Client Overutilization Program

Client-Overutilization Program

The Client-Overutilization Program (COUP) is a statewide surveillance and utilization control 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 greater than expected 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 four or more high risk prescriptions; or
  • Four or more visits to the ED; or
  • Combination of both, four or more high risk prescriptions and four or more visits to the ED; or
  • A referral indicating possible overutilization

How does it work?

The Department monitors all Health First Colorado Members utilization of services. Members usage is reviewed by Department staff and the Department’s UM 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 afterhours 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.