Known Issues & Updates

Durable Medical Equipment (DME) Claim Denials for EOB 1064 and 1065

Claims for procedure codes E0951, E0952, E0961, E0971, E1161, E2211, E2213, E2214, E2361, E2359, E2365, E2363 and K0040 are incorrectly denying for EOB 1064 - “The maximum number of units allowed for this procedure code is two units per state fiscal year.”
 
Claims for procedure codes E0978 and E0960 are incorrectly denying for EOB 1065 – “The maximum number of units allowed for this procedure code is one unit per state fiscal year (July - June).”
 
The Department and DXC are working to resolve the issue.  As a workaround until the issue is resolved, providers can submit PARs above the unit limits to get approval for the limit and resubmit affected claims.

 

Resolved 11/8/19: Durable Medical Equipment (DME)/Supply Claim Denials for Procedure Code K0553 With Modifier KF for Explanation of Benefits (EOB) 4211 – “Modifier Is Invalid for Procedure Code”

DME/supply claims for procedure code K0553 with modifier KF were denying for EOB 4211 – “Modifier is invalid for procedure code.”

While this was previously reported to be resolved on 10/12/19, this issue was later determined as unresolved for provider type 09 (Pharmacy with DME). The issue was later resolved for provider type 09 on 11/8/19.

Some claims were reprocessed by DXC on 10/18/19. The remaining affected claims were reprocessed by DXC on 11/15/19.

Issue resolved 11/8/19

 

Resolved 11/1/19: Durable Medical Equipment (DME)/Supply Claims Recoupment Percentage

Accounts receivable balances on Remittance Advices dated 10/28/19 – 11/4/19 for some DME/supply providers were recouped at the maximum recoupment of 100%. This included the claims affected by the Upper Payment Limits as well as all other adjustments. Per provider request, these DME claims were requested to be recouped at 10%. The recoupment percentage is now set to 10%.

Issue resolved 11/1/19

 

Resolved 7/24/19: Claims Suspending for Across-the-Board Rate Increase for EOB 2861 - "No Rate on File for the Date(s) of Service”
Fiscal Year 2019-2020 Provider Rate Increases and Adjustments

Health First Colorado (Colorado’s Medicaid Program) provider rate increases were approved during the 2019-2020 legislative session and are effective for dates of service beginning July 1, 2019. The fee schedules located on the Provider Rates & Fee Schedule web page have been updated to reflect the approved 1.0% across-the-board (ATB) rate increase and targeted rate increases and decreases. The updated rates were implemented in the Colorado interChange on 7/24/19.

Claims were previously suspending for EOB 2861 - "No rate on file for the date(s) of service" while rates were being updated in the Colorado interChange. Affected claims were reprocessed by DXC on 7/26/19. However, additional reprocessing is required for claims billed for Durable Medical Equipment procedure code A4253 rate decreases which were not applied to the initial rounds of reprocessing.

While it was initially reported that additional reprocessing would be completed in several stages, DXC completed all additional reprocessing on 10/25/19.

Issue resolved 7/24/19

 

Resolved 10/3/19: Durable Medical Equipment Claims (DME) for Code A4459 Denying

Claims for supply/DME providers billed with procedure code A4459 for Peristeen were denying. Additional denial details will be provided as they are available.

Claims with dates of service on or after 9/1/19 were reprocessed by DXC on 10/11/19.

Issue resolved 10/3/19

 

Resolved 10/2/19: Medicare Crossover Claims Not Paying Correctly

Some Medicare crossover claims were not paying correctly when Medicare denied the charges, or the benefits were exhausted.

Claims were reprocessed by DXC on 10/25/19.

Issue resolved 10/2/19

 

Resolved 9/25/19: Durable Medical Equipment (DME) Claims for Enteral Feeding Formulas Denying for EOB 1691 – “This service is not payable for the same date of service as another service included on the same claim, according to the National Correct Coding Initiative”

DME enteral feeding formula claims were denying when greater or lesser of procedures were billed on the same claim and date of service per National Correct Coding Initiative (NCCI) guidelines for EOB 1691 - "This service is not payable for the same date of service as another service included on the same claim, according to the National Correct Coding Initiative."

Centers for Medicare & Medicaid Services (CMS) recently approved the Department’s request to remove the restrictions for these codes for claims with dates of service on or after 1/1/19. Claims were reprocessed by DXC on 10/11/19.

Issue resolved 9/25/19

 

Resolved 8/27/19: Durable Medical Equipment (DME) Claims Rejecting for Invalid Health Maintenance Organization (HMO)
Some DME claims were unable to be submitted and were being rejected with code 41 “Submit to other processor or primary payer HMO coverage exists.” Pharmacies were advised to contact their third-party switch vendors. Colorado Community Health Alliance is a primary care provider not a third-party liability insurance. Providers were advised to continue to provide emergency 72-hour refills of emergent medications for Health First Colorado members. Third-party switch vendors that provide the eligibility results were advised to contact DXC at 1-844-235-2387, option 2, then option 3, for “EDI” (Electronic Data Interchange) for assistance with the eligibility response.

72 hour emergency supplies for medications covered under the pharmacy benefit may be available. The pharmacy may call Magellan (1-800-424-5725) to request this override. This is not available for DME supplies, which are processed through DXC.

Issue resolved 8/27/19

 

Resolved 7/27/19: Claims for Services Requiring a Prior Authorization (PA) Denying for Explanation of Benefits (EOB) 0192, 0504, 5110
Some claims for services that require a PA were denying for one of the following EOB codes because the PA on file had units decremented incorrectly:

• EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
• EOB 0504 – “There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier.”
• EOB 5110 – “The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed."

To verify the correct amount of units remaining on a PA, contact the Provider Services Call Center.
 
Claims were reprocessed by DXC on 7/27/19 and any units decremented incorrectly were replaced on the PA.

Issue resolved 7/27/19

 

Resolved 7/26/19: Rate Increase for Supply/Durable Medical Equipment (DME) Manually-Priced Items
The across-the-board rate increase has been approved for manually-priced claims with date of service 7/1/2019 for claims paid by invoice (UB Modifier) or manufacturer’s suggested retail price (MSRP) (SC Modifier).

Supply/DME claims with UB or SC modifier and a date of service on or after 7/1/19 were reprocessed by DXC on 7/26/19.

 

Resolved 7/24/19: Claims Suspending for Across-the-Board Rate Increase for EOB 2861 - "No Rate on File for the Date(s) of Service”
Fiscal Year 2019-2020 Provider Rate Increases and Adjustments

Health First Colorado (Colorado’s Medicaid Program) provider rate increases were approved during the 2019-2020 legislative session and are effective for dates of service beginning July 1, 2019. The fee schedules located on the Provider Rates & Fee Schedule web page have been updated to reflect the approved 1.0% across-the-board (ATB) rate increase and targeted rate increases and decreases. The updated rates were implemented in the Colorado interChange on 7/24/19.

Claims were previously suspending for EOB 2861 - "No rate on file for the date(s) of service" while rates were being updated in the Colorado interChange. Affected claims were reprocessed by DXC on 7/26/19.

Issue resolved 7/24/19

 

Resolved 3/21/19: Durable Medical Equipment (DME) Claim Denials for E2374 for EOB 2341
Claims for procedure code E2374 were incorrectly denying for EOB 2341 - “Limit 1 every 3 State Fiscal Years” even when there is an approved prior authorization on file.

Claims were reprocessed by DXC 3/29/19.

Issue resolved 3/21/19

 

Resolved 3/8/19: Across the Board Rate Increase for Manually Priced Codes for Dates of Service Beginning 7/1/18
Paid Durable Medical Equipment (DME) claims with UB or SC modifiers with dates of service on or after 7/1/18 through 10/9/18 were adjusted by DXC due to a rate increase. Most of the claims were adjusted on 1/18/19, and the remainder were reprocessed on 1/25/19.

However, the claims reprocessed were not adjusted at the correct percentage, resulting in some claims being overpaid and some being underpaid. These claims were reprocessed by DXC at the correct percentage on 3/8/19.

It was later identified that some claims with dates of service prior to 7/1/18 were reprocessed on 3/8/19 with an additional increase. Additional reprocessing was required, and these claims were suspended until they were manually repriced and funds were recouped over the course of several weeks. As of 4/19/19, all affected claims have been repriced and funds have been recouped.

Issue resolved 3/8/19

Resolved 2/27/19: Durable Medical Equipment (DME) Claim Denials for E0936 RR for Explanation of Benefits (EOB) 4211

Claims for E0936 billed with the RR modifier were incorrectly denying for EOB 4211 – “Modifier is invalid for procedure code.” The Department’s policy allows for E0936 to be billed with the RR modifier.
 
Providers are advised to resubmit affected claims.
 
Issue resolved 2/27/19.

 

Resolved 1/3/19: Durable Medical Equipment (DME) Procedure Code K0739 was denying for (Explanation of Benefits) EOB 1066
Procedure code K0739 was incorrectly denying for EOB 1066 – “The maximum number of units allowed for this procedure code is 5 units per calendar month.”
 
Providers are advised to resubmit affected claims.
 
Issue resolved 1/3/19.

 

Resolved 12/7/18: DME Provider Funds Recouped in Accordance with House Bill (HB) 18-1329

In accordance with HB 18-1329, the Department must adjust claims that were paid between 1/1/18 and 4/27/18 at the old rates. On 9/7/18, DXC adjusted the claims, which resulted in recoupment of funds. This issue reoccurred on 9/28/18, resulting in a secondary claims adjustment and recoupment of funds.

The Department distributed supplemental payments to qualified providers on 12/7/18, following the 30-day period allowed for provider feedback on payment calculations (as described in this communication to DME providers: DME Provider Examination of Supplemental Payment Calculation in Accordance with HB 18-1329 9-13-2018). The supplemental payment appeared on Remittance Advice (RA) reports as of 12/10/18.

The Department has begun weekly recoupments at 10% of the total outstanding accounts receivable balance unless 100% recoupment was requested. The first of these recoupments occurred on 2/8/19 and will appear on RAs beginning 2/11/19.

Issue resolved 12/7/18

 

Resolved 8/22/18: Supply Provider Claim Denials for Certain Procedure Codes for EOB 1178 - “Service is Not Reimbursable for Date(s) of Service”
Supply provider (type 14) claims for codes E2500, E2502, E2508, E2510, K0005, K0011, K0800, K0801, K0802, K0806, K0807 and K0808 were denying for EOB 1178 - “Service is not reimbursable for Date(s) of Service.”
 
Claims were reprocessed on 8/24/18.
 
Issue resolved 8/22/18
 
Note: This issue is not to be confused with the issue resolved on 8/8/18 with a similar title. Please review the list of procedure codes under each Known Issue to determine which applies.

 

Resolved 8/8/18: Supply Provider Claim Denials for A9901 for EOB 1178 - "Service is Not Reimbursable for Date(s) of Service"
Supply provider (type 14) claims for code A9901 were denying for EOB 1178 - "Service is not reimbursable for Date(s) of Service."

It was previously announced in the May 2018 Provider Bulletin (B18004115) that code A9901 should no longer be used for Invoice Manual Pricing, effective for date of service (DOS) 7/1/18. As of DOS 7/1/18, this is a valid denial. However, A9901 should still be payable through DOS 6/30/18, in accordance with Health First Colorado (Colorado’s Medicaid Program) policy.

Claims were previously reported to be reprocessed by DXC on 9/14/18. While most claims were reprocessed on that date, it was later identified that crossover claims were not included. Crossover claims affected by this issue were reprocessed by DXC on 12/21/18.

Issue resolved 8/8/18

 

Resolved 8/8/18: Supply Provider Claim Denials for EOB 1178 - “Service is Not Reimbursable for Date(s) of Service”
Supply provider (type 14) claims for code A4210, A4211, A9276, A9277, A9278, A9280, E0274, E0637, E0973, E1002, E2311, E2313, E2331, E2377, K0861 and L8692 were previously denying for EOB 1178 - “Service is not reimbursable for Date(s) of Service.”
 
This issue was resolved for procedure code A9276 on 7/27/18. Claims were reprocessed for this procedure code on 9/14/18. 

This issue was resolved for procedure codes E0973, E1002, E2311, E2313, E2377 and K0861 on 8/1/18. Claims were reprocessed for these procedure codes only on 8/3/18.

This issue was resolved for procedure codes A4210, A4211, A9277, A9278, A9280, E0274, E0637, E2331 and L8692 on 8/8/18. Claims were reprocessed for these procedure codes only on 9/14/18.

Issue resolved on 8/8/18

 

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved
Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.
Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health. 

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 6/29/18: DME Claims with HCPCS codes S8120 and S8121 denying for EOB 1178

Claims for oxygen contents HCPCS S8120 and S8121 with TG modifier for members using ventilators or oxygen in nursing facilities were denying for EOB 1178 - "Service is not reimbursable for Date(s) of Service."

DXC and the Department have resolved the issue.

Claims were reprocessed by DXC 6/29/18.

Issue resolved 6/29/18

 

Resolved 5/25/18: DME Oxygen Rental Denials for Procedure Code E1390 with Place of Service Nursing Home
Claims for DME oxygen for procedure code E1390 billed with modifier TT were denying for EOB 4211 - "Modifier is invalid for procedure code." Modifier TT should not have been billed for this procedure code after 12/31/17.  Providers should have bill procedure code E1390 with modifier RR after 12/31/17; however, these claims were denying for EOB 2590 - "Bill Medicare first and complete the Medicare information fields on the claim." It is not necessary to bill Medicare for place of service 31 or 32 (Nursing home). If Place of service is 11 (home), then Medicare must be billed first.

Providers are advised to resubmit affected claims.

Issue resolved 5/25/18

 

Resolved 5/24/18: DME Claims Denied for EOB 1691 - This Service is not Payable for the Same Date of Service as Another Service
Procedures were being denied per NCCI guidelines when greater or lesser of procedures were billed on the same claim and date of service for EOB 1691 - "This service is not payable for the same date of service as another service included on the same claim, according to the National Correct Coding Initiative."

Claims were reprocessed on 5/25/18.

Issue resolved 5/24/18

 

Resolved 5/3/18: Claim Denials for DME Providers for EOB 1064
Claims for DME providers were denying incorrectly for EOB 1064  - "The maximum number of units allowed for this procedure code is two units per state fiscal year. You may resubmit the claim for up to the maximum allowed or submit a prior authorization request with justification of medical necessity."  for procedure codes E0961, E0971, E0974, E0995, E221-E226, E2381-E2392, E2394-E2396, K0019, K0040-K0047, K0052, K0070, A5500-A5501, E607, L3001-L3003, L3010, L3020, L3030-L3031, L3040 or L3050.

The two units per fiscal year limit  apply to each procedure code, not combinations of the codes. interChange was incorrectly limiting combinations of the codes listed above.

Claims were reprocessed 5/11/18 by DXC.

Issue resolved 5/3/18

 

Resolved 4/27/18: Over-Recoupment for Duplicate Durable Medical Equipment (DME/Supply) Provider Claims

Some DME/supply providers (provider type 14) experienced a payment issue after submitting a duplicate claim for supply services. While the Colorado interChange should have denied the duplicate claim, a system error occurred resulting in the claim being paid.

This issue was resolved on 3/14/18. When the claim was adjusted by DXC on 4/6/18 in order to recoup the amount paid for the duplicate claim, an error occurred where the amount recouped was equal to the amounts paid for both the duplicate and the original claim.

Claims were reprocessed by DXC on 4/27/18 in order to return payment for the original claim.

Issue resolved 4/27/18

 

Resolved 2/14/18: Providers Unable to see Prior Authorization (PA) Modifiers on the Provider Web Portal

Modifiers on the detail lines of the PA records are now viewable on the Provider Web Portal. DME providers are no longer required to contact eQHealth Solutions, the ColoradoPAR vendor, for this PA information. When providers click the Line # of the detail line in question, Web Portal now displays up to four modifiers in the Modifiers field.

Issue resolved 2/14/18

 

Resolved 2/9/18: Claims Denials for A9900 for EOB 2022
Claims for A9900 were denying incorrectly for EOB 2022 – "A National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) that sets when the units of service are billed in excess of established standards for services that a client would receive on a single date of service for a given CPCS/CPT code."

