  
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the ,strong>individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Not Required  
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #
Conditional Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.

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HCBS-BI, CMHS, and EBD Specialty Manuals Revisions Log

Revision Date Addition/Changes Made by
12/1/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016 Please refer to Archive. HPE (now DXC)
12/27/2016 Updates based on Colorado iC Stage II Provider Billing Manual v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
5/22/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
6/26/2018 Updated billing and timely filing to point to general manual HCPF
6/28/2018 Minor grammatical edit
Updated claims submission
HCPF
3/18/2019 Clarification to signature requirements HCPF
7/2/2019 Updated Appendices’ links and verbiage DXC
12/4/2019 Updated modifiers for BI waiver service HCPF
1/10/2020 Updated units for BI waiver service HCPF
3/3/2020 Converted to web page HCPF
3/4/2020 Updates to NMT services to include public transportation, CDASS FMS providers, added transition services HCPF
8/28/2020 General updates to language reflecting the use of the Bridge, added Adult Day changes. HCPF
9/14/2020 Added Line to Box 32 under the Paper Claim Reference Table HCPF

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