Colorado Choice Transitions (CCT) Program Reference Manual

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Program Overview

Colorado Choice Transitions (CCT), part of the federal Money Follows the Person Rebalancing Demonstration, is a five-year grant program. The primary goal is facilitating the transition of Health First Colorado (Colorado’s Medicaid Program) members from nursing and other long-term care (LTC) facilities to the community using home and community based (HCBS) services and supports. Services are intended to promote independence, improve the transition process, and support individuals in the community. Participants of the CCT program will have access to qualified waiver services as well as demonstration services. They will be enrolled in the program for up to 365 days after which time they will enroll into one of five HCBS waivers so long as they remain Medicaid eligible. Days in a hospital or LTC facility for a period of less than 30 days during the enrollment period will not count towards the 365 days. Qualified services are HCBS waiver services that will continue once the CCT program has ended if the member continues to be eligible for HCBS. Demonstration services are enhanced services provided during an individual’s enrollment in the demonstration program post-transition and end on the last day of CCT enrollment. The grant funding will also be used to streamline and improve the HCBS systems in Colorado.

Health First Colorado members participating in CCT must meet long-term care Health First Colorado eligibility requirements (which include functional and financial eligibility); reside in a long-term care facility for a period of no less than ninety days (90) not counting days for rehabilitation; have been Medicaid eligible for one day; and be willing to move to qualified housing as defined in federal statute. To participate, members must meet financial, medical, and program criteria to access services through the CCT program and be willing to receive services in their homes or communities. A member who receives services through the CCT program is also eligible for all Health First Colorado State Plan services. When a member chooses to receive services under a waiver and the CCT program, the services must be provided by certified Health First Colorado providers.

The CCT program will complement the Elderly, Blind, and Disabled Waiver, Persons with Brain Injury Waiver, Community Mental Health Supports Waiver, Persons with Developmental Disabilities Wavier, and Supported Living Services Waiver. The populations that will be transitioned through the program include: elderly adults aged 65 years or older residing in Health First Colorado nursing facilities; adults aged 18-64 with physical disabilities residing in Health First Colorado nursing facilities; adults aged 18 and older with developmental disabilities residing in Intermediate Care Facilities (ICFs) and Health First Colorado nursing facilities; and adults 65 years and older and individuals under 22 residing in institutions for mental disease (IMDs).

Note: The Department of Health Care Policy and Financing (the Department) periodically modifies billing information. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented.

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Policy Guidance for Services

The Services and Supports Desk Reference offers essential information on CCT demonstration services to providers, members, and stakeholders. The information includes service definitions, minimum provider qualifications, service rates, and other pertinent information. The Department may periodically modify policy guidance.

Providers are notified of changes in policy guidance in the monthly HCBS Provider Bulletin and other Department communications.

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Prior Authorization Requests (PARs) for CCT

All CCT services require prior approval before they can be reimbursed by the Health First Colorado. Case management agencies (CMA) complete the Prior Authorization Request for CCT according to instructions provided by the Department.

The case management agencies responsibilities include, but are not limited to:

  1. Assessing needs;
  2. Determining CCT program eligibility;
  3. Service planning and authorization;
  4. Care coordination;
  5. Risk mitigation;
  6. Service monitoring;
  7. Monitoring the health, welfare and safety of the member;
  8. Promotion of member’s self-advocacy; and
  9. Coordination of the member’s transition from the CCT program to one of the existing HCBS waivers at the end of the member’s participation on the CCT program, as long as the member remains eligible.

 

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PAR Submission

All CCT PAR forms are filed via the "Bridge" which 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 the web portal maintained by Financial Management Service Provider (FMS) in addition to sending a PAR to the Department.

Case managers may also use the PAR form maintained by FMS to create the entire PAR for a member receiving CDASS as a part of the CCT program. In addition, case managers will need to fax the final PAR approval letter to FMS before attendant timesheets will be paid.

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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, 2010 = 01/01/10.
Date of Discharge 6 numbers
(MM/DD/YY)
Required
Enter the member's date of discharge from qualified facility.
Requesting Physician 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 twelve characters, (numbers, letters, and hyphens), which help 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.
Qualified/Demonstration Services Description Text N/A
List of approved procedure codes for qualified and demonstration services.
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 CCT Qualified Service Expenditures Dollar Amount Required
Total automatically populates.
Total Authorized CCT Demonstration Service Expenditures Dollar Amount Required
Total automatically populates.
Grand Total of CCT Qualified and Demonstration Services 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 CCT 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 MI, EBD 65+ and EBD-PD
Enter CDASS information (All CDASS information must be entered in PPL's web portal).
Immediately prior to CCT 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 claim submission information.

