Home and Community Based Services Billing Manual: Children’s Home and Community Based Services (CHCBS), Children with Life Limiting Illness (CLLI)

Return to Billing Manuals Web Page

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, Community Center Boards and Private Case Management Agencies). Members must meet financial, medical, and program criteria to access services under a waiver. The applicant must be at risk of placement in a skilled nursing facility, hospital, or ICF/IID (intermediate care facility for Individuals with an Intellectual Disability). To 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 or by a Health First Colorado contracting managed care organization (MCO).

Applicants may apply for more than one waiver but may only receive services through one waiver at a time.

Effective July 1, 2018, the Children with Autism (CWA) waiver was terminated. Claims submitted for qualified services with dates of service on or before June 30, 2018, will be processed in accordance with the Department of Health Care Policy and Financing (the Department) policy.

Effective July 1, 2018, Prior Authorization Requests (PARs) for the CWA waiver were deactivated. Case Management agencies were unable to authorize qualified services on or after this date using the Bridge for the CWA waiver.

Back to Top

Case Management Agency Responsibilities

Case Management Agencies (Single Entry Points, Community Centered Boards, and some other private case management agencies) are delegated administrative authority over HCBS waivers.

The Case Management Agencies (CMAs) responsibilities include, but are 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 a copy of the Prior Authorization and/or Cost Containment document to the authorizing agent. A list of authorizing agents can be found in Appendix D, 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.
  • Monitoring and evaluating services.
  • Reassessing each member annually or upon change in condition.
  • Demonstrating continued cost-effectiveness whenever services increase or decrease.

 

Back to Top

Claim Submission

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

Back to Top

Prior Authorization Requests (PARs)

Unless otherwise noted, all HCBS services require prior approval before they can be reimbursed by the Health First Colorado. Case Management Agencies (CMA) complete the Prior Approval and/or Cost Containment requests for their specific programs according to instructions published in the regulations for the Department.

Providers may contact the CMA for the status of the PAR or inquire electronically through the Health First Colorado Provider Web Portal.

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 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. Providers are reminded to check member eligibility prior to rendering services.

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 CMA is responsible for timely submission and distribution of copies of approvals to agencies and providers contracted to provide services.

Back to Top

PAR Submission

The following PAR (CHCBS and CLLI) forms are filed via the "Bridge" by case managers employed by Case Management Agencies (CMAs). The Bridge directly interfaces with the Colorado interChange. The Bridge is accessed by case manager agencies via the Medicaid Enterprise User Provisioning System (MEUPS).

Back to Top

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 Checkbox
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 Checkbox
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
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.
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.
Immediately prior to HCBS enrollment, this client lived in one of the following facility types Check box
Nursing facility   Hospital
Required for CHCBS only.
Check the appropriate box.
Case Manager Name Text Required
Enter the name of the Case Manager.
Case Manager Signature Text Required
Enter the name of the Case Manager's Supervisor.
Agency Text Required
Enter the name of the case management 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 of PAR completion.

Back to Top

Children's Home and Community Based Services (CHCBS)

The Children's Home and Community Based Services (CHCBS) waiver program is for medically fragile children who are at risk of institutionalization in a hospital or skilled nursing facility and would not otherwise qualify for Health First Colorado services due to parental income and/or resources. All state plan Health First Colorado benefits are provided to children birth through age 17. The children must meet the established minimum criteria for hospital or skilled nursing facility level of care. Members that meet program eligibility requirements receive an annual long-term care certification by their case manager (can be a Single-Entry Point, Community Centered Board, or Private Case Management Agency).

Back to Top

CHCBS Procedure Code Table

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

HCBS-CHCBS Procedure Code Table
Case Management (HCBS – CM)
Description Procedure Code + Modifiers Units
Case Management T1016 U5 1 unit = 15 minutes

Back to Top

In-Home Support Services (IHSS)

IHSS within the CHCBS waiver is limited to health maintenance activities, which include support for activities of daily living. Additionally, IHSS providers must provide core independent living skills.

HCBS-CHCBS Procedure Code Table
In-Home Support (HCBS-IHSS)
Description Procedure Code + Modifiers Units
Health Maintenance Activities H0038 U5 1 unit = 15 minutes

Back to Top

Home and Community Based Services for Children with Life Limiting Illness (CLLI)

The Home and Community Based Services for Children with Life Limiting Illness (CLLI) Waiver is for children from birth through age 18 with a medical diagnosis of a life-limiting illness who meet the institutional level of care for inpatient hospitalization. Level of care determinations are conducted annually by the Single-Entry Point case management agencies. Services include Bereavement Counseling, Expressive Therapy (Art, Play, and Music), Massage Therapy, Palliative/Supportive Care (Care Coordination and Pain & Symptom Management), Respite Care, and Therapeutic Life Limiting Illness Support Services. Members that are enrolled in the waiver also have access to all state plan Health First Colorado benefits, including curative care. There is no requirement for a nine-month terminal prognosis.