The Department and DXC have resolved this issue. Claims were reprocessed by DXC 2/9/18.

Issue resolved 2/9/18

 

Resolved 1/26/18: Claims Not Paying for DME Providers at Correct Rate for Procedure Code E0445 with KR Modifier for EOBs 9918, 0192 or 2368
Procedure code E0445 with KR modifier was not paying at the correct rate and therefore exceeded the maximum allowable amount, which caused claim denials for one of the following EOBs:
• EOB 9918 – "Pricing Adjustment - Maximum allowable fee pricing applied" for paid details where pricing was cut back
• EOB 0192 – "Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim."
• EOB 2368 – "DME Rent to Own – Purchase Price Limit" for denied details
Prior Authorization Request (PAR) is not required.
Note:
Requires Questionnaire # 6
Purchase is required after a two (2) month rental period. Total reimbursement, including rental, shall not exceed the purchase price.  For members under 3 years of age only: Equipment may be rented by members for a period of up to 3 years or until age 3. However, for rental periods exceeding 2 months, purchase is required when the member reaches age 3.
Rental:
- RR 1 unit = 1 month
- KR 1 unit = 1 day – use only for overnight or 24-hour test period use.
 
Fee Schedule, effective 7/1/2017:
E0445-KR: $49.44
 
Claims were reprocessed on 2/2/18.
Issue resolved 1/26/18

 

Resolved 10/13/17: Claim Denials for DME and Physician Services for Sleep Studies with Place of Service 12
Claims were denying for sleep studies with place of service 12.

Claims were reprocessed by DXC on 10/18/17.

Issue resolved 10/13/17

 

Resolved 10/11/17: Medicare Crossover Claim Denials for DME Providers for Procedure Code E0443 for EOB 1178 – Service Not Reimbursable for DOS
Medicare crossover claims for DME providers were denying when billed for procedure code E0443. These claims are denying for EOB 1178 – "Service is not reimbursable for Date(s) of Service."

Claims were reprocessed by DXC on 11/1/17.

Issue resolved 10/11/17

 

Resolved 8/18/17: Pharmacies with DME Specialty Unable to Bill Ventilators

Pharmacy provider type with the DME specialty was unable to bill ventilator codes (E0465 and E0466). Claims were denying for EOB code 0182, the billing provider type and/or specialty is not allowable for the service billed.

Claims were reprocessed by DXC on 9/1/17.

Issue resolved 8/18/17

 

Resolved 8/11/17: Claim Denials for DME Providers for EOB 2368

Claims for DME providers were denying for EOB 2368 – "DME Rent to Own - Purchase Price limit" for the following procedure codes: B9000, B9002, B9004, B9006, E0193-E0194, E0202, E0445, E0462, E0500, E0603, E0619, E0691-E0694, E0720, E0730, E0762, E0770, E0779-E0780, E0935, E1841, E2402, K0462 and S9001.

This issue was affecting Professional and Professional Crossover claims.

Claims were reprocessed by DXC on 8/18/17.

Issue resolved 8/11/17

 

Resolved 8/3/17: Claim Suspended for EOB 2861 – No Rate on File for the Date(s) of Service
Claims with the following procedure codes were suspending for EOB 2861 – "No Rate on File for the Date(s) of Service."

This issue has been resolved and claims were recycled by DXC on 8/4/17.

Procedure codes have been listed by the affected provider communities below.

DME: E0486, E0635, E0639, E0676, K0462, L8699, S0395
Laboratories: 89259, 81205, 81281, 81287, 81355
Physician Services: 26418, 59898, 69631, 90662, 99100, 99135, 99140, 99288, 01996, G0452, J1050, J3490, J8499, Q2039, S0316, S0613, S4993, S9083, S9088, S9141 
Vision: S0590, V2702, V2790

Issue resolved 8/3/17

 

Resolved 5/18/17: HCBS and DME Claims Suspending for BHO-Level Edits - EOB 3026

Some HCBS and DME claims were incorrectly suspending for BHO level edits. Providers are advised to resubmit claims that were suspended for EOB 3026. 

Issue resolved 5/18/17

 

Resolved 4/20/17: EOB 1381 - No Billing Rule for Procedure for Prosthetics

Claims for prosthetics for podiatry services submitted with the following codes, prior to 4/20/17, were denying for EOB code 1381:

L1904, L1940, L1970, L2275, L2280, L2330, L2340, L2820, L3000, L3020, L3030, L3060, L3100, L3150, L3201, L3216, L3221, L3260, L3320, L3480, L4361, and L4396.

DXC reprocessed all affected claims on 5/10/17. Providers were previously advised that if they wished to resubmit for payment sooner they may do so.

Issue resolved 4/20/17

• Clinic-Practitioner
• Federally Qualified Health Center (FQHC)
• Rural Health Clinic
• Indian Health Services

Claims were reprocessed by DXC 5/17/19.

Issue resolved 5/9/19

 

Resolved 11/6/18: Federally Qualified Health Center (FQHC) Professional Claims Denied for EOB 1223 – “Billing Provider Type/Specialty Not Allowable for Billed Diagnosis”

FQHC provider Fee-for-Service (FFS) professional claims were denying for EOB 1223 – “Billing Provider Type/Specialty not allowable for billed diagnosis.”

Affected claims were reprocessed by DXC on 11/9/18.

Issue resolved 11/6/18

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

Resolved 1/18/18: Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030

Some claims for vaccine procedure codes were denying for Explanation of Benefits (EOB) 1552 -"This procedure is age restricted. Member's age does not fall within the approved range." and EOB 1030 - "The place of service code is invalid for procedure code." The Department and DXC reviewed and assigned the appropriate place of service and age ranges.

Claims were reprocessed by DXC on 3/2/18.

Issue resolved 1/18/18

 

Resolved 11/8/17: Crossover Claim Denials for Services Covered by Medicare but Not Health First Colorado (Colorado's Medicaid Program)

The system was denying crossover claims for services that are covered by Medicare but not Health First Colorado. The Colorado interChange should have reimbursed these claims based on the Medicare assigned coinsurance and deductible. Specifically, Crossover claims for FQHCs were denying when revenue code 0521 was billed to Medicare.

Providers were previously advised to continue to submit these claims, and resubmit them now that the issue is resolved.

Issue resolved 11/8/17

 

Resolved 7/5/17: Dollar Amount Required Where Not Applicable - Provider Types FQHC, RHC, IHS

Provider types FQHC, RHC and IHS were experiencing a Provider Web Portal issue where they were required to enter a dollar amount above $0.00, even when not applicable for the service provided. The portal did not allow for the service detail line to be itemized at $0.00. These claims were denied. Providers are advised to resubmit affected claims.

Issue resolved 7/5/17

 

Resolved 4/5/17: CMS 1500 Claims

There was system issue that affected the following provider types, when submitting CMS 1500 claims:

• PT 32 - Federally Qualified Health Center (FQHC)
• PT 61 - Indian Health Services (IHS) FQHC
• PT 45 - Rural Health Clinic (RHC)

A large portion of Procedure codes were not set to pay for the provider types above. The issue was resolved 4/5/17, and providers should resubmit any denied CMS 1500 claims.

Please refer to this email for more detail.

Resolved 6/1/17: Denied IP/OP Claims with Mental Health or Substance Use Diagnosis - EOB 2580

Inpatient/outpatient claims using a diagnosis from a mental health diagnosis group or substance use disorder group were incorrectly denying for EOB 2580 – "The services must be billed to the HMO/PHP listed on the eligibility inquiry."

These claims have been reprocessed.

Issue resolved 6/1/17

The Department and DXC are aware of the issue and are working to resolve it. No action is necessary for case managers or providers at this time.

 

How to Look Up a PAR on the Provider Web Portal

Providers can now view a member’s Prior Authorization Request (PAR) status in the Provider Web Portal. In order to look up a PAR on Web Portal, users should choose the "Care Management" option from the home page and click on "View Authorization Services." Next, users should enter the member identification number and approved PAR number into Web Portal to search for the PAR status. Providers should still be receiving PAR letters and/or PAR numbers from the case managers. Providers may also call the Provider Services Call Center (1-844-235-2387) to obtain a PAR number. PARs that are visible in the Web Portal are finalized PARs in the interChange. PARs that are in process in the Bridge cannot be viewed through the Web Portal. For more information on viewing PARs on the Web Portal, refer to the Viewing Prior Authorizations in the Portal quick guide.

 

PAR Revisions for PETIs Due to ACF Daily Rate Increase

The ACF daily rate for EBD clients increased by $0.72 for dates of service on or after October 1, 2017, from $51.20 to $51.92. However, the increased rates may not have been paid because case managers did not have the opportunity to revise PETIs and PARs before October billing began. Please be aware this rate increase does not apply to CMHS clients.

You have the option to correct this and receive the additional $0.72 per day per client by following the steps below. Note that claims for all impacted dates of service must be voided by providers in order for PAR revisions to be performed. The steps outlined in this letter, if followed, will minimize the financial impact to your agency and to the case manager.

A copy of this message has been provided to all Single Entry Point Case Management Agencies to assure maximum cooperation across all impacted parties.

 

Claim Denials for PAR When an Approved PAR is On File - EOB 0192 or 5110

To understand why your claims are denying for a Prior Authorization Request (PAR) despite having an approved PAR on file, it is important to know how the Bridge system works with the Colorado interChange. The Bridge is a system used by case managers to submit Prior Authorization Requests (PARs) to the Colorado interChange. Only after a PAR is approved in the Bridge is it transmitted to the Colorado interChange. It will take at least one day after the PAR is approved in the Bridge to appear in the Colorado interChange and be available for claims processing. Once the PAR is on file in the Colorado interChange, there is no further interaction between the Bridge and the claim.

When a claim requires a PAR, the Colorado interChange will use a series of criteria to find the matching authorization. Providers do not need to indicate the PAR number on the claim. The system will automatically populate the PAR number on the claim if it finds a match. If a claim denies for a PAR despite an approved PAR being on file, it means the PAR on file does not match all the criteria that is on the claim.

If your claims have denied for either of the following EOBs despite having an approved PAR on file:

• E0B 0192 - "Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim."
• EOB 5110 - "The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed.

One of the following issues may apply:

1. The prior authorization was never fully approved in the Bridge. Check the Provider Web Portal for prior authorization. If there is no approved PAR for the dates of service on the claim, contact the case manager to confirm status in the Bridge.
    
2. The benefit plan for the member's eligibility has terminated. Please verify member eligibility for the waiver benefit plan prior to submitting claims. If the member does not show an active waiver benefit plan, contact the case manager. A PAR is not a guarantee of member eligibility as the PAR is valid for a span of time (typically one year) and eligibility could change at some point during that span.
    
3. The PAR units are exhausted. If all units have been billed, the claim will deny. If you believe you need additional units, contact your case manager.
    
4. The modifiers do not match. Check the billing manuals to make sure you are using the correct modifiers. The Web Portal has been updated to display up to four modifiers on the detail line within the PA record.

 

Home and Community Based Services (HCBS) Post Eligibility Treatment of Income (PETI) Gross Income Modification

Currently, the gross income information in interChange and the Bridge does not always match the information contained in the Colorado Benefits Management System (CBMS). The Department and DXC are working to display all income information from CBMS on interChange with manual edit capability and to calculate the PETI Rate based on the actual income as reported by CBMS.

An estimated resolution date has yet to be determined.

---

Resolved 10/18/19: Explanation of Benefits (EOB) 3054 – “EVV Record Required and Not Found”

EOB 3054 – “EVV Record Required and Not Found” may have appeared on claims on the Remittance Advice (RA) or the Provider Web Portal. This EOB is informational and was not causing claims to deny.

If the procedure codes billed on the claim are not included on the Colorado Electronic Visit Verification (EVV) Types of Service – Service Code Inclusions list, available on the Electronic Visit  Verification Resources web page under the Provider Resources section, this message is not applicable and the provider type is not required to participate in the EVV program.

If the procedure codes billed on the claim are included on the Colorado Electronic Visit Verification (EVV) Types of Service – Service Code Inclusions list, this is a valid message and providers should refer to the Electronic Visit Verification web page for further details about the program. Providers will be contacted with further instructions in the coming weeks.

Contact Sandata at CO-HCPF-EVVProviderHelpdesk@etraconline.net or (855) 871-8780 with any questions.

Issue resolved 10/18/19

 

Resolved 10/25/19: Claims Recouped for Home & Community-Based (HCBS) Services

Claims for HCBS providers that were previously paid for dates of service between 9/1/18 and 9/21/18 were reversed on 9/23/19. This only impacted members with Denver Health managed care. Denver Health does not pay for waiver benefits and these claims should be billed directly to DXC.

Claims were reprocessed by DXC on 10/25/19 to restore the original payment to the provider. Claims may deny for other reasons.

Issue resolved 10/25/19

 

Resolved 8/29/19: Home & Community Based Services (HCBS) Claims Billed for Procedure Codes S5150 and S5151 Denying for EOB 2021 - National Correct Coding Initiative (NCCI) Procedure to Procedure Edit
HCBS claims billed for procedure codes S5150 and S5151 with the same date of service were denying for EOB 2021 – “A National Correct Coding Initiative (NCCI) procedure to procedure edit that is comprised of three scenarios: Comprehensive/Component (Column I/Column II) edits, Mutually Exclusive edits, and Action on History. These three scenarios are edits that compare procedure code pairs to identify coding logic conflicts.”

The Department received approval from Centers for Medicare & Medicaid Services (CMS) to remove the restrictions on these procedure codes. Claims were reprocessed by DXC on 9/6/19.

Issue resolved 8/29/19

 

Resolved 6/12/19: Home & Community Based Services (HCBS) Claims Decrementing the Incorrect Line of the Prior Authorization (PA)
Some HCBS or Colorado Choice Transition (CCT) claims may not have decremented the correct line of the prior authorization. This occurred when there were two different lines on the Prior Authorization with the same procedure code, but different modifiers with overlapping spans. Claims may have denied for EOB 0192 - “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
 
Issue resolved 6/12/19

 

Resolved 5/17/19: Home & Community-Based Services (HCBS) Prior Authorization Requests (PARs) Decrementing Twice

HCBS PARs were decrementing twice when only billed once for the following procedure codes:

• T2025 with modifier U8
• T2025 with modifiers U8 and SE
• T2040

Issue resolved 5/17/19

 

Resolved 4/26/19: HCBS Claim Denials for Manually Priced Procedure Codes for EOB 0653 – “Claim Requires Manual Pricing. Please Attach Invoice for Medical Services” 
HCBS claims were suspending and then denying for the following procedure codes for EOB 0653 - “Claim requires manual pricing. Please attach invoice for medical services.” However, please note that HCBS providers were not required to submit an invoice. Once the correct rate source was identified, claims no longer denied for manual pricing.

• A0100 - Issue resolved on 7/12/18. Claims were previously reported to be reprocessed by DXC on 7/20/18, however additional affected claims were identified and these were reprocessed by DXC on 11/23/18.
• A9900 - Issue resolved on 9/4/18. Claims were previously reported to be reprocessed by DXC on 10/12/18, however additional affected claims were identified and these were reprocessed by DXC on 1/4/19.
• D2999 - Issue resolved on 9/13/18. Claims were reprocessed by DXC on 11/9/18.
• H0002 - Issue resolved on 8/31/18. No claims were found for reprocessing by DXC. 
• H2024 - Issue resolved on 9/13/18. Providers are advised to resubmit affected claims.
• S5151 - Issue resolved on 9/13/18. Claims were reprocessed by DXC on 12/7/18.
• S5160 - Issue resolved on 4/26/19. Claims were reprocessed by DXC on 5/31/19.
• S5161 - Issue resolved on 11/14/18. Claims were reprocessed by DXC on 11/23/18.
• S5165 - Issue resolved on 10/23/18. Claims were previously reported to be reprocessed by DXC on 11/2/18, however additional affected claims were identified and these were reprocessed by DXC on 1/4/19.
• S5185 - Issue resolved on 3/7/19. Claims were reprocessed by DXC on 3/15/19.
• T2029 with UA or U1 modifier - Issue resolved on 6/13/18. Claims were previously reported to be reprocessed by DXC on 8/10/18, however additional affected claims were identified and these were reprocessed by DXC on 11/30/18.
• T2029 without UA or U1 modifier - Issue resolved on 8/3/18. Claims were previously reported to be reprocessed by DXC on 8/10/18, however additional affected claims were identified and these were reprocessed by DXC on 11/30/18.
• T2038 - Issue resolved on 9/4/18. Claims were reprocessed by DXC on 1/4/19. 
• V2799 - Issue resolved on 2/11/19. Providers are advised to resubmit affected claims.

