Billing FAQs

Billing FAQs

Back to Provider Information


Accounts Receivable (AR) Balances

1. Who should be contacted to find out about an AR balance?
Call the Department’s fiscal agent’s Provider Services at 1-800-237-0757 (toll free) Monday through Friday 8:00 a.m. to 5:00 p.m. for information related to AR balances.

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 PCR?

Allow 30 days for processing.

If the AR balance remains after that period, email hcpfar@state.co.us 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, PCR date in which receivable was established.

Back to Top


Common Billing Questions

4. What unit should be contacted for which services (the fiscal agent's EDI Services vs. the fiscal agent's Provider Services)?

Please contact the Xerox State Healthcare EDI Services at 1-800-237-0757 Monday through Friday, 8:00 a.m. to 5:00 p.m. MST for the following:

  • Electronic claim submission enrollment
  • Electronic Accept/Reject report retrieval
  • Electronic Remittance Statement retrieval

Please contact Xerox State Healthcare Provider Services at 1-800-237-0757 Monday through Friday, 8:00 a.m. to 5:00 p.m. MT 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)

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 PCR 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 is an LBOD, and how is it used?

LBOD stands for Late Bill Override Date. The provider uses the LBOD to document compliance with timely filing requirements. Only use the LBOD if filing a claim with dates of service older than 120 days. Providers must keep LBOD documentation on file. For example, keep a copy of the Web Portal rejection if that supports an LBOD date. An LBOD can be used on either an electronic claim or paper claim. The original claim must have been filed within the original Colorado Medical Assistance Program timely filing period. The LBOD cannot be greater than 60 days from the last date of adverse action (denial or return).

  • UB-04 - Occurrence code 53 and the date are required in FL 31-34
  • CMS 1500 - Indicate LBOD and the date in field 19 - Additional Claim Information
  • 2006 ADA Dental - Indicate LBOD and the date in box 35 - Remarks

Back to Top

8. What is a Delay Reason Code?

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

Choose one of six numeric Delay Reason Codes. In the Notes section on the Claim Information tab, write a general description of why the numeric value is being used.
Delay Reason Codes:

  • 1 Proof of Eligibility Unknown or Unavailable
  • 3 Authorization Delays
  • 7 Third Party Processing Delay
  • 8 Delay in Eligibility Determination
  • 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
  • 11 Other

For more information on how to submit electronic claims, please refer to the appropriate companion guide in the Provider Information section.

Back to Top

9. 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

10. Why does a claim reject with statement saying it cannot be billed electronically?

Common reasons include the following:

  • Sterilization claims - Claim must be billed on paper with the completed Med-178 form.
  • Hysterectomy claims - Claim must be billed on paper with the completed Acknowledgment/Certification Statement for a hysterectomy form.
  • Supply claims - You must indicate that you are billing the invoiced price. Submit the claim electronically using the “UB” modifier.

Back to Top

11. 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

12. Where can CHP+ information be obtained?

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

Back to Top

13. 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

14. How are a baby's charges covered when the baby doesn't have a Colorado Medical Assistance Program member ID number?

If the baby and the mother are both still in the hospital, bill using the mother's Medical Assistance Program member ID number. If the baby is still hospitalized after the mother is discharged or if the baby is transferred to another hospital, the baby's charges must be billed using the baby's Medical Assistance Program ID number.

To submit claims using the mother's Colorado Medical Assistance Program member ID number: 
Use the mother's Medical Assistance Program member ID number along with all of the mother's information (i.e., date of birth and name).

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

Note: The use of the mother's 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 Medical Assistance Program contracted HMOs.

Back to Top

14.1 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

14.2 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

14.3 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 avaliable in the Statement Regarding Billing of Medicaid Members

Back to Top


Electronic Funds Transfer (EFT)

15. 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)
  • EFT is required to receive the X12N 835 (claim payment/claim report)
 
 
16. What needs to be done to have EFT established?
The Electronic Funds Transfer (EFT) form labeled "Authorization Agreement for Automatic Deposits", located in the Forms section, must be completed.

The form can either be faxed to the Department’s fiscal agent’s Provider Enrollment Unit at 303-534-0439 or mailed to:

Xerox State Healthcare, Provider Enrollment
P.O. Box 1100
Denver, CO 80201-1100
 
17. How long does it take to set up/update EFT?
Allow 30 days for processing EFT requests
  • After 30 days, check with the bank to verify that EFT has been set up.
  • Paper checks will be sent until EFT has been established.

Back to Top

18. 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, as well as a new W-9. Processing EFT information takes about a month. While EFT information is in process, providers will receive paper checks (warrants).
 
 
19. 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 30 days from the paid date, send an email to HCPFAR@hcpf.state.co.us for specific account number information.  Please provide the following information in the email in order to expedite the process:
  • Billing Provider Number
  • Billing Provider Name
  • Billing Provider Address
  • Contact Name
  • Contact Telephone Number
  • Contact Email Address
  • Date of Missing EFT (Reference to PCR Date)
  • Dollar Amount
  • If this the first EFT payment from the Colorado Medical Assistance Program
  • Additional Information to help research the problem
 

Electronic Reports

20. 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 Infomration web page for the Web Portal section for more information.
 
