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This page references the Colorado Medical Assistance Program which includes Health First Colorado (Colorado's Medicaid program), Child Health Plan Plus (CHP) and other long-term care programs.
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1. Who should be contacted to find out about an AR balance?Call the Provider Services Call Center at 1 (844) 235-2387 (toll-free) for information related to AR balances. Hours of operation are Monday, Tuesday, and Thursday from 7:00 a.m. to 5:00 p.m. MST as well as Wednesday and Friday from 10 a.m. to 5 p.m. MST
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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 RA?
Allow 30 days for processing.
4. Who should be contacted for billing or Electronic Data Interchange (EDI) questions?
Please call the Provider Services Call Center at 1 (844) 235-2387 for the following:
The Provider Services Call Center is available Monday, Tuesday, and Thursday from 7:00 a.m. to 5:00 p.m. MST as well as Wednesday and Friday from 10 a.m. to 5 p.m. MST.
5. If Medicare claims don't automatically crossover to Medicaid, what steps does a provider need to take?
Allow 30 days for the Colorado Medical Assistance Program to process the crossover claim. If automatic crossover does not appear on the Colorado Medical Assistance Program RA within 30 days of the Medicare processing date, it is the provider’s responsibility to submit crossover claims electronically or on paper.
If the crossover claim is submitted on paper, a copy of the Medicare Standard Paper Remit (SPR) must be attached. Be sure to retain the original SPR for audit purposes.
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 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.
8. How does a provider bill the Colorado Medical Assistance Program when there is a contractual write-off with other insurance?
Providers must bill their usual and customary charge to the Colorado Medical Assistance Program. The TOTAL CHARGES are the provider's usual and customary charges.
The NET CHARGE (TOTAL CHARGES less THIRD PARTY PAID) is the payment actually received plus the contractual write-off amount.
If the THIRD PARTY PAID amount is less than the Colorado Medical Assistance Program allowable amount, the Colorado Medical Assistance Program will pay the difference up to the Colorado Medical Assistance Program allowable amount toward the other insurance copay amount.
If the THIRD PARTY PAID amount is greater than the Colorado Medical Assistance Program allowable amount, the Medical Assistance Program makes no payment.
9. Where can CHP+ information be obtained?
CHP+ information may be accessed by visiting the Child Health Plan Plus (CHP+) web page.
10. How can the Colorado Medicaid fee schedule be accessed?
The current fee schedule and the instructions for reading the fee schedule may be accessed by visiting the Provider Rates & Fee Schedule web page. Code information includes: procedure code, system parameter, price begin date, price end date, factor code, relative value, gender, min age, max age, post-op days, and if a PAR is required.
11. How are newborn charges covered?
If the newborn and the mother are both still in the hospital, bill using the mother's Colorado Medical Assistance Program member ID along with all of the mother's information (i.e., date of birth and name).
Use the -UK modifier. The -UK modifier on the CMS 1500 paper claim form identifies the claim as belonging to the baby.
Note: The use of the mother's Colorado Medical Assistance Program member ID number and the -UK modifier only applies to charges billed on the CMS 1500 for members in the Fee-for-Service or Primary Care Physician Program. This does not apply to members covered under Medicaid contracted HMOs.
If the baby is still hospitalized after the mother is discharged, or if the baby is transferred to another hospital, the baby's charges must be billed using the baby's Colorado Medical Assistance Program ID number.
12.1 To whom does the birth of a baby need to be reported to?
The birth of babies of women on Medicaid need to be reported to the assigned county or Medical Assistance (MA) site case worker in the member’s county of residence.
12.2 What can Providers do to report the birth of a baby in an emergency situation?
An online form provides a secure means of submitting the newborn’s information to the Department. For emergent requests, the newborn’s information will be added to its mother’s case within two business days from its receipt. A confirmation of receipt of the form is provided through the online process.
12.3 Can a provider bill a Medicaid member for the cost or the cost remaining after payment by Medicaid, Medicare, or a private insurer?
No, Medicaid members cannot be billed for any service covered by Medicaid. More information is available in the Statement Regarding Billing of Medicaid Members. Back to Top
20. Who determines a member's eligibility?
The member's county’s Department of Human/Social Services agency helps to establish member eligibility for Colorado Medical Assistance Program benefits. More information can be found on the Colorado Department of Human Services website.
21. What is delayed/retroactive eligibility?
A member’s Colorado Medical Assistance Program eligibility may be made retroactive prior to the application date. Charges for services are the member’s responsibility until eligibility is established. Claims are denied if the member’s eligibility status is not available through eligibility verification methods.
22. What are Load Letters and Late Bill Override Dates?
Load Letters (LL) allow providers to submit claims that are outside of the timely filing period. Providers may submit requests on the LL form. Providers have 120 days from the date of the load letter to submit the claim with the attached form for review by the fiscal agent.
23. What is Dual Eligibility?
Members with coverage by Medicare and Medicaid are referred to as Medicare-Medicaid enrollees. Providers are reminded that Medicaid is always the payer of last resort, therefore, services for Medicare-Medicaid enrollees must be billed first to Medicare. Providers must be able to show evidence that claims for members with dual eligibility, where appropriate, have been denied by Medicare prior to submission to the Colorado Medical Assistance Program. Per the Provider Participation Agreement, this evidence must be retained for six years following the Medicare denial. The Colorado Medical Assistance Program requires that the Medicare Standard Paper Remit (SPR) accompany any paper claims submitted for Medicare-Medicaid enrollees.
24. What is Presumptive Eligibility (PE)?
Presumptive Eligibility (PE) allows children age 18 and under and pregnant women to be enrolled in either Medicaid or CHP+ as presumptively eligible. Medicaid PE for children includes coverage of all Medicaid covered services. However, Medicaid PE for pregnant women only covers outpatient services.
25. What is the Modified Medical Program?
The Modified Medical Program provides care for Colorado old age pensioners with limited incomes who do not qualify for the Colorado Medical Assistance Program.
26. What are Qualified Medicare Beneficiaries?
Elderly and disabled Medicare beneficiaries with incomes below the federal poverty level and resources at twice the Supplemental Security Income (SSI) level are eligible for Colorado Medicaid payments of Medicare deductibles and coinsurance. Individuals who qualify are called Qualified Medicare Beneficiaries (QMBs).
27.1. Are non-citizens eligible for Medicaid benefits?
Benefits available to non-citizens are limited to care and services necessary to treat immediate emergency conditions, including labor and delivery.
27.2 What is a newborn’s eligibility when the mother gives birth while on Medicaid?
A baby born to a woman on Medicaid at the time of the newborn’s birth is guaranteed continuous eligibility through the baby’s first birthday.
28. What are the provider responsibilities under HIPAA?
Please refer to the Provider Information HIPAA web page.
37. Where can a software vendor interested in programming a practice management system get a copy of the Colorado Medical Assistance Program Specification Manual(s)?
The specification manuals can be downloaded from the Provider Information Specifications section.