 

Resolved 4/18/19: Home & Community Based Services (HCBS) Colorado Choice Transitions (CCT) Claims for Procedure Codes A9900, H2014, H2015, S5170 and T2038 with Modifier UC Denying for Explanation of Benefits (EOB) 1512 or 4758
HCBS CCT claims for the procedure codes listed below were denying for EOB 1512 – “The Procedure Code/Modifier combination is not payable for the Date of Service” or EOB 4758 – “Billing Provider Type/Specialty Restriction on Procedure Coverage Rule.”

• A9900 with modifier UC
• H2014 with modifier UC
• H2015 with modifier UC
• S5170 with modifier UC
• T2038 with modifier UC

Claims were reprocessed by DXC on 4/26/19.

Issue resolved 4/18/19

 

Resolved 3/29/19: Home & Community Based Services (HCBS) Claims for Procedure Code S5130 Modifier U7 or U8 with Modifier 22 Paying at the Incorrect Rate
HCBS Supported Living Services Enhanced Homemaker waiver claims for procedure code S5130 with modifiers U7 and 22 or U8 and 22 were paying at the incorrect rate of $6.32. Per the current HCBS SLS Fee Schedule, available under the HCBS drop-down of the Provider Rates & Fee Schedule web page, effective 3/1/19, the correct rate is $6.73.

Claims were reprocessed by DXC on 3/29/19.

Issue resolved 3/29/19

 

Resolved 3/21/19: Home & Community Based Services (HCBS) Claims Billed for Procedure Code T2003 With Modifiers U8 and SC Paid Incorrectly
HCBS claims billed for procedure code T2003 with modifiers U8 and SC were paid incorrectly.

Claims were reprocessed by DXC on 3/29/19.

Issue resolved 3/21/19

 

Resolved 2/28/19: HCBS Waiver Claims for Procedure Code T1017 Denying for Explanation of Benefits (EOB) 3280  “The Members Age is Invalid for this Procedure Code"
HCBS Waiver Claims for procedure code T1017 were denying for EOB 3280 "The members age is invalid for this procedure code.  Verify the members birth date." The age range for procedure code T1017, targeted case management, was modified to include ages 0 – 18 for the CES (HCBS Children’s Extensive Support Waiver) Benefit Plan. The age range was previously 3 – 18.
 
Claims were reprocessed by DXC on 3/1/19.
 
Issue resolved 2/28/19

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

Resolved 8/25/18: Resubmitted Claims for Home and Community Based Services (HCBS) Providers for Timely Filing Denying for EOB 1786 - "Date of Service Date is Out of Timely Filing"
Claims that were outside 365 days, but referenced a valid previous Internal Control Number (ICN), were still being denied for EOB 1786 - "The date of service date is out of timely filing.” The Colorado interChange was previously not adjudicating the previous ICN information.
  
Claims were reprocessed by DXC on 12/7/18.  After reprocessing, many of these claims denied appropriately for duplicate claims or for a prior authorization (PA). Check previous Remittance Advices (RAs) for payment.
 
Issue resolved 8/25/18

 

Resolved 7/19/18: H2019 Claim Denials for EOB 1381  
Claims for H2019 with dates of service on or after July 1, 2018, were denying for EOB 1381 - "No billing rule for procedure." The issue has been resolved.

Claims were reprocessed by DXC on 7/27/18.

Issue resolved 7/19/18

 

Resolved 2/28/18: Claims Voided via the Provider Web Portal Denying for Atypical Providers for EOB 1960 – "No Provider Billing Indicator Found"
Providers who do not use an NPI (atypical providers) were not able to successfully void a claim using the Provider Web Portal.  While the portal may have displayed a message stating that the claim was successfully voided, the system was erroneously creating the claim without the billing provider ID, causing claim denials for EOB 1960 - "No Provider Billing Indicator Found. Please make sure the billing provider has been revalidated and that you are using the correct billing provider service location."

For questions, please contact Provider Services Call Center (1-844-235-2387).

Issue resolved 2/28/18

 

Resolved 2/14/18: Providers Unable to see Prior Authorization (PA) Modifiers on the Provider Web Portal

Modifiers on the detail lines of the PA records are now viewable on the Provider Web Portal. HCBS Providers may still require additional information from case managers regarding the amount, scope, and duration of services authorized by the service plan, and should verify all information contained in the service plan before billing. In order to access this functionality, providers must have the client ID and an approved Prior Authorization ID. When providers click the Line # of the detail line in question, Web Portal now displays up to four modifiers in the Modifiers field.

Issue resolved 2/14/18

 

Resolved 12/19/17: Claim Denials for Procedure Code S5161 for EOB 1544 – Procedure is Not Billable with Client's Benefit Plan

HCBS provider claims for procedure code S5161 were denying for Explanation of Benefits (EOB) Code 1544 – "Procedure is not billable with client’s benefit plan."

Claims were reprocessed by DXC on 12/29/17. As a reminder, please verify member eligibility as claims could still appropriately deny if the member is not eligible on the waiver plan.

Issue resolved 12/19/17

 

Resolved 11/22/17: Specialty Code Update – Community Transition Services (CCT)

Specialty codes for Brain Injury (BI), Elderly, Blind and Disabled (EBD),and Community Mental Health Services (CMHS) are unavailable as enrollment choices for CCT services. Currently they are only available to the BI population, but should also be applicable to the EBD, CMHS and Supported Living Services (SLS) populations. DXC and the Department are working to allow the following two specialties to be available:

• 738 – Independent Living Skills Training CCT – EBD - CMHS
• 739 – Independent Living Skills Training CCT – SLS

The H2014 procedure code will still require prior authorization. The UC modifier will still be used to indicate CCT-specific populations. Providers rendering CCT services to BI, EBD and CMHS members will need to add this specialty to their existing enrollment profile, but will not need to re-enroll. This change can be done via the Provider Web Portal in the modification tab. The Department and DXC are working to resolve the issue. Upon issue resolution, affected claims should be resubmitted.

Issue Resolved 11/22/17

 

Resolved 5/18/17: HCBS and DME Claims Suspending for BHO-Level Edits - EOB 3026

Some HCBS and DME claims were incorrectly suspending for BHO level edits. Providers are advised to resubmit claims that were suspended for EOB 3026.

Issue resolved 5/18/17

 

Resolved 4/5/17: HCBS Duplicate Claim Payments

Some HCBS claims were allowing duplicate payments.

Duplicate logic has been corrected. Department will wait until 5/1/17 to recoup duplicate payments from providers.

Issue resolved 4/5/17

Issue resolved 6/1/17

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved

Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.
Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health. 

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 1/8/18: Claims for Revenue Code 434 Paying at the Incorrect Rate
Home health provider claims for revenue code 434 were not paying the current rate. The Department and DXC have fixed this issue.

Claims with dates of service on or after 7/1/17 were reprocessed by DXC on 1/19/18, 1/26/18 and 2/16/18.
 
For a complete list of current rates, please refer to the Home Health Rate Schedule.

Issue resolved 1/8/18

Resolved 12/7/17: Claim Denials for Revenue Codes 270, 424, 434, 569, 583, 589 and 780 for EOB 2222 – Policy Not Currently Enforced
Home health provider claims for revenue codes 270, 424, 434, 569 and 589 and Telehealth revenue codes 583 and 780 were denying for EOB 2222 – "Policy not currently enforced."

Some claims with dates of service on or before 6/30/17 were reprocessed by DXC on 12/1/17, 12/8/17, 2/16/18 and 2/23/18. Claims with dates of service on or after 7/1/17 were not affected and should have processed properly.

Issue resolved 12/7/17

Resolved 2/7/18: Claim Adjustment Denials for EOB 1977 or 1988 - Unique Provider Service Location Could Not Be Found for Other 1 NPI
UB-04 claim adjustments were denying for the following EOBs, even when the Other Provider Number 1 field was filled out correctly:

• EOB 1977 – "Unique Provider Service Location could not be found for Other 1 NPI – Detail"

• EOB 1988 – "Unique Provider Service Location was not found for Other 2 NPI – Detail"

This issue was resolved on 2/8/18. Claims were reprocessed by DXC on 2/9/18.

However, new claims may deny correctly for these EOBs if the NPI is shared with more than one provider ID. The Department and DXC are currently researching the best work-around approach for providers to avoid these claim denials. The Department and DXC will communicate those instructions to providers as soon as possible.

Issue resolved 2/7/18 for claim adjustments only

 

Resolved 2/7/18: Claim Denials for EOB 2580 for Hospice Providers
Some hospice claims were incorrectly denying for Explanation of Benefits (EOB) 2580 - "The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry" when the member is enrolled with Denver Health. Hospice services are not covered under Denver Health and should be billed directly to Health First Colorado.

Claims were reprocessed 8/17/18 by DXC.

Issue resolved 2/7/18

 

Resolved 11/22/17: Modification to the Source of Nursing Facility Patient Liability Data

For nursing facility and hospice claims received on or after 3/1/2017, Patient Liability was calculated using data from the Colorado Benefits Management System (CBMS). It has been determined the claim data from Value Code 31 (Patient Liability Amount) is generally more accurate; therefore, the Colorado interChange system has been updated to calculate Patient Liability using the Value Code 31 data submitted on the claim.

Nursing facility claims have been reprocessed. Affected hospice claims were also reprocessed by DXC on 3/30/18; however, many claims that were reprocessed were unable to be paid due to enrollment changes with the nursing facility National Provider Identifier (NPI). Providers are advised to resubmit any outstanding claims that may result in a higher reimbursement due to a change in patient liability.

Issue resolved 11/22/17

 

Resolved 5/9/17: EOBs 1970 and 1977 (Other Provider NPI) for Hospital Claims

All inpatient and outpatient claims that posted this error have been reprocessed and will appear on the 5/15/17 RA. Hospice providers may continue to receive this denial.

Issue resolved 5/9/2017

Hospital Claims Denials for Part-B Only for EOB 0103 - "This is a Duplicate Item That was Previously Processed and Paid"
Claims may suspend for a possible conflict when billing for a member that has Part B only Medicare coverage. Either the claim with 11X or 12X may deny depending on when the claim was received. As a result, claims may deny for EOB 0103 - "This is a duplicate item that was previously processed and paid."

DXC and the Department are working to fix the issue.

 

Claim Denials for Newborn Services

Claims are denying when a male baby is receiving gender-specific services such as circumcision, and the claim is being submitted with the mother's Health First Colorado Provider ID. This is due to the mother's gender not matching the baby's. This is affecting claims where the gender-specific or age-specific service is identified by either procedure or diagnosis codes.

This could be causing claims to deny for any of the following EOBs:
Diagnosis/Gender related errors - 0801, 1100, 1105, 1106, 1107, 1108, 1109, 1120, 3241, 3242, 3243, 3244,  4192, 7310, 7316, 7322, 7328, 7334, 7340, 7346, 7352, 7358, 7364, 7370, 7376, 7382, 7388, 7394, 7400.
Procedure/Gender related errors - 3290, 1281

If the mother and baby are together in the hospital, providers should continue to submit claims under the mother’s Health First Colorado Provider ID; once either member is discharged the baby’s Provider ID should be used. Please note that at this time, the UK modifier cannot be used to identify that the claim is for the baby and not the mother.

DXC and the Department are reviewing this issue. An estimated resolution date has yet to be determined.

 

National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

• First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
• If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
• Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

---

Resolved 2/12/20: Provider Web Portal Eligibility Display and Short-Term Behavioral Health Service Limits

The eligibility responses on the Provider Web Portal were incorrectly calculating a fiscal year (July 1 to June 30) as a two-year span rather than a one-year span when calculating and displaying some short-term behavioral health visit benefit claims. This caused the “Used” units under the Limit Details panel to incorrectly show greater than the “Limit”.

Claims were not denying due to this eligibility response issue. If providers receive EOB 5807 - "The short-term behavioral health service limit has been met, please submit the service to the Member’s RAE." denials on the procedure codes below, those claims should be billed to the member’s Regional Accountable Entity (RAE) and not to DXC:

• 90791
• 90832
• 90834
• 90837
• 90846
• 90847

Providers are reminded to reference the Short-term Behavioral Health Services in the Primary Care Setting Fact Sheet regarding policy for the short-term behavioral health benefit. 

Issue resolved 2/12/20

 

Resolved 10/2/19: Outpatient Hospital Claims Billed with JW Modifier Overpaying
Outpatient hospital provider claims billed with the JW modifier for discarded drugs were overpaying. Per program policy, Health First Colorado (Colorado’s Medicaid Program) does not reimburse for any drug which is discarded or not administered to a Health First Colorado member other than for a Medicare Crossover claim.

Per provider request, reprocessing is being conducted over the course of several weeks. Claims previously reported to be reprocessed and funds recouped on 11/15/19 applied to claims paid in 2017 only. Claims paid in 2018 were reprocessed and funds were recouped on 11/22/19. Providers were notified by email before recoupment occurred. Claims paid in 2019 were reprocessed and funds were recouped on 11/29/19 and communication was sent to notify providers once complete.

Issue resolved 10/2/19

 

Resolved 10/2/19: Medicare Crossover Claims Not Paying Correctly

Some Medicare crossover claims were not paying correctly when Medicare denied the charges, or the benefits were exhausted.

Claims were reprocessed by DXC on 10/25/19.

Issue resolved 10/2/19

 

Resolved 9/21/19: Inpatient Hospital Claim Denials for Explanation of Benefits (EOB) 3053 – “Prior Authorization (PA) Is Required for Inpatient Services”
Inpatient hospital claims with maternity diagnosis were denying for EOB 3053 – “Prior Authorization (PA) is required for inpatient services.”

Issue resolved 9/21/19

 

Resolved 12/12/18: Provider Enrollment Portal Clinical Laboratory Improvement Amendments (CLIA) Panel Not Displaying for New Enrollments
When creating a new enrollment in the Provider Web Portal, the CLIA panel was not displaying for Community Clinics (CC) and Community Clinic and Emergency Centers (CCEC) provider type 86.

Until the issue was resolved, providers were advised to complete and save all other sections of the enrollment application. Now that the issue has been resolved, providers should return to the saved application and complete the CLIA panel and submit the enrollment application.

Issue resolved 12/12/18

 

Resolved 11/8/18: Inpatient Hospital Claims Paying Incorrectly for Non-Covered Days
Inpatient hospital provider claims where the covered days were less than the total days on the claim and outlier days were paid were paying non-covered days incorrectly due to a miscalculation of outlier days.

Claims were previously reported to have been reprocessed on 11/9/18, however reprocessing was completed by DXC on 11/30/18 and funds may have been recouped.

Issue resolved 11/8/18

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

Resolved 7/27/18: Inpatient Hospital Claims for Diagnosis Code Z302 Paid When Billed with ICD Surgical Procedure Codes
Inpatient hospital claims for diagnosis code Z302 were paid if they were billed with ICD surgical procedure codes when they should have been denied. This issue affected claims processed between 3/1/17 and 7/27/18.

Affected claims were reprocessed and payment was recouped on 8/3/18.

Issue resolved 7/27/18

 

Resolved 7/13/18: Outpatient Hospital Claims for Radiology and Imaging Services Billed Without TC Modifier Denying for EOB 1010 – "This Is a Duplicate Item that was Previously Processed and Paid"
Outpatient hospital claims billed without the previously required technical component (TC) modifier were denying for EOB 1010 – "This is a duplicate item that was previously processed and paid" if the separate professional component claim (modifier 26) was paid first.

It was previously announced in the June 2018 Provider Bulletin (B1800417) that the TC modifier will no longer be required on outpatient institutional claims (UB-04) for procedure codes that allow a technical and professional component split. The technical component, not the global service, will be assumed for these codes when billed on the UB-04 claim.

Affected claims were reprocessed by DXC on 7/13/18.

Issue resolved 7/13/18

 

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved
Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.
Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health. 