 
21. Who do providers contact to get set up for electronic report retrieval?
Contact the Department’s fiscal agent’s EDI Services at 1-800-237-0757 (toll free) Monday through Friday, 8:00 a.m. to 5:00 p.m. MST.
 
 
22. If several group providers want to get all reports under a single trading partner ID, what needs to be done? 
Submit an Application for EDI enrollment, or submit an EDI Update Form if a trading partner ID # has already been approved and assigned to your agency. Both forms are located in the Provider Information EDI Support section.

Enter the receiving trading partner ID number in the receiving TP ID box next to each report. 

Note: When a billing agent is authorized to receive reports, the reports may not be directed to an additional trading partner ID for retrieval.
 
 
23. For what length of time are the reports available electronically?
All reports are available electronically for 60 days. Once a report is purged, the provider must request a paper copy.
 
 
24. How can duplicate copies of PCRs be obtained?
The Department’s fiscal agent does not provide copies of Provider Claim Reports (Remittance Statements) free of charge to providers who:
  • Currently bill or retrieve reports electronically or
  • Are requesting Provider Claim Reports over 30 days old

There are two options to obtain a duplicate copy of a PCR. 
Option One (1):
The Department’s fiscal agent will send an encrypted email with the duplicate copy PCR attached. The charge for this service is $2.00 per page. 
Option Two (2):
The Department’s fiscal agent will mail the duplicate copy PCR via FedEx. The charge for this service is a flat rate cost of $2.61 per page for a business address or $2.86 per page for a residential address.

Contact the Department’s fiscal agent at 1-800-237-0757 to request the number of pages per report and mail a check to:
Xerox State Healthcare
P.O. Box 30
Denver, CO 80201-0030
Make check payable to Xerox State Healthcare, LLC. Note the provider number, week of the PCR, mailing address, and to whose attention the mailing should be sent. Allow 30 days for processing after receipt of the request, and additional time for return mail.
 
Back to Top

Eligibility

25. 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

26. 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 members’s eligibility status is not available through eligibility verification methods.

Back to Top

27. What needs to be done to get setup for Fax-Back?

Fax-Back information is located in the Provider Enrollment Application. The application is available in the Provider Enrollment section. Completed information may be faxed to the Department’s fiscal agent’s Provider Enrollment Unit at 303-605-4134 or mailed to:

Xerox State Healthcare, Provider Enrollment
PO Box 1100
Denver, CO 80201-1100
Providers may also contact the Department’s fiscal agent's Provider Services at 1-800-237-0757 (toll free) for Fax-Back information.

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

Load Letters (LL) and Late Bill Override Dates (LBOD) allow providers to submit claims that are outside of the timely filing period. LLs are issued for claims with dates of service (DOS) past 365 days. LBODs are issued for claims with DOS past 120 days, but not exceeding 364 days.

The LBOD process allows providers to submit claims for services rendered past the 120 day timely filing period. Providers may submit LBOD requests on the LL form.
 
NOTE: The purpose of the Load Letter and Late Bill Override Date is to allow providers to submit claims outside of the timely filing period; however, they are not a guarantee of payment. For CHP+ members, please contact the HMO listed on the back of the member’s medical card for an LL or LBOD.
 
A Load Letter can only be issued when the provider has verified the member’s eligibility and receives an Eligibility Status of “Eligible” through the Web Portal (Web Portal), FaxBack, or Automatic Voice Response System (AVRS). The Load Letter Request form is available under Other Forms in the Forms section. Upon receiving the request from providers, the Department will generate an LL or LBOD as long as the request meets all of the following 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.
 

29. 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.

Contact the Department’s fiscal agent’s Provider Services at 1-800-237-0757 (toll free) Monday through Friday, 8:00 a.m. to 5:00 p.m. MST with questions.
 

30. 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

31. 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

32. 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

33. 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

33.1 What is a mother’s eligibility if she 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

33.2 What are the provider responsibilities under HIPAA?

Please refer to the Provider Informationa HIPAA web page. 


Notification of Non-Payment

34. What generates a Notification of Non-Payment letter?
Claims processed by the Department’s fiscal agent, Xerox State Healthcare, to a provider number that is not active in the State's financial system results in incomplete payment.

This usually occurs when the rendering provider number is used in the billing provider number field on the claim(s). It can also occur when there is a question about a Tax Identification Number (TIN). In addition, if there has been no payment to a provider in the last 18 months, the State's financial system purges the account. 

If a Notification of Non-Payment form is received, follow the instructions and fax the information directly to 303-866-3669, attention “Accounting”. Keep all of the forms as one packet and fax them together. Do not separate the forms.
 