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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 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.
Waiver Services
Providers should refer to specific billing instructions on the use of span billing.
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
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.

Waiver Services
Providers should refer to the member's approved Prior Authorization (PAR).
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.
Waiver Services
Providers should refer to the member's approved Prior Authorization (PAR).
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 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.

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CCT Procedure Code Table

Providers may bill the following procedure codes for the CCT program. Below is a breakdown of services by population.

CCT- BI Services Procedure Code Table (Special Program Code 95)
Description Procedure Code + Modifiers Units
Qualified Services
Adult Day Services S5102 UC 1 unit = 1 day
Assistive Technology, per purchase T2029 UC, HB 1 unit = 1 purchase
Behavioral Programming H0025 UC, TF 1 unit = 30 minutes
CDASS (Cent/Unit) T2025 UC 1 unit = 1 cent
CDASS Per Member/Per Month T2040 UC 1 unit = 1 month
Day Treatment H2018 UC 1 unit = 1 day
Home Modifications S5165 UC 1 unit = 1 modification
Independent Living Skills Training (ILST) T2013 UC 1 unit = 1 hour
Mental Health Counseling, Family H0004 UC, HR 1 unit = 15 minutes
Mental Health Counseling, Group H0004 UC, HQ 1 unit = 15 minutes
Mental Health Counseling, Individual H0004 UC 1 unit = 15 minutes
Non-Medical Transportation, Taxi A0100 UC 1 unit = 1-way trip
Non-Medical Transportation, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
UC
UC, TT
UC, TN
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, 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
UC
UC, TT, HB
UC, TN, HB
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
UC
UC, TT
UC, TN
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, 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
UC
UC, TT, HB
UC, TN, HB
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Personal Care T1019 UC, TG 1 unit = 15 minutes
Personal Emergency Response System (PERs), Install/Purchase S5160 UC 1 unit = 1 purchase
PERs, Monitoring S5161 UC 1 unit = 1 month of service
Relative Personal Care T1019 UC, HR, TG 1 unit = 15 minutes
Respite Care, In Home S5150 UC 1 unit = 15 minutes
Respite Care, NF H0045 UC, TF 1 unit = 1 day
Substance Abuse Counseling, Family T1006 UC, HR, HF 1 unit = 1 hour
Substance Abuse Counseling, Group H0047 UC, HQ, TF, HF 1 unit = 1 hour
Substance Abuse Counseling, Individual H0047 UC, TF, HF 1 unit = 1 hour
Supported Living Program T2033 UC 1 unit = 1 day
Transitional Living, per day T2016 UC, HB 1 unit = 1 day
Demonstration Services
Caregiver Education S5110 UC 1 unit = 15 minutes
Community Transition Services, Coordinator T2038 UC 1 unit = 1 transition
Community Transition Services, Items Purchased A9900 UC 1 unit = 1 purchase
Home Delivered Meals S5170 UC 1 unit = 1 delivery/meal
Intensive Case Management T1016 UC 1 unit = 15 minutes
Peer Mentorship H2015 UC 1 unit = 15 minutes