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 4/16/18: Incorrect Dollar Amount for Co-Pay Deduction on Outpatient Claims for General Hospital and Dialysis Providers
General Hospital providers submitting an outpatient claim with date of service on or after 1/1/18 were experiencing a system issue where an incorrect dollar amount ($40.00) was applied as a co-pay deduction when the co-pay deduction should have been $4.00.

Dialysis Center providers submitting an outpatient claim for revenue code 429 with date of service on or after 1/1/18 were also experiencing this system issue where an incorrect dollar amount ($40.00) was applied as a co-pay deduction when the co-pay deduction should have been $4.00.

Claims were reprocessed by DXC on 5/4/18.

Issue resolved 4/16/18

 

Resolved 3/23/18: Claim Denials for CPT Codes 92925 and 77085 for EOB 1030 with Place of Service (POS) 22
CPT 92925 was denying for EOB 1030 - "The place of service code is invalid for procedure code"  when billed with POS 22 (Outpatient Hospital); however, the issue was resolved on 2/28/18. Claims for 92925 were reprocessed on 3/13/18.

Claims for CPT 77085 billed with POS 22 were also denying for EOB 1030. The Department and DXC have resolved the issue.

Claims for 77085 were reprocessed 3/23/18 by DXC.

Issue resolved 3/23/18

 

Resolved 3/15/18: Inpatient Claims Reimbursing Incorrectly when "To" and "From" Dates of Service are the Same Day
Inpatient transfer claims were not reimbursing correctly when the "to" and "from" dates of service were the same day.

Claims were reprocessed by DXC on 4/13/18.

Issue resolved 3/15/18

 

Resolved 3/1/18: Inpatient Claims Denying for EOB 3891 – "The Assigned DRG is not on File"
When submitted via Provider Web Portal, some inpatient hospital claims were denying or suspending incorrectly for EOB 3891 – "The assigned DRG is not on File".

Claims were reprocessed by DXC on 8/24/18.

Issue resolved 3/1/18

 

Resolved 2/7/18: Claim Adjustment Denials for EOB 1977 or 1988 - Unique Provider Service Location Could Not Be Found for Other 1 NPI
UB-04 claim adjustments were denying for the following EOBs, even when the Other Provider Number 1 field was filled out correctly:

• EOB 1977 – "Unique Provider Service Location could not be found for Other 1 NPI – Detail"

• EOB 1988 – "Unique Provider Service Location was not found for Other 2 NPI – Detail"

This issue was resolved on 2/8/18. Claims were reprocessed by DXC on 2/9/18.

However, new claims may deny correctly for these EOBs if the NPI is shared with more than one provider ID. The Department and DXC are currently researching the best work-around approach for providers to avoid these claim denials. The Department and DXC will communicate those instructions to providers as soon as possible.

Issue resolved 2/7/18 for claim adjustments only

 

Resolved 1/26/18: Claim Denials for Hospital Providers Due to Admit Date

Claims for Hospital providers were denying when the admit date falls after the "from" date for any of the following EOBs: 1730, 1731, 1393, 1395, 1920, 1930 and 1702. Policy currently allows one day before the admit date to cover bundle/pre-admit services or one day after the "to" date/discharge date on Inpatient claims.

Claims were reprocessed by DXC on 2/16/18 and 2/23/18.

Issue resolved 1/26/18

 

Resolved 1/19/18: Inpatient Claims Denying for EOB 5340 when Billed with ICD 10 Codes Z381, Z384 and Z387
Inpatient claim billed with ICD 10 Codes Z381, Z384 and Z387 as the primary diagnosis were denying for EOB 5340 – "The principal diagnosis is invalid for DRG claims. Correct the principal diagnosis." DXC and the Department have resolved this issue so that these codes can be listed as a primary diagnosis.
 
DXC reprocessed claims on 2/16/18.
 
Issue resolved 1/19/18

 

Resolved 11/30/17: Claim Denials for Some CLIA Waived Codes

Claims for some CLIA waived codes were incorrectly denying for EOB 3660 – "The service is not within the scope of the billing provider's CLIA certification. Please update the MMIS provider records with the correct CLIA number."

DXC has made progress on this issue, and some affected claims were reprocessed by DXC 11/3/17. This issue was previously reported as resolved on 10/21/17; however, it was determined that further research was required for complete resolution of the issue. The Department and DXC completed work on the issue and DXC reprocessed the remaining affected claims on 11/30/17.

For more information on billing CLIA waived codes and the link to a complete list of codes on the CMS website, refer to the article titled "Clinical Laboratory Improvement Amendments (CLIA) System Issues Resolved" in the July 2017 Provider Bulletin.

Issue Resolved 11/30/17

 

Resolved 9/28/17: Claim Denials for Laboratory Codes with BHO-Covered Diagnoses - EOB 2580

Claims for laboratory codes 80047 - 89398 provided to members for the ICD-10 diagnoses listed below were incorrectly denying for Explanation of Benefits (EOB) 2580 – "The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry." These codes are not part of the BHO contract and need to be billed Fee-for-Service (FFS).

BHO MH Diagnoses Ranges		SUD Diagnoses Ranges
Start Value	End Value	Start Value	End Value
F20.0	F42.3	F10.10	F10.26
F42.8	F48.1	F10.28	F10.96
F48.9	F51.03	F10.98	F13.26
F51.09	F51.12	F13.28	F13.96
F51.19	F51.9	F13.98	F18.159
F60.0	F63.9	F18.18	F18.259
F68.10	F69	F18.28	F18.959
F90.0	F99	F18.980	F19.16
R45.1	R45.2	F19.18	F19.26
R45.5	R45.82	F19.28	F19.99

Claims were reprocessed by DXC on 10/27/17 and 2/9/18.

Issue Resolved 9/28/17

 

Resolved 9/28/17: Hospital Provider Claim Denials for E/M Procedure Codes for EOB 2580
The Department and DXC are aware that some claims for all E/M procedure codes were denying incorrectly for hospital providers for EOB 2580. The Colorado interChange was not using diagnosis to determine BHO coverage.

Claims were reprocessed by DXC on 10/27/17 and 2/9/18.

Issue resolved 9/28/17

 

Resolved 9/28/17: Claim Denials for EOB 2580 for Hospital Providers and Members with Kaiser Access Plan
The Department and DXC are aware that some claims were denying incorrectly for hospital providers for EOB 2580. The Colorado interChange was not using diagnosis to determine BHO coverage.

The Department and DXC are also aware that some claims were denying incorrectly for EOB 2580 for members with Kaiser Access plan. Kaiser does not reimburse for hospital claims and these should be billed directly to DXC.

Claims were reprocessed by DXC on 10/27/17 and 2/9/18.

Issue Resolved 9/28/17

 

Resolved 8/23/17: Non-EPSDT Denials for Clinics with CRNA or Podiatrist as Rendering Providers
Clinic claims for non-EPSDT services were incorrectly denying for EOB 0678 – "Billing Provider Type and Specialty is not allowable for the Rendering Provider" when a Certified Registered Nurse Anesthetist (CRNA) or a Podiatrist was listed as the rendering provider. Clinic providers are allowed to bill non-EPSDT services for these provider types.

Claims were reprocessed by DXC on 9/1/17.

Issue resolved 8/23/17

 

Resolved 8/18/17: Outpatient Hospital Denials for EOB 0393 - Revenue/Procedure Code Conflict
Outpatient claims for Hospital – General providers with Type of Bill 13x were denying for EOB 0393 - "The revenue code and procedure code are in conflict. Please verify whether a HCPC can be used with this revenue code and ensure the procedure code is appropriate for the revenue code used."

The majority of the affected claims were submitted prior to 8/18/17 and were reprocessed by DXC on 8/25/17. Some additional claims submitted on 8/18/17 were also affected by this issue and were reprocessed by DXC on 9/1/17.

Please note that claims may still deny appropriately for this EOB for reasons not related to this issue. Claims with dates of service before 10/31/16 were not affected by this issue.

Issue resolved 8/18/17

 

Resolved 8/2/17: Physician Services with Different Rendering Providers for Multiple Visits
Claims with procedure codes 99221-99233 were denying for EOB 0010 – "The number of hospital visits exceeds the guidelines for the procedure billed" when the same service for a member was performed by different rendering providers in an outpatient setting.  

Providers are advised to resubmit affected claims.

Issue resolved 8/2/17

 

Resolved 7/17/17: Updated EAPG Schedule Settings
The Colorado interChange system was not updated with the Colorado-specific Enhanced Ambulatory Patient Group (EAPG) schedule settings.  Claims processed since the transition to Colorado interChange were processed under the default EAPG settings which may have resulted in inaccurate payments. All claims submitted after 7/17/17 should pay correctly.

Claims were reprocessed by DXC in stages over the course of several months, with the final round of reprocessing completed on 6/6/18.

Issue resolved 7/17/17

 

Resolved 7/12/17: Professional and Outpatient Claim Denials for EOB 0101 – Duplicate Service
Professional and Outpatient claims were incorrectly denying for EOB 0101 – "This is a duplicate service."  However, this is a valid denial in the case of duplicate laboratory codes.

Claims were reprocessed by DXC on 7/21/17.

Issue resolved 7/12/17

 

Resolved 5/17/17: Hospital Back Up Claims for Nursing Facilities Suspended for EOB 1340
Hospital back up claims for nursing facilities were suspending for EOB 1340 – "Reimbursement rate is not on file for provider." The rate has now been loaded and all suspended claims have been reprocessed by DXC.

Issue resolved 5/17/17

 

Resolved 5/9/17: EOBs 1970 and 1977 (Other Provider NPI) for Hospital Claims
All inpatient and outpatient claims that posted this error have been reprocessed and will appear on the 5/15/17 RA. Hospice providers may continue to receive this denial.

Issue resolved 5/9/2017

 

Resolved 3/30/17: Outpatient Duplicate Claim Payments
Some outpatient claims were allowing duplicate payments. Duplicate logic has been corrected. Department will wait until 5/1/17 to recoup duplicate payments from providers.

Issue resolved 3/30/17

 

Resolved 3/19/17: Accommodation Units for Babies
Claims were suspending for Edit 3033 (Inpatient Units/Covered/Non-Covered Days Conflict). Providers billed the mom’s and baby’s accommodation units correctly and also submitted the Value Code 80 Covered Days accurately. However, the calculation for EOB 3033 was not excluding the baby’s accommodation units as it should.

Affected claims have been recycled by DXC. No further action required.

Issue resolved 3/19/17

 

Resolved 3/13/17: Out-of-State EAPG Rates
Incorrect EAPG rates were loading for out-of-state providers.

Issue resolved 3/13/17

 

Resolved 3/9/17: Inpatient Claims Not Paying Outlier Days
After the transition to the new Colorado interChange system outlier days were not calculated for payment. This issue was resolved on 3/9/17 however, inpatient claims that were originally processed between 3/1/17 and 3/9/17 may not have paid the outlier days.

Providers are advised to resubmit the affected claims. 

Issue resolved 3/9/17

Resolved 2/12/20: Provider Web Portal Eligibility Display and Short-Term Behavioral Health Service Limits

The eligibility responses on the Provider Web Portal were incorrectly calculating a fiscal year (July 1 to June 30) as a two-year span rather than a one-year span when calculating and displaying some short-term behavioral health visit benefit claims. This caused the “Used” units under the Limit Details panel to incorrectly show greater than the “Limit”.

Claims were not denying due to this eligibility response issue. If providers receive EOB 5807 - "The short-term behavioral health service limit has been met, please submit the service to the Member’s RAE." denials on the procedure codes below, those claims should be billed to the member’s Regional Accountable Entity (RAE) and not to DXC:

• 90791
• 90832
• 90834
• 90837
• 90846
• 90847

Providers are reminded to reference the Short-term Behavioral Health Services in the Primary Care Setting Fact Sheet regarding policy for the short-term behavioral health benefit. 

Issue resolved 2/12/20

 

Resolved 12/11/19: Payment Correction for Mental Health Hospitals When Admit Date is Prior To or Same As From Date of Service (FDOS)
Mental health hospitals were not being paid appropriately. Per program policy, mental health hospitals are allowed to bill and receive payment if the admit date was prior to or the same as the From Date of Service (FDOS) on the member’s claim and allow covered days to be the FDOS to To Date of Service (TDOS) on the claim.

Claims were reprocessed by DXC on 12/20/19.

Issue resolved 12/11/19

 

Resolved 10/2/19: Outpatient Hospital Claims Billed with JW Modifier Overpaying
Outpatient hospital provider claims billed with the JW modifier for discarded drugs were overpaying. Per program policy, Health First Colorado (Colorado’s Medicaid Program) does not reimburse for any drug which is discarded or not administered to a Health First Colorado member other than for a Medicare Crossover claim.

Per provider request, reprocessing is being conducted over the course of several weeks. Claims previously reported to be reprocessed and funds recouped on 11/15/19 applied to claims paid in 2017 only. Claims paid in 2018 were reprocessed and funds were recouped on 11/22/19. Providers were notified by email before recoupment occurred. Claims paid in 2019 were reprocessed and funds were recouped on 11/29/19 and communication was sent to notify providers once complete.

Issue resolved 10/2/19

 

Resolved 6/1/17: Denied IP/OP Claims with Mental Health or Substance Use Diagnosis - EOB 2580

Inpatient/outpatient claims using a diagnosis from a mental health diagnosis group or substance use disorder group were incorrectly denying for EOB 2580 – "The services must be billed to the HMO/PHP listed on the eligibility inquiry."

These claims have been reprocessed.

Issue resolved 6/1/17

Resolved 7/13/18: Claims Billed for the Professional Component for Radiology and Imaging Services Denying for EOB 1010 – "This Is a Duplicate Item that was Previously Processed and Paid"
Professional claims billed with modifier 26 may have denied for EOB 1010 – "This is a duplicate item that was previously processed and paid" if the separate hospital claim (modifier TC) was paid first.

It was previously announced in the June 2018 Provider Bulletin (B1800417) that the TC modifier will no longer be required on outpatient institutional claims (UB-04) for procedure codes that allow a technical and professional component split. The technical component, not the global service, will be assumed for these codes when billed on the UB-04 claim.

Affected claims were reprocessed by DXC on 7/13/18.

Issue resolved 7/13/18

 

Resolved 11/30/17: Claim Denials for Some CLIA Waived Codes

Claims for some CLIA waived codes were incorrectly denying for EOB 3660 – "The service is not within the scope of the billing provider's CLIA certification. Please update the MMIS provider records with the correct CLIA number."

DXC has made progress on this issue, and some affected claims were reprocessed by DXC 11/3/17. This issue was previously reported as resolved on 10/21/17; however, it was determined that further research was required for complete resolution of the issue. The Department and DXC completed work on the issue and DXC reprocessed the remaining affected claims on 11/30/17.

For more information on billing CLIA waived codes and the link to a complete list of codes on the CMS website, refer to the article titled "Clinical Laboratory Improvement Amendments (CLIA) System Issues Resolved" in the July 2017 Provider Bulletin.

Issue Resolved 11/30/17

 

Resolved 9/28/17: Claim Denials for Laboratory Codes with BHO-Covered Diagnoses - EOB 2580

Claims for laboratory codes 80047 - 89398 provided to members for the ICD-10 diagnoses listed below were incorrectly denying for Explanation of Benefits (EOB) 2580 – "The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry." These codes are not part of the BHO contract and need to be billed Fee-for-Service (FFS).

BHO MH Diagnoses Ranges		SUD Diagnoses Ranges
Start Value	End Value	Start Value	End Value
F20.0	F42.3	F10.10	F10.26
F42.8	F48.1	F10.28	F10.96
F48.9	F51.03	F10.98	F13.26
F51.09	F51.12	F13.28	F13.96
F51.19	F51.9	F13.98	F18.159
F60.0	F63.9	F18.18	F18.259
F68.10	F69	F18.28	F18.959
F90.0	F99	F18.980	F19.16
R45.1	R45.2	F19.18	F19.26
R45.5	R45.82	F19.28	F19.99

Claims were reprocessed by DXC on 10/27/17 and 2/9/18.

Issue Resolved 9/28/17

 

Resolved 8/3/17: Claim Suspended for EOB 2861 – No Rate on File for the Date(s) of Service
Claims with the following procedure codes were suspending for EOB 2861 – "No Rate on File for the Date(s) of Service."