 
35. What reasons would cause a provider to need a new provider number?
This could be due to a business type or name conflict between the provider information in the Medicaid Management Information System (MMIS) and the billing provider number information in the State's financial system.
  • A provider number may only bill using one TIN. However, one Employer Identification Number (EIN) may have multiple provider numbers.
  • A provider enrolled with an individual Social Security Number (SSN), as well as an EIN would have two provider numbers.
  • If the provider number is linked to a SSN, and the purpose is to have payments reported on that SSN, a new provider number is not necessary.
  • A single Medical Assistance Program provider number cannot be assigned to both an SSN and EIN.
  • The billing provider number must correspond to either your SSN or EIN.
Note: The billing provider number is the one receiving payments and the corresponding TIN is reported to the Internal Revenue Service (IRS).
 
 
36. 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.
 
 
37. What reasons would cause the need to submit a W-9 more than once?
It could be that the W-9 form that was submitted was completed incorrectly, with both a SSN and an EIN or with a legal name that does not match the TIN on file. The form must be completed correctly to set up provider payments and comply with federal tax laws.
 
 
38. Why would a provider who is already enrolled in the Colorado Medical Assistance Program, but bills infrequently, need to complete another W-9?
If it has been longer than 18 months since the provider’s last payment from the Colorado Medical Assistance Program, a new W-9 must be completed and submitted to receive payment because the State's financial system purges the account. Send the completed W-9 to:
 
Xerox State Healthcare, Provider Enrollment
P.O. Box 1100
Denver, CO 80201-1100
 
39. 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

40. 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, call the Department's fiscal agent at 1-800-237-0757 (toll free).
  • The customer service representative can submit a check trace.
  • Ask the representative for the warrant number for your reference.

Back to Top

41. How can a copy of a cashed check be obtained?
Send an email to HCPFAR@hcpf.state.co.us to request copies of cashed checks and provide the following information in order to expedite your request:
  • Billing Provider Number
  • Billing Provider Name
  • Billing Provider Address
  • Contact Name
  • Contact Telephone Number
  • Contact Email Address
  • Warrant Number
  • Warrant Date
  • Warrant Amount
  • Multiple warrants on one request are acceptable but please include all warrant information for each warrant you are requesting.
The following is the charge per warrant requested:
  • Warrant Date Prior to July 1, 2003 - $9.00 per warrant requested
  • Warrant Date After June 30, 2003 - $1.00 per warrant requested
Make 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.
 
 
42. How can a check be reissued?
If the check trace research verifies that the check was not cashed or was not found, send an email to HCPFAR@hcpf.state.co.us to request a check to be reissued. Please provide the following information in order to expedite your request:
  • Billing Provider Number
  • Billing Provider Name
  • Billing Provider Address
  • Contact Name
  • Contact Telephone Number
  • Contact Email Address
  • Warrant Number
  • Warrant Date
  • Warrant Amount
  • Fax Number
  • Multiple warrants on one request 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 Web Portal’s (MMIS) Provider Data Maintenance area. Once the information is entered, verify it the following day.
 
 
43. 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 Web Portal. Changes made through the Web Portal are effective within 24 hours.

Providers who are unable to update address information through the Web Portal may submit a Provider Enrollment Update Form, located in the Provider Services Forms section of the Department’s Web site, or send updated information on the provider’s letterhead to Provider Enrollment (PO Box 1100; Denver, CO 80201-1100). Changes sent by mail may take up to two weeks to process.

Once a check is returned to the fiscal agent, claims will deny until the information is updated. 
If the Web Portal is used for updates, notify the Department’s fiscal agent’s Provider Services Unit on the next business day (at least 24 hours) after the update is completed. 

When the claims are re-billed, another payment/check will be issued and mailed to the corrected address.
 
 
44. 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

45. 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

46. 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 Provider Claim Reports (PCRs). 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.
 
 
47. How can more information be obtained for Colorado Medical Assistance Program providers who are interested in submitting claims electronically through the Web Portal?
Download and complete an EDI Enrollment form located in the Provider Information EDI Support section. Return the completed form to:
 
Xerox State Healthcare, EDI Services
P.O. Box 1100 
Denver, CO 80201-1100

The Department will follow-up on the enrollment process and send the necessary username and password for the Trading Partner Administrator (TPA) to access the Web Portal. 

Note: The TPA is responsible for assigning additional usernames and passwords to other users within their practice or facility.
 
 
48. If the proper paperwork has been submitted to use the Web Portal and a username and password haven't been received, what needs to be done?
Providers who have submitted the enrollment packet to the Department’s fiscal agent’s EDI Services, but have not received a response, should contact the EDI Services Unit at 1-800-237-0757 (toll free).

Back to Top

49. What should a provider do if a response to an emergent request to add-a-baby is not documented on the Web Portal?

If after 15 days a response has not been documented on the Provider’s Web Portal access, the Department may be contacted by emailing add-a-baby@hcpf.state.co.us or by calling (303) 866-4456.

Back to Top