Client Overutilization Program

Client-Overutilization Program

The Client-Overutilization Program (COUP) is a statewide utilization program that safeguards against unnecessary or inappropriate use of care or services. This program provides a post-payment review process of Health First Colorado’s (Colorado’s Medicaid Program) Accountable Care Collaborative (ACC) Member utilization profile. It identifies excessive patterns of utilization in order to assist with over-utilization practices of Members. When there is documented evidence of over-utilization of allowable medical benefits, COUP assists Members in receiving appropriate care coordination services through their Regional Accountable Entity (RAE) and helping them select an appropriate Primary Care Medical Provider (PCMP).

Members may be placed in COUP whose utilization of Medicaid benefits without medical necessity has exceeded any one of the following parameters during a three-month period:

  • Use of six or more high risk prescriptions, filled prescriptions from three or more different pharmacies and filled prescriptions from three or more different prescribers.
  • Four or more visits to the Emergency Department (ED);
  • Combination of both, i.e. six or more high risk prescriptions, filled prescriptions from three or more different pharmacies, filled prescriptions from three of more different prescribers and four or more visits to the ED; or
  • A RAE or PCMP referral or care analysis indicating overutilization.

How does it work?

The Department reviews all Health First Colorado Members utilization of services. Members usage is reviewed by Department staff and the Department’s Utilization Management vendor on a quarterly basis. Members who meet one or more of the criteria listed above will be placed into COUP for an initial three-month period. During this time RAEs will help coordinate COUP Members’ care coordination with an appropriate PCMP.

Program Contact

For assistance with the Client Overutilization Program, please contact your Regional Accountable Entity (RAE).

For after-hours care, your Health First Colorado benefits include access to the free 24/7 Nurse Advice Line. To speak with a nurse please call 800-283-3221.