This issue has been resolved and claims were recycled by DXC on 8/4/17.

Procedure codes have been listed by the affected provider communities below.

DME: E0486, E0635, E0639, E0676, K0462, L8699, S0395
Laboratories: 89259, 81205, 81281, 81287, 81355
Physician Services: 26418, 59898, 69631, 90662, 99100, 99135, 99140, 99288, 01996, G0452, J1050, J3490, J8499, Q2039, S0316, S0613, S4993, S9083, S9088, S9141 
Vision: S0590, V2702, V2790

Issue resolved 8/3/17

 

Resolved 3/30/17: Outpatient Duplicate Claim Payments

Some outpatient claims were allowing duplicate payments. Duplicate logic has been corrected. Department will wait until 5/1/17 to recoup duplicate payments from providers.

Issue resolved 3/30/17

National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

• First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
• If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
• Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

---

Resolved 12/5/19: Claims Paying at Zero Incorrectly for Federally Qualified Health Center (FQHC), Indian Health Services (IHS) and Rural Health Center (RHC) Providers

 

Some claims for services from FQHC, IHS and RHC providers were paying $0 when there was a reimbursable visit. Claims that included procedures subject to NCCI edits or included procedure codes that require National Drug Code (NDC) identifiers without providing the NDC caused the claim to pay $0. All providers are required to submit claims for services according to NCCI guidelines. For FQHC, IHS and RHC provider types, the inclusion of procedure codes that were not allowed to be billed together resulted in payment of $0 for a claim. 

 

Affected claims with a paid date on or after 1/1/18 were reprocessed by DXC on 12/27/19. 

 

Issue resolved 12/5/19

 

 

Resolved 5/9/19: Clinic Claim Denials for Explanation of Benefits (EOB) 1599
Some clinic claims were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed." when one of the following provider types was the billing provider on the claim:

• Clinic-Practitioner
• Federally Qualified Health Center (FQHC)
• Rural Health Clinic
• Indian Health Services

Claims were reprocessed by DXC 5/17/19.

Issue resolved 5/9/19

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

1/18/18: Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030

Some claims for vaccine procedure codes were denying for Explanation of Benefits (EOB) 1552 -"This procedure is age restricted. Member's age does not fall within the approved range." and EOB 1030 - "The place of service code is invalid for procedure code." The Department and DXC reviewed and assigned the appropriate place of service and age ranges.

Claims were reprocessed by DXC on 3/2/18.

Issue resolved 1/18/18

 

Resolved 7/5/17: Dollar Amount Required Where Not Applicable - Provider Types FQHC, RHC, IHS

Provider types FQHC, RHC and IHS were experiencing a Provider Web Portal issue where they were required to enter a dollar amount above $0.00, even when not applicable for the service provided. The portal did not allow for the service detail line to be itemized at $0.00. These claims were denied. Providers are advised to resubmit affected claims.

Issue resolved 7/5/17

 

Resolved 6/7/17: Suspended Claims Due to Manual Pricing for Hepatitis B Vaccine (90746)

Claims with procedure code 90746 were suspended for EOB 0653.

Claims were reprocessed by DXC on 6/15/17.

Issue resolved 6/7/17

Previously Paid Physical and Occupational Therapy Claims Adjustments Denying for EOB 2305 - "Occupational Therapy and Physical Therapy Services Limited to a Maximum of 48 Units"

DXC and the Department initiated a mass adjustment for claims for the Fiscal Year 2017-2018 rate updates. Claims were incorrectly denied for EOB 2305 – “Occupational therapy and physical therapy services limited to a maximum of 48 units.” In the Colorado interChange, if an adjustment denies, it retracts the original paid claim.

This issue has been resolved for adjusted claims billed prior to 8/3/18, and these adjustments were reprocessed by DXC on 8/3/18.

The Department and DXC are continuing to work on a long-term resolution for this issue to address adjusted claims billed on or after 8/3/18. While the initial issue affected only DXC-initiated adjustments, after 8/3/18, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.

---

Resolved 2/12/20: Provider Web Portal Eligibility Display and Short-Term Behavioral Health Service Limits

The eligibility responses on the Provider Web Portal were incorrectly calculating a fiscal year (July 1 to June 30) as a two-year span rather than a one-year span when calculating and displaying some short-term behavioral health visit benefit claims. This caused the “Used” units under the Limit Details panel to incorrectly show greater than the “Limit”.

Claims were not denying due to this eligibility response issue. If providers receive EOB 5807 - "The short-term behavioral health service limit has been met, please submit the service to the Member’s RAE." denials on the procedure codes below, those claims should be billed to the member’s Regional Accountable Entity (RAE) and not to DXC:

• 90791
• 90832
• 90834
• 90837
• 90846
• 90847

Providers are reminded to reference the Short-term Behavioral Health Services in the Primary Care Setting Fact Sheet regarding policy for the short-term behavioral health benefit. 

Issue resolved 2/12/20

 

Resolved 10/18/19: Explanation of Benefits (EOB) 3054 – “EVV Record Required and Not Found”

EOB 3054 – “EVV Record Required and Not Found” may have appeared on claims on the Remittance Advice (RA) or the Provider Web Portal. This EOB is informational and was not causing claims to deny.

If the procedure codes billed on the claim are not included on the Colorado Electronic Visit Verification (EVV) Types of Service – Service Code Inclusions list, available on the Electronic Visit  Verification Resources web page under the Provider Resources section, this message is not applicable and the provider type is not required to participate in the EVV program.

If the procedure codes billed on the claim are included on the Colorado Electronic Visit Verification (EVV) Types of Service – Service Code Inclusions list, this is a valid message and providers should refer to the Electronic Visit Verification web page for further details about the program. Providers will be contacted with further instructions in the coming weeks.

Contact Sandata at CO-HCPF-EVVProviderHelpdesk@etraconline.net or (855) 871-8780 with any questions.

Issue resolved 10/18/19

 

Resolved 7/27/19: Claims for Services Requiring a Prior Authorization (PA) Denying for Explanation of Benefits (EOB) 0192, 0504, 5110
Some claims for services that require a PA were denying for one of the following EOB codes because the PA on file had units decremented incorrectly:

• EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
• EOB 0504 – “There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier.”
• EOB 5110 – “The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed."

To verify the correct amount of units remaining on a PA, contact the Provider Services Call Center.
 
Claims were reprocessed by DXC on 7/27/19 and any units decremented incorrectly were replaced on the PA.

Issue resolved 7/27/19

 

Resolved 7/24/19: Claims Suspending for Across-the-Board Rate Increase for EOB 2861 - "No Rate on File for the Date(s) of Service”
Fiscal Year 2019-2020 Provider Rate Increases and Adjustments

Health First Colorado (Colorado’s Medicaid Program) provider rate increases were approved during the 2019-2020 legislative session and are effective for dates of service beginning July 1, 2019. The fee schedules located on the Provider Rates & Fee Schedule web page have been updated to reflect the approved 1.0% across-the-board (ATB) rate increase and targeted rate increases and decreases. The updated rates were implemented in the Colorado interChange on 7/24/19.

Claims were previously suspending for EOB 2861 - "No rate on file for the date(s) of service" while rates were being updated in the Colorado interChange. Affected claims were reprocessed by DXC on 7/26/19.

Issue resolved 7/24/19

 

​Resolved 3/7/19: Physical and Occupational Therapy (PT/OT) Claim Denials for Explanation of Benefits (EOB) 0182 - Billing Provider Type and/or Specialty Not Allowable Service Billed and EOB 1599 - Rendering Provider Type and/or Specialty Not Allowable for Service Billed
PT/OT claims with an appropriate rendering provider type 17 (Physical Therapist) or 28 (Occupational Therapist) and a billing provider type 25 (Non-Physician Practitioner – Group) were incorrectly denying for EOB 0182 – “Billing Provider Type and/or Specialty is not allowable for the service billed” and EOB 1599 – “Rendering Provider Type and/or Specialty is not allowable for the service billed.”

Claims were reprocessed by DXC on 3/8/19.

Issue resolved 3/7/19

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

Resolved 8/9/18: Claim Denials for 90791, 90832, 90834, 90837, 90846, 90847 and 90792 for EOB 0182

Claims for procedure codes 90791, 90832, 90834, 90837, 90846, 90847 and 90792 were denying for EOB 0182 - "Billing Provider Type and/or Specialty is not allowable for the service billed."

Claims were reprocessed 8/17/18 by DXC.

Issue resolved 8/9/18

 

Resolved 7/31/18: Claims for Circumcision Procedure Code Denying for EOB 3280 – "Client’s Age is Invalid for this Procedure Code"

Claim detail lines billed for CPT code 54161 were denying for EOB 3280 – "The client’s age is invalid for this procedure code. Verify the client’s birth date/procedure code." Per program policy, there is no age restriction for this circumcision procedure code. A Prior Authorization is required.

Claims were reprocessed by DXC on 8/3/18.

Issue resolved 7/31/18

 

Resolved 7/19/18: Physical and Occupational Therapy Claims Paying $0.00
Some physical and occupational therapy claims were paying $0.00.

Claims were reprocessed by DXC on 9/7/18, which resulted in payment or valid claim denials.

Issue resolved 7/19/18

 

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved

Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.

Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health.

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 3/23/18: Claim Denials for CPT Codes 92925 and 77085 for EOB 1030 with Place of Service (POS) 22

CPT 92925 was denying for EOB 1030 - "The place of service code is invalid for procedure code"  when billed with POS 22 (Outpatient Hospital); however, the issue was resolved on 2/28/18. Claims for 92925 were reprocessed on 3/13/18.

Claims for CPT 77085 billed with POS 22 were also denying for EOB 1030. The Department and DXC have resolved the issue.

Claims for 77085 were reprocessed 3/23/18 by DXC.

Issue resolved 3/23/18

 

Resolved 3/16/18: Overpayment for Anesthesia Claims

Anesthesia claims received on or after 3/1/17 were overpaying the full rate per minute instead of the converted unit. Each unit is 15 minutes. The Department and DXC have resolved the issue.

Claims were reprocessed by DXC on 4/20/18 and overpaid funds were recouped. Providers who are signed up for email communications were notified of the recoupment via email.

Issue resolved 3/16/18

 

Resolved 1/18/18: Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030

Some claims for vaccine procedure codes were denying for Explanation of Benefits (EOB) 1552 -"This procedure is age restricted. Member's age does not fall within the approved range." and EOB 1030 - "The place of service code is invalid for procedure code." The Department and DXC reviewed and assigned the appropriate place of service and age ranges.

Claims were reprocessed by DXC on 3/2/18.

Issue resolved 1/18/18

 

Resolved 1/12/18: Claims Denying for CPT 81025 for EOB 1030 with Place of Service (POS) Code 71 (State/Local Health Clinic)

CPT 81025 was denying for EOB 1030 - "The place of service code is invalid for procedure code" when billed with POS 71 (State/Local Health Clinic). This procedure code is separate from vaccine procedure codes denying for EOB 1030 (see separate Known Issue "Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030").

Claims were reprocessed by DXC on 1/19/18.

Issue resolved 1/12/18

 

Resolved 10/25/17: Delivery, Antepartum and Postpartum Care Claims Denied for EOB 1030 when the Place of Service (POS) is 12 (Home)

Claims for procedure codes 59400, 59409, 59410, 59610, 59612, 59614, 59425, 59426, and 59430, billed with Place of Service (POS) 12 – Home, were incorrectly denying for Explanation of Benefits (EOB) 1030 - "Place of Service restriction on proc billing rule." Home births may be performed by physicians and certified nurse-midwives carrying malpractice insurance that covers home births.

Affected claims were reprocessed by DXC 10/27/17.

Issue resolved 10/25/17

 

Resolved 7/17/17: Claims Denials for Provider Type 25 for EOB 0182

Claims for Provider Type 25 - Non-Physician Practitioner Group were denying for some services that should have been allowed for this provider type. These claims were denying for EOB 0182 – "Billing Provider Type and/or Specialty is not allowable for the service billed."

Claims were reprocessed by DXC on 7/26/17.

Issue resolved 7/17/17

Resolved 2/7/18: Claim Adjustment Denials for EOB 1977 or 1988 - Unique Provider Service Location Could Not Be Found for Other 1 NPI
UB-04 claim adjustments were denying for the following EOBs, even when the Other Provider Number 1 field was filled out correctly:

• EOB 1977 – "Unique Provider Service Location could not be found for Other 1 NPI – Detail"

• EOB 1988 – "Unique Provider Service Location was not found for Other 2 NPI – Detail"

This issue was resolved on 2/8/18. Claims were reprocessed by DXC on 2/9/18.

However, new claims may deny correctly for these EOBs if the NPI is shared with more than one provider ID. The Department and DXC are currently researching the best work-around approach for providers to avoid these claim denials. The Department and DXC will communicate those instructions to providers as soon as possible.

Issue resolved 2/7/18 for claim adjustments only

 

Resolved 1/26/18: Claims for Nursing Facility Providers Denying or Suspending for EOB 1930 - "The Covered/Non-Covered Days are Missing or Invalid"
Claims for nursing facility providers were denying or suspending for EOB 1930 - "The covered/non-covered days are missing or invalid. Enter/Correct the number of covered/non-covered days."
 
Claims were reprocessed by DXC on 1/26/18.
 
Issue resolved 1/26/18

 

Resolved 12/13/17: Incorrect Claim Payments for Nursing Facility Providers on Crossover Claims
Part A crossovers were paying the full coinsurance and deductible instead of using the "lower of" pricing logic. Part B crossovers were paying at zero when they should have paid the coinsurance and deductible.

Claims were reprocessed by DXC in three stages. The first stage of claims reprocessing occurred on 12/15/17. The second stage of claims reprocessing occurred on 12/22/17. The third and final stage of claims reprocessing occurred on 12/29/17. All affected claims have now been reprocessed.

Issue resolved 12/13/17

 

Resolved 11/22/17: Modification to the Source of Nursing Facility Patient Liability Data
For nursing facility claims received on or after 3/1/2017, Patient Liability was calculated using data from the Colorado Benefits Management System (CBMS). It has been determined the claim data from Value Code 31 (Patient Liability Amount) is generally more accurate; therefore, the Colorado interChange system has been updated to calculate Patient Liability using the Value Code 31 data submitted on the claim.

The first stage of claims reprocessing occurred on 12/8/17. The second stage of claims reprocessing occurred on 12/15/17.

Issue resolved 11/22/17

 

Resolved 11/1/17: Nursing Facility and ICF/IID Provider Claim Denials When Room and Board Billed on Same Dates as Therapy for EOB 0101 – Duplicate Service

Claims for nursing facility provider types 20 and 21 were denying for EOB 0101 – "This is a duplicate service" when room and board (inpatient – revenue code 100 series) were billed on the same dates as therapy (outpatient – revenue code 400 series).

Affected claims were reprocessed by DXC on 11/3/17.

Issue resolved 11/1/17

 

Resolved 5/17/17: PETI PARs 

Providers were experiencing an issue where they were unable to submit PETI PARs due to the member information not populating the page as expected.

A workaround was provided while DXC was working on the fix.

Issue resolved 5/17/17

 

Resolved 5/17/17: Member Not Found During Claims Submission

Some providers were receiving a "Member not found" error message when trying to submit a claim. A workaround was provided while DXC was working on the fix.

Issue resolved 5/17/17

 

Resolved 5/17/17: Hospital Back Up Claims for Nursing Facilities Suspended for EOB 1340

Hospital back up claims for nursing facilities were suspending for EOB 1340 – "Reimbursement rate is not on file for provider." The rate has now been loaded and all suspended claims have been reprocessed by DXC.
Issue resolved 5/17/17

 

Resolved 3/17/17: Nursing Facility Patient Liability Deduction

Nursing Home Patient Liability was incorrectly deducted. System was using patient liability from CBMS to auto deduct when a claim goes through. However, instead of deducting the liability amount once for the month, it deducted every time a claim was submitted.

Patient liability now deducting correctly. Claims where patient liability was incorrectly deducted were adjusted by DXC on 3/17/17.  

Issue resolved 3/17/17

Incorrect Quantity of Physical and Occupational Therapy Units Displayed in the Provider Web Portal

The quantity of physical and occupational therapy units displayed on the Provider Web Portal Coverage Details screen may not reflect the total amount of units the member has used.

