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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.
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2. What creates an AR balance?There are several reasons that an AR balance may be created:
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.
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:
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:
5. If Medicare claims don't automatically crossover to Health First Colorado (Colorado's Medicaid Program), 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.
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.
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).
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:
For more information on how to submit electronic claims, please refer to the appropriate companion guide in the Provider Information section.
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.
10. Why does a claim reject with statement saying it cannot be billed electronically?
Common reasons include the following:
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.
12. Where can CHP+ information be obtained?
CHP+ information may be accessed by visiting the Child Health Plan Plus (CHP+) web page.
13. How can the Health First Colorado (Colorado's Medicaid Program) 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.
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.
14.1 To whom does the birth of a baby need to be reported to?
The birth of babies of women on Health First Colorado (Colorado's Medicaid Program) need to be reported to the assigned county or Medical Assistance (MA) site case worker in the member’s county of residence.
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.
14.3 Can a provider bill a Health First Colorado (Colorado's Medicaid Program) member for the cost or the cost remaining after payment by Health First Colorado, Medicare, or a private insurer?
No, Health First Colorado members cannot be billed for any service covered by Health First Colorado. More information is avaliable in the Statement Regarding Billing of Medicaid Members. Back to Top
The form can either be faxed to the Department’s fiscal agent’s Provider Enrollment Unit at 303-534-0439 or mailed to:
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.
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.
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:
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.
29. What is Dual Eligibility?
Members with coverage by Medicare and Health First Colorado (Colorado's Medicaid Program) are referred to as Medicare-Medicaid enrollees. Providers are reminded that Health First Colorado 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.
30. What is Presumptive Eligibility (PE)?
Presumptive Eligibility (PE) allows children age 18 and under and pregnant women to be enrolled in either Health First Colorado (Colorado's Medicaid Program) or Child Health Plan Plus (CHP+) as presumptively eligible. Health First Colorado PE for children includes coverage of all Health First Colorado-covered services. However, Health First Colorado PE for pregnant women only covers outpatient services.
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.
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 Health First Colorado (Colorado's Medicaid Program) payments of Medicare deductibles and coinsurance. Individuals who qualify are called Qualified Medicare Beneficiaries (QMBs).
33. Are non-citizens eligible for Health First Colorado (Colorado's Medicaid Program) benefits?
Benefits available to non-citizens are limited to care and services necessary to treat immediate emergency conditions, including labor and delivery.
33.1 What is a mother’s eligibility if she gives birth while on Health First Colorado (Colorado's Medicaid Program)?
A baby born to a woman on Health First Colorado at the time of the newborn’s birth is guaranteed continuous eligibility through the baby’s first birthday.
33.2 What are the provider responsibilities under HIPAA?
Please refer to the Provider Informationa HIPAA web page.
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.
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 firstname.lastname@example.org or by calling (303) 866-4456.