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The Department of Health Care Policy & Financing (the Department) is committed to improving health and quality services to our members while ensuring appropriate claims payments to Health First Colorado (Colorado’s Medicaid Program) providers.
In accordance with Senate Bill 18-266, the Department is implementing its Ensuring Appropriate Claims Payment project. The project is comprised of two components:
The Ensuring Appropriate Claims Payment project was implemented effective September 26, 2020, and is now live. Please contact the Provider Call Center with any questions.
ClaimsXten™ Provider Training Schedule
The ClaimsXten™ tool is a product of Change Healthcare. The tool automatically reviews claims to identify inappropriate bill coding and reduce overpayments. The goal is to increase billing transparency, so providers submit accurate claims for reimbursement on the first attempt.
The ClaimsXten™ tool is currently in use by many private insurance companies, so most providers will be somewhat familiar with the tool and basic functionality.
The first phase of ClaimsXten™ implementation will exclude home and community-based services (HCBS) claims.
Outpatient hospital claims currently process through the 3M EAPG grouper. 3M has several return codes that edit on invalid or incorrect data on the claim and are mapped to interChange edits that either pay or deny.
This project will utilize technology that will automate and increase the accuracy of claims review and adjudication.
Mapping 3M’s EAPG return codes to new edits within the interChange will improve the Department’s ability to ensure appropriate payments for outpatient hospital claims.