The Department and DXC are working to resolve the issue. Providers are encouraged to obtain and submit a PAR to eQHealth Solutions, the Department’s prior authorization vendor, even if all the previous PAR units are not exhausted.  
 

 

Previously Paid Physical and Occupational Therapy Claims Adjustments Denying for EOB 2305 - "Occupational Therapy and Physical Therapy Services Limited to a Maximum of 48 Units"

DXC and the Department initiated a mass adjustment for claims for the Fiscal Year 2017-2018 rate updates. Claims were incorrectly denied for EOB 2305 – “Occupational therapy and physical therapy services limited to a maximum of 48 units.” In the Colorado interChange, if an adjustment denies, it retracts the original paid claim.

This issue has been resolved for adjusted claims billed prior to 8/3/18, and these adjustments were reprocessed by DXC on 8/3/18.

The Department and DXC are continuing to work on a long-term resolution for this issue to address adjusted claims billed on or after 8/3/18. While the initial issue affected only DXC-initiated adjustments, after 8/3/18, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.

---

Resolved 7/27/19: Claims for Services Requiring a Prior Authorization (PA) Denying for Explanation of Benefits (EOB) 0192, 0504, 5110
Some claims for services that require a PA were denying for one of the following EOB codes because the PA on file had units decremented incorrectly:

• EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
• EOB 0504 – “There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier.”
• EOB 5110 – “The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed."

To verify the correct amount of units remaining on a PA, contact the Provider Services Call Center.
 
Claims were reprocessed by DXC on 7/27/19 and any units decremented incorrectly were replaced on the PA.

Issue resolved 7/27/19

 

​Resolved 7/24/19: Claims Suspending for Across-the-Board Rate Increase for EOB 2861 - "No Rate on File for the Date(s) of Service”
Fiscal Year 2019-2020 Provider Rate Increases and Adjustments

Health First Colorado (Colorado’s Medicaid Program) provider rate increases were approved during the 2019-2020 legislative session and are effective for dates of service beginning July 1, 2019. The fee schedules located on the Provider Rates & Fee Schedule web page have been updated to reflect the approved 1.0% across-the-board (ATB) rate increase and targeted rate increases and decreases. The updated rates were implemented in the Colorado interChange on 7/24/19.

Claims were previously suspending for EOB 2861 - "No rate on file for the date(s) of service" while rates were being updated in the Colorado interChange. Affected claims were reprocessed by DXC on 7/26/19.

Issue resolved 7/24/19

 

Resolved 3/7/19: Physical and Occupational Therapy (PT/OT) Claim Denials for Explanation of Benefits (EOB) 0182 - Billing Provider Type and/or Specialty Not Allowable Service Billed and EOB 1599 - Rendering Provider Type and/or Specialty Not Allowable for Service Billed
PT/OT claims with an appropriate rendering provider type 17 (Physical Therapist) or 28 (Occupational Therapist) and a billing provider type 25 (Non-Physician Practitioner – Group) were incorrectly denying for EOB 0182 – “Billing Provider Type and/or Specialty is not allowable for the service billed” and EOB 1599 – “Rendering Provider Type and/or Specialty is not allowable for the service billed.”

Claims were reprocessed by DXC on 3/8/19.

Issue resolved 3/7/19

 

Resolved 10/17/18: Claims for Occupational Therapy Denying for EOB 1599 – “Rendering Provider Type and/or Specialty is Not Allowable for the Service Billed”​
Claims for procedure code 92526 were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed" when billed with either the following provider type combinations:

• Rendering provider type 28 (Occupational Therapist) billed with Billing provider type 48 (Rehabilitation Agency)
• Rendering provider type 28 (Occupational Therapist) billed with Billing provider type 25 (Non-Physician Practitioner- Group)

Claims were reprocessed on 10/26/18.

Issue resolved 10/17/18

 

Resolved 7/19/18: Physical and Occupational Therapy Claims Paying $0.00
Some physical and occupational therapy claims were paying $0.00.

Claims were reprocessed by DXC on 9/7/18, which resulted in payment or valid claim denials.

Issue resolved 7/19/18

 

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved
Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.
Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health. 

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 3/7/18: Habilitative Therapy Claims Denying for SZ Modifier and/or CPT 97532 and Suspending for Procedure Code G0515
Habilitative therapy claims for CPT 97532 for dates of service after 12/31/17 will deny for either or both of the following EOBs:
•    EOB 3261 - "The procedure code currently is not a benefit for date of service billed.  Refer to the CPT or the HCPCS listing for valid procedure codes."
•    EOB 3181 - "The procedure code is invalid for date of service. Correct the procedure code.  Refer to the CPT or the HCPCS listing for valid procedure codes."
This is due to CPT 97532 being replaced by procedure code G0515, effective 1/1/18. This code was part of the HCPCS 2018 annual update, and HCPCS 2018 procedure codes and the billing rules were loaded into the Colorado interChange system on 3/7/18. Therefore, claims billed for procedure code G0515 will no longer suspend for EOB 0000 - "This claim/service is pending for program review."

Habilitative therapy claims with the SZ modifier for dates of service after 12/31/17 will deny for any of the following EOBs, depending on the position the modifier is in:
•    EOB 3170 - "The first modifier code is invalid for date of service.  Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a listing of valid modifiers."
•    EOB 3171 - "The second modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a list of valid modifiers."
•    EOB 1127 - "The third modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a listing of valid modifiers."
•    EOB 1514 - "The fourth modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a list."

This is due to the SZ modifier being replaced by the 96 modifier, effective 1/1/18. Claims billed with the 96 modifier were denying for EOB 0504 – "There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier." These claims were reprocessed on 3/9/18.

The Department is working on a solution to address PARs that cross from 2017 to 2018 for the SZ modifier or CPT 97532. Providers are advised to call eQHealth Solutions for further direction on revising current authorizations to reflect the new codes for dates of service in 2018.

Issue resolved on 3/7/18

 

Resolved 2/14/18: Providers Unable to see Prior Authorization (PA) Modifiers on the Provider Web Portal

Modifiers on the detail lines of the PA records are now viewable on the Provider Web Portal. Physical and Occupational Therapy providers are no longer required to contact eQHealth Solutions, the ColoradoPAR vendor, for this PA information. When providers click the Line # of the detail line in question, Web Portal now displays up to four modifiers in the Modifiers field.

Issue resolved 2/14/18

 

Physical and Occupational Therapy Units Displayed in the Provider Web Portal 

The Provider Web Portal displays physical and occupational therapy (PT/OT) total dollars and service units "used" from claims processed in the Colorado interChange system only (claims processed on or after 3/1/17). Dollars and service units used in the legacy MMIS system are not calculated into the amount displayed on the web portal, however, they are still counted towards limits when claims are adjudicated. The amounts displayed on the portal may not reflect the total amount of units the member has used.

Resolved 7/24/19: Claims Suspending for Across-the-Board Rate Increase for EOB 2861 - "No Rate on File for the Date(s) of Service”

Fiscal Year 2019-2020 Provider Rate Increases and Adjustments

Health First Colorado (Colorado’s Medicaid Program) provider rate increases were approved during the 2019-2020 legislative session and are effective for dates of service beginning July 1, 2019. The fee schedules located on the Provider Rates & Fee Schedule web page have been updated to reflect the approved 1.0% across-the-board (ATB) rate increase and targeted rate increases and decreases. The updated rates were implemented in the Colorado interChange on 7/24/19.

Claims were previously suspending for EOB 2861 - "No rate on file for the date(s) of service" while rates were being updated in the Colorado interChange. Affected claims were reprocessed by DXC on 7/26/19.

Issue resolved 7/24/19

 

Resolved 7/20/19: Pediatric Behavioral Therapy Claims Billed for Procedure Codes 97153 or 97155 Denying for EOB 2022 - National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE)
Pediatric Behavioral Therapy claims billed for procedure codes 97153 or 97155 were denying for EOB 2022 – “A National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) that sets when the units of service are billed in excess of established standards for services that a member would receive on a single date of service for a given CPCS/CPT code.”

The Centers for Medicare & Medicaid Services (CMS) approved the Department's request to remove the restrictions on these procedure codes.

DXC reprocessed affected claims on 7/26/19.

Issue resolved 7/20/19

 

Resolved 2/27/19: Behavioral Therapy (Provider Type 84) Claims with Place of Service (POS) 12 Denying for EOB 0182 and/or EOB 1030

Behavioral therapy (provider type 84) claims billed with POS 12 were denying for one or both of the following EOBs:

• EOB 0182 – "Billing Provider Type and/or Specialty is not allowable for the service billed."
• EOB 1030 – "The place of service code is invalid for procedure code. Correct the place of service code. Refer to the Provider Manual or Help Screens for valid place of service codes."  

Claims were reprocessed by DXC on 3/1/19.

Issue resolved 2/27/19

 

Resolved 2/22/19: Pediatric Behavioral Therapy Claims Denying for Explanation of Benefits (EOB) 2029 - “The Services Must Be Billed to the Member’s RAE”
Pediatric Behavioral Therapy Claims were denying for EOB 2029 - “The services must be billed to the member’s RAE.” Regional Accountable Entities (RAEs) do not cover Pediatric Behavioral Therapy and claims should be billed directly to DXC.
 
Claims reprocessed by DXC on 3/1/19.
 
Issue resolved 2/22/19

 

Resolved 2/22/19: Pediatric Behavioral Therapy Claims Denying for Explanation of Benefits (EOB) 2030 – “The Services Must be Billed to Denver Health Medicaid Choice Plan”
Pediatric Behavioral Therapy claims were denying for EOB 2030 - "The services must be billed to Denver Health Medicaid Choice plan." Denver Health does not cover pediatric behavioral therapy claims.
 
Claims reprocessed by DXC on 3/1/19.
 
Issue resolved 2/22/19

 

Resolved 2/16/19: Authorization Status Not Matching Prior Authorization Request (PAR) Letter
As of 2/7/19, Authorization Details in eQSuite® did not match the PAR letter on the Provider Web Portal.

Until the solution was implemented on 2/16/19, new prior authorizations that were approved by eQHealth from 2/14/19 to 2/16/19 were not being posted to the Provider Web Portal. Now that the issue has been resolved, new prior authorizations approved within that timeframe are available on the Web Portal.

Issue resolved 2/16/19

 

Resolved 2/14/19: Co-Pay Deductions Applied to Pediatric Behavioral Therapy Claims for CPT Codes 97151, 97153, 97154, 97155 and 97158
Co-pay deductions were being applied to Pediatric Behavioral Therapy claims for CPT Codes 97151, 97153, 97154, 97155 and 97158. Per program policy, Pediatric Behavioral Therapy claims should not be subject to co-pays.

Claims were reprocessed by DXC on 2/22/19.

Issue resolved 2/14/19

 

Resolved 1/31/19: Pediatric Behavioral Therapy Claims (Provider Types 83 and 84) Suspended or Denied for Duplicate for Procedure Code H0046 with Modifier TJ
Pediatric Behavioral Therapy claims billed with both procedure codes H0046 (without modifier TJ) and H0046 (with modifier TJ) were incorrectly denying when both procedure codes were billed for the same day for EOB 0101 – "This is a duplicate service." This issue was previously resolved for provider types 24 and 25 and is now resolved for provider types 83 and 84.

Claims were reprocessed by DXC on 2/1/19.

Issue resolved 1/31/19

 

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved

Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.

Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health. 

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 6/6/18: Behavioral Therapy Provider Claim Denials for EOB 0678 – "Billing Provider Type and Specialty Not Allowable for Rendering Provider"
Claims were denying for Behavioral Therapist providers for EOB 0678 – "Billing Provider Type and Specialty is not allowable for the Rendering Provider" when:
o    the billing provider type on the claim was 25 with a rendering provider type of 84; OR
o    the billing provider type on the claim was 83 with a rendering provider type of 24
These provider type combinations should be allowable per program policy.

Claims were reprocessed on 6/15/18.

Issue resolved 6/6/18

 

Resolved 10/26/17: Pediatric Behavioral Therapy Claims Suspended or Denied for Duplicate, for Procedure Code H0046, Modifier TJ

Pediatric Behavioral Therapy claims billed with both procedure codes H0046 (without modifier TJ) and H0046 (with modifier TJ) were incorrectly denying when both procedure codes were billed for the same day for EOB 0101 – "This is a duplicate service."

Claims were reprocessed on 11/3.

Issue resolved 10/26/17

 

Resolved 10/18/17: Claims Denying for Behavioral Therapy Providers with EOB 2580 when the Member is Enrolled in a Managed Care Organization

Claims for procedure codes H0046 and T1024 for members who may be enrolled in a managed care organization were incorrectly denying for Explanation of Benefits (EOB) 2580 - "The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry." The new behavioral therapy codes were not excluded from managed care lists. Claims for members who are not enrolled in a managed care plan were not affected. 

Providers are advised to resubmit affected claims.

Issue Resolved 10/18/17

 

Resolved 9/18/17: Pediatric Behavioral Therapy Providers

Claims for Behavioral Therapy Procedure Codes T1024 and H0046 were suspending for Prior Authorization Request (PAR) Requirement. Until the PARs are converted from the old codes to the new codes, the PAR requirement has been temporarily lifted to allow claims to process. Providers are still responsible for obtaining authorization for new service plans with the new codes. Providers are also responsible to only provide services up to the allowed units on the old codes.

Resolved 9/18/17

Pharmacy Claim Denials for Procedure Code K0554 With Modifier NU for Explanation of Benefits (EOB) 4211 – “Modifier Is Invalid for Procedure Code” and EOB 0182 – "Billing Provider Type and/or Specialty Not Allowable for Service Billed”

Pharmacy claims for procedure code K0554 with modifier NU are denying for EOB 4211 – “Modifier is invalid for procedure code” and EOB 0182  – "Billing Provider Type and/or Specialty is not allowable for the service billed.”

DXC and the Department are working to resolve this issue.

Claims will be reprocessed by DXC.

 

National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

• First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
• If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
• Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

---

Resolved 8/18/17: Pharmacies with DME Specialty Unable to Bill Ventilators

Pharmacy provider type with the DME specialty was unable to bill ventilator codes (E0465 and E0466). Claims were denying for EOB code 0182, the billing provider type and/or specialty is not allowable for the service billed.

Claims were reprocessed by DXC on 9/1/17.

Issue resolved 8/18/17

 

Resolved 5/1/17: Incarceration Indicator on Member Eligibility 

Some members were incorrectly showing as "incarcerated" in the Colorado interChange system. This issue was fixed, but in some very limited cases, members may still be listed incorrectly as incarcerated in the system.

Pharmacists should call Magellan at 1-800-424-5725 to confirm whether the system is incorrectly showing someone as incarcerated.

Issue resolved 5/1/17

Incorrect Quantity of Physical and Occupational Therapy Units Displayed in the Provider Web Portal

The quantity of physical and occupational therapy units displayed on the Provider Web Portal Coverage Details screen may not reflect the total amount of units the member has used.

The Department and DXC are working to resolve the issue. Providers are encouraged to obtain and submit a PAR to eQHealth Solutions, the Department’s prior authorization vendor, even if all the previous PAR units are not exhausted. 

 

Previously Paid Physical and Occupational Therapy Claims Adjustments Denying for EOB 2305 - "Occupational Therapy and Physical Therapy Services Limited to a Maximum of 48 Units"

DXC and the Department initiated a mass adjustment for claims for the Fiscal Year 2017-2018 rate updates. Claims were incorrectly denied for EOB 2305 – “Occupational therapy and physical therapy services limited to a maximum of 48 units.” In the Colorado interChange, if an adjustment denies, it retracts the original paid claim.

This issue has been resolved for adjusted claims billed prior to 8/3/18, and these adjustments were reprocessed by DXC on 8/3/18.

The Department and DXC are continuing to work on a long-term resolution for this issue to address adjusted claims billed on or after 8/3/18. While the initial issue affected only DXC-initiated adjustments, after 8/3/18, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.

---

​Resolved 7/27/19: Claims for Services Requiring a Prior Authorization (PA) Denying for Explanation of Benefits (EOB) 0192, 0504, 5110
Some claims for services that require a PA were denying for one of the following EOB codes because the PA on file had units decremented incorrectly:

• EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
• EOB 0504 – “There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier.”
• EOB 5110 – “The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed."