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CCT- EBD 65+ Services Procedure Code Table (Special Program Code 95)
Description Procedure Code + Modifiers Units
Qualified Services
Adult Day Services, Basic S5105 UC 1 unit = 4-5 hours
Adult Day Services, Specialized S5105 UC, TF 1 unit = 3-5 hours
Consumer Directed Attendant Support Services (CDASS), (Cent/Unit) T2025 UC 1 unit = 1 cent
CDASS Per Member/ Per Month (PM/PM) T2040 UC 1 unit = 1 month
Home Modifications S5165 UC 1 unit = 1 modification
Homemaker S5130 UC 1 unit = 15 minutes
IHSS Health Maintenance Activities H0038 UC 1 unit = 15 minutes
IHSS Homemaker S5130 UC, KX 1 unit = 15 minutes
IHSS Personal Care T1019 UC, KX 1 unit = 15 minutes
IHSS Relative Personal Care T1019 UC, HR, KX 1 unit = 15 minutes
Medication Reminder, Install/Purchase T2029 UC, TF 1 unit = 1 purchase
Medication Reminder, Monitoring S5185 UC 1 unit = 1 month
Non-Medical Transportation, Taxi A0100 UC 1 unit = 1-way trip
Non-Medical Transportation, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
UC
UC, TT
UC, TN
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, 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
UC
UC, TT, HB
UC, TN, HB
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
UC
UC, TT
UC, TN
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, 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
UC
UC, TT, HB
UC, TN, HB
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Personal Care T1019 UC 1 unit = 15 minutes
Personal Emergency Response System (PERs), Install/Purchase S5160 UC 1 unit =1 purchase
PERs, Monitoring S5161 UC 1 unit = 1 month
Relative Personal Care T1019 UC, HR 1 unit = 15 minutes
Respite Care, ACF S5151 UC 1 unit = 1 day
Respite Care, In Home S5150 UC 1 unit = 15 minutes
Respite Care, NF H0045 UC 1 unit = 1 day
Demonstration Services
Caregiver Education S5110 UC 1 unit = 15 minutes
Community Transition Services, Coordinator T2038 UC 1 unit = 1 transition
Community Transition Services, Items Purchased A9900 UC 1 unit = 1 purchase
Home Delivered Meals S5170 UC 1 unit = 1 delivery/meal
Independent Living Skills Training (ILST) H2014 UC 1 unit = 15 minutes
Intensive Case Management T1016 UC 1 unit = 15 minutes
Peer Mentorship H2015 UC 1 unit = 15 minutes
Transitional Behavioral Health Supports H0025 UC 1 unit = 30 minutes

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CCT- EBD 18- 64 Services Procedure Code Table (Special Program Code 95)
Description Procedure Code + Modifiers Units
Qualified Services
Adult Day Services, Basic S5105 UC 1 unit = 4-5 hours
Adult Day Services, Specialized S5105 UC, TF 1 unit = 3-5 hours
Consumer Directed Attendant Support Services (CDASS), (Cent/Unit) T2025 UC 1 unit = 1 cent
CDASS Per Member/ Per Month (PM/PM) T2040 UC 1 unit = 1 month
Home Modifications S5165 UC 1 unit = 1 modification
Homemaker S5130 UC 1 unit = 15 minutes
IHSS Health Maintenance Activities H0038 UC 1 unit = 15 minutes
IHSS Homemaker S5130 UC, KX 1 unit = 15 minutes
IHSS Personal Care T1019 UC, KX 1 unit = 15 minutes
IHSS Relative Personal Care T1019 UC, HR, KX 1 unit = 15 minutes
Medication Reminder, Install/Purchase T2029 UC, TF 1 unit = 1 purchase
Medication Reminder, Monitoring S5185 UC 1 unit = 1 month
Non-Medical Transportation, Taxi A0100 UC 1 unit = 1-way trip
Non-Medical Transportation, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
UC
UC, TT
UC, TN
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, 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
UC
UC, TT, HB
UC, TN, HB
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
UC
UC, TT
UC, TN
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, 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
UC
UC, TT, HB
UC, TN, HB
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Personal Care T1019 UC 1 unit = 15 minutes
Personal Emergency Response System (PERs), Install/Purchase S5160 UC 1 unit =1 purchase
PERs, Monitoring S5161 UC 1 unit = 1 month
Relative Personal Care T1019 UC, HR 1 unit = 15 minutes
Respite Care, ACF S5151 UC 1 unit = 1 day
Respite Care, In Home S5150 UC 1 unit = 15 minutes
Respite Care, NF H0045 UC 1 unit = 1 day
Demonstration Services
Caregiver Education S5110 UC 1 unit = 15 minutes
Community Transition Services, Coordinator T2038 UC 1 unit = 1 transition
Community Transition Services, Items Purchased A9900 UC 1 unit = 1 purchase
Home Delivered Meals S5170 UC 1 unit = 1 delivery/meal
Independent Living Skills Training (ILST) H2014 UC 1 unit = 15 minutes
Intensive Case Management T1016 UC 1 unit = 15 minutes
Peer Mentorship H2015 UC 1 unit = 15 minutes
Transitional Behavioral Health Supports H0025 UC 1 unit = 30 minutes