Back to Top

HCBS-CLLI Procedure Code Table

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

HCBS-CLLI Procedure Code Table
Description Procedure Code + Modifiers Place of Service Units
Art and Play Therapy H2032 UD, HA 11 - Office
12 - Home
1 unit = 15 minutes
Art and Play Therapy - Group H2032 UD, HA, HQ 11 - Office
12 - Home
1 unit = 15 minutes
Music Therapy H2032 UD 11 - Office
12 - Home
1 unit = 15 minutes
Music Therapy - Group H2032 UD, HQ 11 - Office
12 - Home
1 unit = 15 minutes
Massage Therapy 97124 UD 11 - Office
12 - Home
1 unit = 15 minutes
Care Coordination G9012 UD 11 - Office
12 - Home
1 unit = 15 minutes
Pain and Symptom Management S9123 UD 11 - Office
12 – Home
34 - Hospice
1 unit = 1 hour
Respite Care – Unskilled (4 hours or less) S5150 UD 12 - Home 1 unit = 15 minutes
Respite Care – Unskilled (4 hours or more) S5151 UD 12 - Home 1 unit = 1 day
Respite Care – CNA (4 hours or less) T1005 UD 12 - Home 1 unit = 15 minutes
Respite Care – CNA (4 hours or more) S9125 UD 12 - Home 1 unit = 1 day
Respite Care - Skilled RN, LPN (4 hours or less) T1005 UD, TD 12 - Home 1 unit = 15 minutes
Respite Care - Skilled RN, LPN (4 hours or more) S9125 UD, TD 12 - Home 1 unit = 1 day
Bereavement Counseling S0257 UD, HK 11 - Office
12 - Home
1 unit = lump sum
Therapeutic Life Limiting Illness Support – Individual S0257 UD 11 - Office
12 - Home
1 unit = 15 minutes
Therapeutic Life Limiting Illness Support – Family S0257 UD, HR 11 - Office
12 - Home
1 unit = 15 minutes
Therapeutic Life Limiting Illness Support - Group S0257 UD, HQ 11 - Office
12 - Home
1 unit = 15 minutes

Back to Top

Service Limitations

Reimbursement for HCBS-CLLI Therapeutic Life Limiting Illness Support services (S0257 with any "UD" modifier) shall be limited to 98 hours per annual certification. Reimbursement for HCBS-CLLI respite care services (T1005, S9125, S5150 and S5151) shall be limited to 30 days (unique dates of service) per annual certification. Reimbursement for HCBS-CLLI respite care services (T1005, S9125, S5150 and S5151) shall not be duplicated at the same time of service as state plan Home Health or Palliative/Supportive Care services (S9123) and shall be denied. Expressive Therapy (H2032 – Art, Play, and Music) is limited to 39 hours per annual certification. Massage Therapy (97124) is limited to 24 hours per annual certification.

Back to Top

 

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-CHCBS and CLLI 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
CHCBS and CLLI 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 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.
03 School
11 Office
12 Home
34 Hospice
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 CHCBS or CLLI procedure code tables.
24D. Modifier Required 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.
Refer to the CHCBS or CLLI 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-pay 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 EPSDT shaded area)
Not Required
Family Planning (unshaded area)
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.

Back to Top

 

CMS 1500 CHCBS Claim Example

CMS 1500 HCBS-CHCBS Claim Example

Back to Top

 

CMS 1500 HCBS-CLLI Claim Example

CMS 1500 HCBS-CLLI Claim Example

Back to Top

 

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.

Back to Top

HCBS-CHCBS and CLLI 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 Manuals Comment Log v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage II 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)
2/10/2017 Removed all references to Special Program Codes HCPF
3/13/2017 Changed Modifier code from UL to U2 HCPF
5/26/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
6/15/2018 Updated timely filing information and removed references to LBOD; removed general billing information already available in the General Provider Information manual DXC
6/27/2018 Updated ToC, minor edits, added link to general manual for claim submission info, updated Timely Filing HCPF
12/20/2018 Clarification to signature requirements HCPF
3/18/2019 Clarification to signature requirements HCPF
7/2/2019 Updated Appendices’ links and verbiage DXC
3/9/2020 Converted to web page; removed CWA sections as waiver discontinued 7/2018 HCPF
3/24/2020 Removed CWA references other than stating when the program was discontinued; removed outdated images. HCPF
9/14/2020 Added Line to Box 32 under the Paper Claim Reference Table HCPF

Back to Top