To verify the correct amount of units remaining on a PA, contact the Provider Services Call Center.
 
Claims were reprocessed by DXC on 7/27/19 and any units decremented incorrectly were replaced on the PA.

Issue resolved 7/27/19

 

Resolved 3/7/19: Physical and Occupational Therapy (PT/OT) Claim Denials for Explanation of Benefits (EOB) 0182 - Billing Provider Type and/or Specialty Not Allowable Service Billed and EOB 1599 - Rendering Provider Type and/or Specialty Not Allowable for Service Billed
PT/OT claims with an appropriate rendering provider type 17 (Physical Therapist) or 28 (Occupational Therapist) and a billing provider type 25 (Non-Physician Practitioner – Group) were incorrectly denying for EOB 0182 – “Billing Provider Type and/or Specialty is not allowable for the service billed” and EOB 1599 – “Rendering Provider Type and/or Specialty is not allowable for the service billed.”

Claims were reprocessed by DXC on 3/8/19.

Issue resolved 3/7/19

 

Resolved 10/17/18: Claims for Occupational Therapy Denying for EOB 1599 – “Rendering Provider Type and/or Specialty is Not Allowable for the Service Billed”​
Claims for procedure code 92526 were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed" when billed with either the following provider type combinations:

• Rendering provider type 28 (Occupational Therapist) billed with Billing provider type 48 (Rehabilitation Agency)
• Rendering provider type 28 (Occupational Therapist) billed with Billing provider type 25 (Non-Physician Practitioner- Group)

Claims were reprocessed on 10/26/18.

Issue resolved 10/17/18

 

Resolved 7/19/18: Physical and Occupational Therapy Claims Paying $0.00
Some physical and occupational therapy claims were paying $0.00.

Claims were reprocessed by DXC on 9/7/18, which resulted in payment or valid claim denials.

Issue resolved 7/19/18

 

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved
Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.
Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health. 

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 4/1/18: Physical and Occupational Therapy Units Displayed in the Provider Web Portal 

The Provider Web Portal displays physical and occupational therapy (PT/OT) total dollars and service units "used" from claims processed in the Colorado interChange system only (claims processed on or after 3/1/17). Dollars and service units used in the legacy MMIS system are not calculated into the amount displayed on the web portal, however, they are still counted towards limits when claims are adjudicated. The amounts displayed on the portal may not reflect the total amount of units the member has used.

Issue resolved 4/1/18

 

Resolved 3/7/18: Habilitative Therapy Claims Denying for SZ Modifier and/or CPT 97532 and Suspending for Procedure Code G0515
Habilitative therapy claims for CPT 97532 for dates of service after 12/31/17 will deny for either or both of the following EOBs:
•    EOB 3261 - "The procedure code currently is not a benefit for date of service billed.  Refer to the CPT or the HCPCS listing for valid procedure codes."
•    EOB 3181 - "The procedure code is invalid for date of service. Correct the procedure code.  Refer to the CPT or the HCPCS listing for valid procedure codes."
This is due to CPT 97532 being replaced by procedure code G0515, effective 1/1/18. This code was part of the HCPCS 2018 annual update, and HCPCS 2018 procedure codes and the billing rules were loaded into the Colorado interChange system on 3/7/18. Therefore, claims billed for procedure code G0515 will no longer suspend for EOB 0000 - "This claim/service is pending for program review."

Habilitative therapy claims with the SZ modifier for dates of service after 12/31/17 will deny for any of the following EOBs, depending on the position the modifier is in:
•    EOB 3170 - "The first modifier code is invalid for date of service.  Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a listing of valid modifiers."
•    EOB 3171 - "The second modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a list of valid modifiers."
•    EOB 1127 - "The third modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a listing of valid modifiers."
•    EOB 1514 - "The fourth modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a list."

This is due to the SZ modifier being replaced by the 96 modifier, effective 1/1/18. Claims billed with the 96 modifier were denying for EOB 0504 – "There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier." These claims were reprocessed on 3/9/18.

The Department is working on a solution to address PARs that cross from 2017 to 2018 for the SZ modifier or CPT 97532. Providers are advised to call eQHealth Solutions for further direction on revising current authorizations to reflect the new codes for dates of service in 2018.

Issue resolved on 3/7/18

 

2/14/18: Providers Unable to see Prior Authorization (PA) Modifiers on the Provider Web Portal

Modifiers on the detail lines of the PA records are now viewable on the Provider Web Portal. Physical and Occupational Therapy providers are no longer required to contact eQHealth Solutions, the ColoradoPAR vendor, for this PA information. When providers click the Line # of the detail line in question, Web Portal now displays up to four modifiers in the Modifiers field.

Issue resolved 2/14/18

 

Resolved 7/27/17: Clinic Claim Denials for Procedure Code 97162 for Physical Therapy Evaluation

Claims for Clinic providers were incorrectly denying for procedure code 97162. These claims were denying for EOB 1381 - "No billing rule for procedure." 

Claims were reprocessed by DXC on 8/4/17.

Issue resolved 7/27/17

Resolved 2/12/20: Provider Web Portal Eligibility Display and Short-Term Behavioral Health Service Limits

The eligibility responses on the Provider Web Portal were incorrectly calculating a fiscal year (July 1 to June 30) as a two-year span rather than a one-year span when calculating and displaying some short-term behavioral health visit benefit claims. This caused the “Used” units under the Limit Details panel to incorrectly show greater than the “Limit”.

Claims were not denying due to this eligibility response issue. If providers receive EOB 5807 - "The short-term behavioral health service limit has been met, please submit the service to the Member’s RAE." denials on the procedure codes below, those claims should be billed to the member’s Regional Accountable Entity (RAE) and not to DXC:

• 90791
• 90832
• 90834
• 90837
• 90846
• 90847

Providers are reminded to reference the Short-term Behavioral Health Services in the Primary Care Setting Fact Sheet regarding policy for the short-term behavioral health benefit. 

Issue resolved 2/12/20

 

Resolved 12/24/19: Back and Reconstructive Emergency Surgery Claim Denials for Explanation of Benefits (EOB) 0192 – “Prior Authorization (PA) is Required for This Service” 

Back surgeries and some other reconstructive surgeries submitted with the emergency indicator were previously denying for EOB 0192 – “Prior Authorization (PA) is required for this service.” Reference the list of affected back and other surgical codes requiring a Prior Authorization Request (PAR) that may have been affected by this issue.

Affected claims were reprocessed by DXC on 12/20/19.  

Issue resolved 12/24/19

 

Resolved 10/18/19: Explanation of Benefits (EOB) 3054 – “EVV Record Required and Not Found”

EOB 3054 – “EVV Record Required and Not Found” may have appeared on claims on the Remittance Advice (RA) or the Provider Web Portal. This EOB is informational and was not causing claims to deny.

If the procedure codes billed on the claim are not included on the Colorado Electronic Visit Verification (EVV) Types of Service – Service Code Inclusions list, available on the Electronic Visit  Verification Resources web page under the Provider Resources section, this message is not applicable and the provider type is not required to participate in the EVV program.

If the procedure codes billed on the claim are included on the Colorado Electronic Visit Verification (EVV) Types of Service – Service Code Inclusions list, this is a valid message and providers should refer to the Electronic Visit Verification web page for further details about the program. Providers will be contacted with further instructions in the coming weeks.

Contact Sandata at CO-HCPF-EVVProviderHelpdesk@etraconline.net or (855) 871-8780 with any questions.

Issue resolved 10/18/19

 

Resolved 10/2/19: Medicare Crossover Claims Not Paying Correctly

Some Medicare crossover claims were not paying correctly when Medicare denied the charges, or the benefits were exhausted.

Claims were reprocessed by DXC on 10/25/19.

Issue resolved 10/2/19

 

Resolved 7/27/19: Claims for Services Requiring a Prior Authorization (PA) Denying for Explanation of Benefits (EOB) 0192, 0504, 5110
Some claims for services that require a PA were denying for one of the following EOB codes because the PA on file had units decremented incorrectly:

• EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
• EOB 0504 – “There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier.”
• EOB 5110 – “The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed."

To verify the correct amount of units remaining on a PA, contact the Provider Services Call Center.
 
Claims were reprocessed by DXC on 7/27/19 and any units decremented incorrectly were replaced on the PA.

Issue resolved 7/27/19

 

Resolved 7/24/19: Claims Suspending for Across-the-Board Rate Increase for EOB 2861 - "No Rate on File for the Date(s) of Service”
Fiscal Year 2019-2020 Provider Rate Increases and Adjustments

Health First Colorado (Colorado’s Medicaid Program) provider rate increases were approved during the 2019-2020 legislative session and are effective for dates of service beginning July 1, 2019. The fee schedules located on the Provider Rates & Fee Schedule web page have been updated to reflect the approved 1.0% across-the-board (ATB) rate increase and targeted rate increases and decreases. The updated rates were implemented in the Colorado interChange on 7/24/19.

Claims were previously suspending for EOB 2861 - "No rate on file for the date(s) of service" while rates were being updated in the Colorado interChange. Affected claims were reprocessed by DXC on 7/26/19.

Issue resolved 7/24/19

 

Resolved 7/24/19: Multi-Surgery Claims Suspended for Explanation of Benefits (EOB) 1460 – “There is No Additional Benefit for This Service”
Effective 2/20/19, global surgery covered days were not calculating correctly for multi-surgery claims. These claims were suspending for EOB 1460 – “There is no additional benefit for this service. Payment for this procedure was included in the payment for the surgery.”

Claims were initially reported to be reprocessed by DXC in two stages, with the first round of reprocessing occurring on 8/9/19 and the second round occurring on 9/13/19. However, a third round of reprocessing was later determined to be required, which occurred on 9/20/19.

Issue resolved 7/24/19

 

Resolved 5/9/19: Clinic Claim Denials for Explanation of Benefits (EOB) 1599
Some clinic claims were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed." when one of the following provider types was the billing provider on the claim:

• Clinic-Practitioner
• Federally Qualified Health Center (FQHC)
• Rural Health Clinic
• Indian Health Services

Claims were reprocessed by DXC 5/17/19.

Issue resolved 5/9/19

 

Resolved 2/22/19: Professional Claims for CPT Codes 70000 – 79999 with Modifier 76 or 77 Denying for EOB 0101 – “This Is a Duplicate Service”
Physician services/clinic providers and x-ray facility professional claims billed for CPT codes 70000 – 79999 with modifier 76 or modifier 77 were denying for EOB 0101 – “This is a duplicate service,” if the provider also submitted a separate claim for the same CPT code (regardless of the modifier).

A small sample of affected claims were reprocessed by DXC on 3/8/19. The remaining affected claims were reprocessed by DXC in several stages, with the final round of reprocessing on 5/31/19.

Issue resolved 2/22/19

 

Resolved 11/28/18: Diagnostic Radiology Claims for Procedure Code A9552 Denied for EOB 0653 - Claim Requires Manual Pricing
Claims for procedure code A9552 were denying for EOB 0653 – “Claim requires manual pricing. Please attach invoice for medical services.”
 
Claims were reprocessed by DXC on 11/30/18. After reprocessing, many of these claims denied appropriately for duplicate claims. Check previous Remittance Advices (RAs) for payment.
 
Issue resolved 11/28/18

 

Resolved 11/28/18: Clinic Claim Denials for EOB 0182 – “Billing Provider Type and/or Specialty Is Not Allowable for the Service Billed”
Clinic claims for the following procedure codes were denying for EOB 0182 – “Billing Provider Type and/or Specialty is not allowable for the service billed.”

• 23473, 23474 (Orthopedic Surgery)
• 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349 and 99350 (Evaluation and Management [E and M])
• 95250, 95251 (Medicine Endocrinology)

Claims were reprocessed by DXC 11/30/18.
 
Issue resolved 11/28/18

 

Resolved 11/28/18: Pathology Claims with Procedure Code 88112 Denying for EOB 4211
When billed with a TC modifier or no modifier, procedure code 88112 was denying for EOB 4211 - “Modifier is invalid for procedure code. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.” Per policy, procedure code 88112 can be billed with a TC or 26 modifier, or no modifier indicating the global procedure. The Department and DXC have resolved this issue.

Claims were reprocessed by DXC 11/30/18.

Issue resolved 11/28/18

 

Resolved 11/8/18: Claims Denied for Procedure Codes 90700 and 98925 – 98928 for EOB 1030 – “The Place of Service Code is Invalid for Procedure Code”
Professional claims billed with Place of Service (POS) 19, 22, 23, 24, 31 or 32 for procedure codes 90700, 98925, 98926, 98927 and 98928 were denied for EOB 1030 – “The place of service code is invalid for procedure code.”

Claims were reprocessed by DXC on 11/16/18.

Issue resolved 11/8/18

 

Resolved 11/6/18: Claim Suspends for HCPCS Codes for EOB 0000 – “The Claim/Service is Pending for Program Review"
The following HCPCS codes were not being processed for payment:

• Q9991 – issue resolved 11/1/18. Claims for this procedure code were reprocessed by DXC on 11/2/18.
• Q9992 – issue resolved 11/1/18. Claims for this procedure code were reprocessed by DXC on 11/2/18.
• Q9995 – issue resolved 11/1/18. Claims for this procedure code were reprocessed by DXC on 11/2/18.
• Q5103 – issue resolved 11/1/18. Claims for this procedure code were reprocessed by DXC on 11/2/18.
• Q5104 – issue resolved 11/1/18. Claims for this procedure code were reprocessed by DXC on 11/2/18.
• Q5105 – issue resolved 11/1/18. Claims for this procedure code were reprocessed by DXC on 11/2/18.
• Q5106 – issue resolved 11/1/18. Claims for this procedure code were reprocessed by DXC on 11/2/18.
• C9466 – issue resolved 11/6/18. Providers can now submit claims for this procedure code.

This issue caused claims to suspend for EOB 0000 – “The Claim/Service is Pending for Program Review."

Procedure codes Q9991, Q9992, Q9993, Q9994, Q9995, Q5105 and Q5106 are HCPCS updates effective July 1, 2018. Procedure codes Q5103, Q5104 and C9466 are HCPCS updates effective April 1, 2018.

Issue resolved on 11/6/18

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

Resolved 8/9/18: Claims Denials for 90791, 90832, 90834, 90837, 90846, 90847 and 90792 for EOB 0182

Claims for procedure codes 90791, 90832, 90834, 90837, 90846, 90847 and 90792 were denying for EOB 0182 - "Billing Provider Type and/or Specialty is not allowable for the service billed."

Claims were reprocessed 8/17/18 by DXC.

Issue resolved 8/9/18

 

Resolved 7/31/18: Claims for Circumcision Procedure Code Denying for EOB 3280 – "Client’s Age is Invalid for this Procedure Code"

Claim detail lines billed for CPT code 54161 were denying for EOB 3280 – "The client’s age is invalid for this procedure code. Verify the client’s birth date/procedure code." Per program policy, there is no age restriction for this circumcision procedure code. A Prior Authorization is required.

Claims were reprocessed by DXC on 8/3/18.

Issue resolved 7/31/18

 

Resolved 7/19/18: Physical and Occupational Therapy Claims Paying $0.00
Some physical and occupational therapy claims were paying $0.00.

Claims were reprocessed by DXC on 9/7/18, which resulted in payment or valid claim denials.

Issue resolved 7/19/18

 

Resolved 7/18/18: Claim Denials for Clinic Procedure Code 88341 for EOB 1381
Clinic claims for procedure code 88341 billed with modifier 26 and Place of Service (POS) 21 were denying for EOB 1381 – "No billing rule for procedure."
 
Claims were reprocessed 7/27/18 by DXC.

Issue resolved 7/18/18

 

Resolved 7/13/18: Claims Billed for the Professional Component for Radiology and Imaging Services Denying for EOB 1010 – "This Is a Duplicate Item that was Previously Processed and Paid"
Professional claims billed with modifier 26 may have denied for EOB 1010 – "This is a duplicate item that was previously processed and paid" if the separate hospital claim (modifier TC) was paid first.