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CCT- CMHS Services Procedure Code Table (Special Program Code 95)
Description Procedure Code + Modifiers Units
Qualified Services
Adult Day Services, Basic S5105 UC 1 unit = 4-5 hours
Adult Day Services, Specialized S5105 UC, TF 1 unit = 3-5 hours
Consumer Directed Attendant Support Services (CDASS), (Cent/Unit) T2025 UC 1 unit = 1 cent
CDASS Per Member/ Per Month (PM/PM) T2040 UC 1 unit = 1 month
Home Modifications S5165 UC 1 unit = 1 modification
Homemaker S5130 UC 1 unit = 15 minutes
Medication Reminder, Install/Purchase T2029 UC, TF 1 unit = 1 purchase
Medication Reminder, Monitoring S5185 UC 1 unit = 1 month
Non-Medical Transportation, Taxi A0100 UC 1 unit = 1-way trip
Non-Medical Transportation, Mobility Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0120
A0120
A0120
UC
UC, TT
UC, TN
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, 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
UC
UC, TT, HB
UC, TN, HB
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, Wheelchair Van
Mileage Band 1 (0-10 miles)
Mileage Band 2 (11-20 miles)
Mileage Band 3 (over 20 miles)
A0130
A0130
A0130
UC
UC, TT
UC, TN
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Non-Medical Transportation, 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
UC
UC, TT, HB
UC, TN, HB
1 unit = 1-way trip
1 unit = 1-way trip
1 unit = 1-way trip
Personal Care T1019 UC 1 unit = 15 minutes
Personal Emergency Response System (PERs), Install/Purchase S5160 UC 1 unit =1 purchase
PERs, Monitoring S5161 UC 1 unit = 1 month
Relative Personal Care T1019 UC, HR 1 unit = 15 minutes
Respite Care, ACF S5151 UC 1 unit = 1 day
Respite Care, NF H0045 UC 1 unit = 1 day
Demonstration Services
Caregiver Education S5110 UC 1 unit = 15 minutes
Community Transition Services, Coordinator T2038 UC 1 unit = 1 transition
Community Transition Services, Items Purchased A9900 UC 1 unit = 1 purchase
Home Delivered Meals S5170 UC 1 unit = 1 delivery/meal
Independent Living Skills Training (ILST) H2014 UC 1 unit = 15 minutes
Intensive Case Management T1016 UC 1 unit = 15 minutes
Peer Mentorship H2015 UC 1 unit = 15 minutes
Transitional Behavioral Health Supports H0025 UC 1 unit = 30 minutes

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CCT- DD Services Procedure Code Table (Special Program Code 95)
Description Procedure Code Modifiers Level Units
Qualified Services
Behavioral Services
Line Service H2019 UC   1 unit = 15 minutes
Behavioral Consultation H2019 UC, HI, TG   1 unit = 15 minutes
Behavioral Counseling, Individual H2019 UC, TF, TG   1 unit = 15 minutes
Behavioral Counseling, Group H2019 UC, TF, HQ   1 unit = 15 minutes
Behavioral Plan Assessment T2024 UC, HI   1 unit = 15 minutes
Day Habilitation
Specialized Day Habilitation T2021
T2021
T2021
T2021
T2021

T2021
T2021
UC, HQ
UC,HI, HQ
UC, TF, HQ
UC, TF, HI, HQ
UC, TG, HQ
UC, TG, HI, HQ
UC, SC, HQ
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Supported Community Connections T2021
T2021
T2021
T2021
T2021

T2021
T2021
UC
UC, HI
UC, TF
UC, TF, HI
UC, TG
UC, TG, HI
UC, SC
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Dental
Dental, Basic/ Preventive D2999 UC, HI   1 unit = 1 dollar
Dental, Major D2999 UC, TF   1 unit = 1 dollar
Non-Medical Transportation
To/From Day Program, Mileage Range T2003
T2003
T2003
UC
UC, HI
UC, TF
0-10 Miles
11-20 Miles
21- up Miles
1 unit = 2 trips per day
1 unit = 2 trips per day
1 unit = 2 trips per day
Other (Public Conveyance) T2004 UC   1 unit = 1 dollar
Pre-Vocational Services
Pre-Vocational Services T2015
T2015
T2015
T2015
T2015
T2015
UC, HQ
UC, HI, HQ
UC, TF, HQ
UC, TF, HI, HQ
UC, TG, HQ
UC, TG, HI, HQ
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Residential Services
Group Home T2016
T2016
T2016
T2016
T2016
T2016
T2016
UC, HQ
UC, HI, HQ
UC, TF, HQ
UC, TF, HI, HQ
UC, TG, HQ
UC, TG, HI, HQ
UC, SC, HQ
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Personal Care Alternative T2016
T2016
T2016
T2016
T2016
T2016
T2016
UC
UC, HI
UC, TF
UC, TF, HI
UC, TG
UC, TG, HI
UC, SC
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
Host Home T2016
T2016
T2016
T2016
T2016
T2016
T2016
UC, TT
UC, HI, TT
UC, TF, TT
UC, TF, HI, TT
UC, TG, TT
UC, TG, HI, TT
UC, SC, TT
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
1 unit = 1 day
1 unit = individual approved rate
Supported Employment
Supported Employment, Individual, All Levels (1-6) T2019 UC, SC All Levels (1-6) 1 unit = 15 minutes
Supported Employment, Group T2019
T2019
T2019
T2019
T2019
T2019
UC, HQ
UC, HI, HQ
UC, TF, HQ
UC, TF, HI, HQ
UC, TG, HQ
UC, TG, HI, HQ
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Job Development, Individual, Level 1-2 H2023 UC Level 1-2 1 unit = 15 minutes
Job Development, Individual, Level 3-4 H2023 UC, HI Level 3-4 1 unit = 15 minutes
Job Development, Individual, Level 5-6 H2023 UC, TF Level 5-6 1 unit = 15 minutes
Job Development, Group, All Levels H2023 UC, HQ All Levels (1-6) 1 unit = 15 minutes
Job Placement, Individual, All Levels (1-6) H2024 UC All Levels (1-6) 1 unit = 1 dollar
Job Placement, Group, All Levels (1-6) H2024 UC, HQ All Levels (1-6) 1 unit = 1 dollar
Specialized Medical Equipment
Specialized Medical Equipment and Supplies, Disposable T2028 UC   1 unit = 1 dollar
Specialized Medical Equipment T2029 UC, TF   1 unit = 1 dollar
Vision V2799 UC, HI   1 unit = 1 dollar
Demonstration Services
Assistive Technology, Extended T2029 UC   1 unit = 1 purchase
Caregiver Education S5110 UC   1 unit = 15 minutes
Community Transition Services, Coordinator T2038 UC   1 unit = 1 transition
Community Transition Services, Items Purchased A9900 UC   1 unit = 1 purchase
Intensive Case Management T1016 UC   1 unit = 15 minutes
Peer Mentorship H2015 UC   1 unit = 15 minutes

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CCT- SLS Services Procedure Code Table (Special Program Code 95)
Description Procedure Code Modifiers Level Units
Qualified Services
Assistive Technology * T2035 UC   1 unit = 1 dollar
Mentorship H2021 UC   1 unit = 15 minutes
Personal Care T1019 UC, TF   1 unit = 15 minutes
Personal Emergency Response (PERs) S5161 UC   1 unit = 1 dollar
Vehicle Modifications * T2039 UC   1 unit = 1 dollar
Vision * V2799 UC, HI   1 unit = 1 dollar
Behavioral Services
Line Services H2019 UC   1 unit = 15 minutes
Behavioral Consultation H2019 UC, HI, TG   1 unit = 15 minutes
Behavioral Counseling, Group H2019 UC, TF, HQ   1 unit = 15 minutes
Behavioral Counseling, Individual H2019 UC, TF, TG   1 unit = 15 minutes
Behavioral Plan Assessment T2024 UC, HI   1 unit = 15 minutes
Day Habilitation
Specialized Day Habilitation T2021
T2021
T2021
T2021
T2021
T2021
UC, HQ
UC. HI, HQ
UC, TF, HQ
UC, TF, HI, HQ
UC, TG, HQ
UC, TG, HI, HQ
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Supported Community Connections T2021
T2021
T2021
T2021
T2021
T2021
UC
UC, HI
UC, TF
UC, TF, HI
UC, TG
UC, TG, HI
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Dental
Dental, Basic/ Preventive Services * D2999 UC, HI   1 unit = 1 dollar
Dental, Major Services * D2999 UC, TF   1 unit = 1 dollar
Homemaker
Homemaker, Basic S5130 UC, HI   1 unit = 15 minutes
Homemaker, Enhanced S5130 UC, TF   1 unit = 15 minutes
Home Accessibility Adaptations * S5165 UC   1 unit = 1 dollar
Non-Medical Transportation
To/From Day Program, Mileage Range * T2003
T2003
T2003
UC
UC, HI
UC, TF
0-10 Miles
11-20 Miles
21- up Miles
1 unit = 2 trips per day
1 unit = 2 trips per day
1 unit = 2 trips per day
Mileage Not Day Program * T2003 UC, HB   1 unit = 4 trips per week
Other (Public Conveyance) * T2004 UC   1 unit = 1 dollar
Pre-Vocational Services
Pre-Vocational Services T2015
T2015
T2015
T2015
T2015
T2015
UC, HQ
UC, HI, HQ
UC, TF, HQ
UC, TF, HI, HQ
UC, TG, HQ
UC, TG, HI, HQ
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Professional Services
Massage Therapy 97124 UC   1 unit = 15 minutes
Movement Therapy, Bachelor’s Degree G0176 UC, HN   1 unit = 15 minutes
Movement Therapy, Master’s Degree G0176 UC   1 unit = 15 minutes
Hippotherapy, Group S8940 UC, HQ   1 unit = 15 minutes
Hippotherapy, Individual S8940 UC   1 unit = 15 minutes
Rec Pass, Access Fee S5199 UC   1 unit = 1 dollar
Respite Services
Respite Care, Camp T2036 UC   1 unit = 1 dollar
Respite Care, Group S5151 UC, HQ, TG   1 unit = 1 dollar
Respite Care, Individual, 15 Minutes S5150 UC, TG   1 unit = 15 minutes
Respite Care, Individual, Day S5151 UC, TG   1 unit = 1 dollar
Specialized Medical Equipment and Supplies
Specialized Medical Equipment and Supplies, Disposable T2028 UC   1 unit = 1 dollar
Specialized Medical Equipment T2029 UC, TF   1 unit = 1 dollar
Supported Employment
Supported Employment, Individual, All Levels (1-6) T2019 UC, HI All Levels (1-6) 1 unit = 15 minutes
Supported Employment, Group T2019
T2019
T2019
T2019
T2019
T2019
UC, HQ
UC, HI, HQ
UC, TF, HQ
UC, TF, HI, HQ
UC, TG, HQ
UC, TG, HI, HQ
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
1 unit = 15 minutes
Job Development, Individual, Level 1-2 H2023 UC Level 1-2 1 unit = 15 minutes
Job Development, Individual, Level 3-4 H2023 UC, HI Level 3-4 1 unit = 15 minutes
Job Development, Individual, Level 5-6 H2023 UC, TF Level 5-6 1 unit = 15 minutes
Job Development, Group, All Levels H2023 UC, HQ All Levels (1-6) 1 unit = 15 minutes
Job Placement, Individual, All Levels (1-6) H2024 UC All Levels (1-6) 1 unit = 1 dollar
Job Placement, Group, All Levels (1-6) H2024 UC, HQ All Levels (1-6) 1 unit = 1 dollar
Demonstration Services
Caregiver Education S5110 UC   1 unit = 15 minutes
Community Transition Services, Coordinator * T2038 UC   1 unit = 1 transition
Community Transition Services, Items Purchased * A9900 UC   1 unit = 1 purchase
Independent Living Skills Training (ILST) H2014 UC   1 unit = 15 minutes
Intensive Case Management * T1016 UC   1 unit = 15 minutes
* Outside of Service Plan Authorization Limit (SPAL)

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CCT Claim Examples

CMS 1500 CCT-BI Claim Example

CMS 1500 CCT-BI Claim Example

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CMS 1500 CCT-CMHS Claim Example

CMS 1500 CCT-CMHS Claim Example

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CMS 1500 CCT-DD Claim Example

CMS 1500 CCT-DD Claim Example

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CMS 1500 CCT-EBD (18-64) Claim Example

CMS 1500 CCT-EBD (18-64) Claim Example

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CMS 1500 CCT-EBD (65+) Claim Example

CMS 1500 CCT-EBD 65+ Claim Example

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CMS 1500 CCT-SLS Claim Example

CMS 1500 CCT-SLS Claim Example

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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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CCT 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 Comment Log 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 Timely Filing
Removal of information duplicated from general manual
HCPF
6/28/2018 Minor grammatical updates HCPF
12/21/2018 Clarification to signature requirements HCPF
3/19/2018 Clarification to signature requirements HCPF
3/12/2020 Converted to web page HCPF
9/14/2020 Added Line to Box 32 under the Paper Claim Reference Table HCPF