It was previously announced in the June 2018 Provider Bulletin (B1800417) that the TC modifier will no longer be required on outpatient institutional claims (UB-04) for procedure codes that allow a technical and professional component split. The technical component, not the global service, will be assumed for these codes when billed on the UB-04 claim.

Affected claims were reprocessed by DXC on 7/13/18.

Issue resolved 7/13/18

 

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved
Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.
Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health. 

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 7/6/18: Claim Denials for Injections Procedure Codes Q9985, Q9986, Q9989, C9485 and C9489 for EOB 3180 – Procedure Code is Invalid
Claims for procedure codes C9485, C9489, Q9985, Q9986 and Q9989 were previously denied for EOB 3180 – "The procedure code is invalid. Correct the procedure code. Refer to the CPT or the HCPCS listing for valid procedure codes." Please see below for the resolution and reprocessing status of each procedure code affected by this issue:

• C9485 - Issue resolved on 12/22/17. Claims were reprocessed by DXC on 2/9/18.
• C9489 - Issue resolved on 12/22/17. Claims were reprocessed by DXC on 2/9/18.
• Q9986 - Issue resolved on 4/6/18. Claims were reprocessed by DXC on 4/27/18.
• Q9985 - Issue resolved on 7/6/18. Claims were reprocessed by DXC on 7/13/18.
• Q9989 - Issue resolved on 7/6/18. Claims were reprocessed by DXC on 7/13/18.

 

Resolved 5/31/18: Claim Denials for Procedure Code J2704 for EOB 1381
Claims with procedure code J2704 were denying for EOB 1381 – " No billing rule for procedure."

Claims were reprocessed 7/6/18 by DXC.

Issue was resolved 5/31/18

 

Resolved 5/24/18: Claim Denials for Laboratory Codes for EOB 2580
Some claims for procedure codes 80047-89398 were incorrectly denying for EOB 2580 – "The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry."
 
Claims were reprocessed by DXC 5/25/18.
 
Issue resolved 5/24/18

 

Resolved 4/27/18: Claim Denials for Speech Therapy Procedure Code 92508 for EOB 1030 or 1599
Claims where the billing provider was either type 16 (Clinic - Practitioner) or 48 (Rehabilitation Agency) and the rendering provider was type 27 (Speech Therapist - Individual) were incorrectly denying for speech therapy procedure code 92508 for EOB 1030 - "The place of service code is invalid for procedure code" or EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed."

Some claims were reprocessed by DXC on 5/4/18. The remainder of the affected claims were reprocessed by DXC on 5/11/18.

Issue resolved 4/27/18

 

Resolved 7/10/18: Clinic Claim Denials for Procedure Code 46220 for EOB 1381 - "No Billing Rule for Procedure"
Clinic claims with procedure code 46220 were denying for EOB 1381 – “No billing rule for procedure.”

Claims were reprocessed by DXC on 7/20/18.

Issue resolved 7/10/18

 

Resolved 4/25/18: Claim Denials for Speech Therapy Procedure Code 92507 for EOB 1030 or 1599
Claims where the billing provider is either type 16 (Clinic - Practitioner) or 48 (Rehabilitation Agency) and the rendering provider is type 27 (Speech Therapist - Individual) were incorrectly denying for speech therapy procedure code 92507 for EOB 1030 - "The place of service code is invalid for procedure code" or EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed."

Some claims were reprocessed by DXC on 5/4/18. The remainder of the affected claims were reprocessed by DXC on 5/11/18.

Issue resolved 4/25/18

 

Resolved 3/23/18: Claim Denials for Clinics/Physician Services for Procedure Code 78071 for EOB 1381 – "No Billing Rule for Procedure"

Professional claims billed for procedure code 78071 were denying for EOB 1381 – "No Billing Rule for Procedure."

Claims were reprocessed by DXC on 3/26/18.

Issue resolved 3/23/18

 

Resolved 3/23/18: Claim Denials for CPT Codes 92925 and 77085 for EOB 1030 with Place of Service (POS) 22
CPT 92925 was denying for EOB 1030 - "The place of service code is invalid for procedure code"  when billed with POS 22 (Outpatient Hospital); however, the issue was resolved on 2/28/18. Claims for 92925 were reprocessed on 3/13/18.

Claims for CPT 77085 billed with POS 22 were also denying for EOB 1030. The Department and DXC have resolved the issue.

Claims for 77085 were reprocessed 3/23/18 by DXC.

Issue resolved 3/23/18

 

Resolved 3/22/18: Claim Denials for Clinic/Practitioner Providers for Procedure Code 62304 for EOB 1381 or 1030

Claims billed for procedure code 62304 with place of service (POS) 11, 19, 20, 21, 22, 23, 24 or 81 were denying for EOB 1381 – "No billing rule for procedure" or EOB 1030 – "The place of service code is invalid for procedure code. Correct the place of service code. Refer to the Provider Manual or Help Screens for valid place of service codes."

Affected claims were reprocessed by DXC on 3/23/18. 

Issue resolved 3/22/18

 

Resolved 3/16/18: Claim Denials for Clinic/Practitioner Providers for Procedure Code 44970 for EOB 1030 – Place of Service Code Invalid for Procedure Code

Claims billed for procedure code 44970 with place of service (POS) 23 were denying for EOB 1030 – "The place of service code is invalid for procedure code. Correct the place of service code. Refer to the Provider Manual or Help Screens for valid place of service codes."

Affected claims were reprocessed by DXC on 3/23/18.

Issue resolved 3/16/18

 

Resolved 3/15/18: Incorrect Radiology and Imaging Rates Listed on Fee Schedule

The technical and professional fees for radiology and imaging codes billed with the TC and 26 modifiers were incorrect on the HCPCS Rate Updates Information and Resources fee schedule and in Colorado interChange.

Claims were reprocessed on 4/6/18 and 4/13/18 by DXC.

Issue resolved 3/15/18

 

Resolved 3/7/18: Habilitative Therapy Claims Denying for SZ Modifier and/or CPT 97532 and Suspending for Procedure Code G0515
Habilitative therapy claims for CPT 97532 for dates of service after 12/31/17 will deny for either or both of the following EOBs:
•    EOB 3261 - "The procedure code currently is not a benefit for date of service billed.  Refer to the CPT or the HCPCS listing for valid procedure codes."
•    EOB 3181 - "The procedure code is invalid for date of service. Correct the procedure code.  Refer to the CPT or the HCPCS listing for valid procedure codes."
This is due to CPT 97532 being replaced by procedure code G0515, effective 1/1/18. This code was part of the HCPCS 2018 annual update, and HCPCS 2018 procedure codes and the billing rules were loaded into the Colorado interChange system on 3/7/18. Therefore, claims billed for procedure code G0515 will no longer suspend for EOB 0000 - "This claim/service is pending for program review."

Habilitative therapy claims with the SZ modifier for dates of service after 12/31/17 will deny for any of the following EOBs, depending on the position the modifier is in:
•    EOB 3170 - "The first modifier code is invalid for date of service.  Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a listing of valid modifiers."
•    EOB 3171 - "The second modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a list of valid modifiers."
•    EOB 1127 - "The third modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a listing of valid modifiers."
•    EOB 1514 - "The fourth modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a list."

This is due to the SZ modifier being replaced by the 96 modifier, effective 1/1/18. Claims billed with the 96 modifier were denying for EOB 0504 – "There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier." These claims were reprocessed on 3/9/18.

The Department is working on a solution to address PARs that cross from 2017 to 2018 for the SZ modifier or CPT 97532. Providers are advised to call eQHealth Solutions for further direction on revising current authorizations to reflect the new codes for dates of service in 2018.

Issue resolved on 3/7/18

 

Resolved 2/23/18: Claims Denying for Vision Providers for Codes V2025, V2626 and 92015
Vision providers claims were denying for V2025, V2626 for EOB 1381 - "No billing rule for procedure"

92015 was denying for EOB 3280 - "The client’s age is invalid for this procedure code.  Verify the client’s birth date/procedure code."

Claims were reprocessed by DXC on 3/30/18.

Issue resolved 2/23/18

 

Resolved 1/19/18: Claims Denying for Procedure Code J2407 for EOB 1178 - "Service is not Reimbursable for Date(s) of Service"
Claims were denying for procedure code J2407 for EOB 1178 - "Service is not reimbursable for Date(s) of Service."
 
Claims were reprocessed on 1/26/18.
 
Issue resolved 1/19/18

 

Resolved 1/18/18: Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030

Some claims for vaccine procedure codes were denying for Explanation of Benefits (EOB) 1552 -"This procedure is age restricted. Member's age does not fall within the approved range." and EOB 1030 - "The place of service code is invalid for procedure code." The Department and DXC reviewed and assigned the appropriate place of service and age ranges.

Claims were reprocessed by DXC on 3/2/18.

Issue resolved 1/18/18

 

Resolved 1/12/18: Claims Denying for CPT 81025 for EOB 1030 with Place of Service (POS) Code 71 (State/Local Health Clinic)
CPT 81025 was denying for EOB 1030 - "The place of service code is invalid for procedure code" when billed with POS 71 (State/Local Health Clinic). This procedure code is separate from vaccine procedure codes denying for EOB 1030 (see separate Known Issue "Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030").

Claims were reprocessed by DXC on 1/19/18.

Issue resolved 1/12/18

 

Resolved 12/23/17: Claim Denials for Injection Procedure Codes Q2050 and Q5101 for EOB 0182
Claims were denying for clinic providers when billed for procedure codes Q2050 and Q5101 for EOB 0182 – "Billing Provider Type and/or Specialty is not allowable for the service billed."

Claims for procedure code Q2050 with dates of service (DOS) 1/1/17 – 1/10/18 were reprocessed by DXC in two stages, with the first occurring on 11/2/17, and the second occurring on 2/22/18.

Claims for procedure code Q5101 with DOS 10/1/16 – 12/22/17 were reprocessed by DXC in two stages, with the first occurring on 11/2/17, and the second occurring on 1/11/18.

Issue resolved for Q2050 on 1/10/18

Issue resolved for Q5101 on 12/23/17

 

Resolved 12/22/17: Women’s Health/Family Planning Claims Denying for Q9984 (Kyleena) for EOB 3180
Procedure code Q9984 (Kyleena) was not being processed for payment. This was causing claim denials for EOB 3180 – "The procedure code is invalid. Correct the procedure code. Refer to the CPT or the HCPCS listing for valid procedure codes."
 
This procedure code is part of the quarterly HCPCS update.  The Department and DXC are currently working on getting the quarterly HCPCS update codes loaded into the Colorado interChange system.

Claims were reprocessed by DXC on 1/5/18.

Issue resolved 12/22/17

 

Resolved 11/30/17: Claim Denials for Some CLIA Waived Codes

Claims for some CLIA waived codes were incorrectly denying for EOB 3660 – "The service is not within the scope of the billing provider's CLIA certification. Please update the MMIS provider records with the correct CLIA number."

DXC has made progress on this issue, and some affected claims were reprocessed by DXC 11/3/17. This issue was previously reported as resolved on 10/21/17; however, it was determined that further research was required for complete resolution of the issue. The Department and DXC completed work on the issue and DXC reprocessed the remaining affected claims on 11/30/17.

For more information on billing CLIA waived codes and the link to a complete list of codes on the CMS website, refer to the article titled "Clinical Laboratory Improvement Amendments (CLIA) System Issues Resolved" in the July 2017 Provider Bulletin.

Issue Resolved 11/30/17

 

Resolved 10/26/17: Claims Denying for Clinic Providers with Place of Service Code 24 (Ambulatory Surgical Center) for EOB 1030 - Place of Service Code is Invalid for Procedure Code
Claims for clinic providers were denying when billed with place of service code 24 (Ambulatory Surgical Center) for EOB 1030 - "The place of service code is invalid for procedure code."

Claims were reprocessed by DXC on 10/27/17.

Issue resolved 10/26/17

 

Resolved 10/25/17: Delivery, Antepartum and Postpartum Care Claims Denied for EOB 1030 when the Place of Service (POS) is 12 (Home)
Claims for procedure codes 59400, 59409, 59410, 59610, 59612, 59614, 59425, 59426, and 59430, billed with Place of Service (POS) 12 – Home, were incorrectly denying for Explanation of Benefits (EOB) 1030 - "Place of Service restriction on proc billing rule." Home births may be performed by physicians and certified nurse-midwives carrying malpractice insurance that covers home births.
 
Affected claims were reprocessed by DXC 10/27/17.

Issue resolved 10/25/17

 

Resolved 10/13/17: Claim Denials for DME and Physician Services for Sleep Studies with Place of Service 12
Claims were denying for sleep studies with place of service 12.

Claims were reprocessed by DXC on 10/18/17.

Issue resolved 10/13/17

 

Resolved 10/7/17: Multi-Surgery Claims Suspending for Clinic Providers for Explanation of Benefits (EOB) 0110 – No Additional Benefit for this Service
Multi-surgery claims for clinic providers were suspending for EOB 0110 - "There is no additional benefit for this service. Payment for this procedure was included in the payment for the primary procedure." This issue was affecting claims with multiple lines of surgical codes as well as multiple surgery modifiers: bilateral procedures (modifier 50), co-surgeon (modifier 62) and assistant surgeon (modifier 80).

Providers were previously advised to continue to submit multiple surgery claims as usual.

An interim solution was implemented on 10/7/17 to manually process these claims rather than allowing them to suspend. The long-term solution was implemented on 2/20/19 to stop these claims from suspending and automate claims processing. Since manual processing is no longer needed for multi-surgery claims with modifiers 50, 62 or 80, providers may experience shorter claims processing turnaround times.

Some affected claims were processed on 10/7/17. Affected claims paid between 4/1/17 and 6/30/17 were reprocessed by DXC on 5/24/19. The remaining affected claims paid between 7/1/17 and 12/31/17 were reprocessed by DXC on 6/7/19.

Issue resolved 10/7/17

 

Resolved 9/28/17: Claim Denials for Laboratory Codes with BHO-Covered Diagnoses - EOB 2580

Claims for laboratory codes 80047 - 89398 provided to members for the ICD-10 diagnoses listed below were incorrectly denying for Explanation of Benefits (EOB) 2580 – "The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry." These codes are not part of the BHO contract and need to be billed Fee-for-Service (FFS).

BHO MH Diagnoses Ranges		SUD Diagnoses Ranges
Start Value	End Value	Start Value	End Value
F20.0	F42.3	F10.10	F10.26
F42.8	F48.1	F10.28	F10.96
F48.9	F51.03	F10.98	F13.26
F51.09	F51.12	F13.28	F13.96
F51.19	F51.9	F13.98	F18.159
F60.0	F63.9	F18.18	F18.259
F68.10	F69	F18.28	F18.959
F90.0	F99	F18.980	F19.16
R45.1	R45.2	F19.18	F19.26
R45.5	R45.82	F19.28	F19.99

Claims were reprocessed by DXC on 10/27/17 and 2/9/18.

Issue Resolved 9/28/17

 

Resolved 9/27/17: Physician and Clinic Provider Claims Denied for Procedure Code J9301 for EOB 1381 – No Billing Rule for Procedure
Claims for physician and clinic providers were denying for procedure code J9301 for EOB 1381 – "No billing rule for procedure."

Claims were reprocessed by DXC on 9/29/17.

Issue resolved 9/27/17

 

Resolved 9/27/2017: Claims Denials for Procedure Code 64615 for EOB 1381
Some claims for procedure code 64615 were denying incorrectly for EOB 1381 – "No billing rule for procedure." The procedure code is covered by Health First Colorado for the Physician and /or Clinic Provider Type.

Affected claims were reprocessed 9/29/17.

Issue resolved 9/27/17

 

Resolved 9/22/17: Claims Denials for OB Services for EOB 0260
Claims were previously denying for EOB 0260 – "The OB services are billed incorrectly. Refer to the OB billing instructions in the Provider Manual."
Claims were reprocessed on 10/19/17.
Issue resolved 9/22/17

 

Resolved 9/21/17: Claim Denials for Hysterectomy and Sterilization Services for EOBs 6700 and 0675
Claims were previously denying for certain procedure codes for hysterectomy and sterilization services.

Sterilization claims billed for the following codes were denied for EOB 6700 – "Required sterilization form is missing or incomplete. Please resubmit electronic claim with correct attachment."

• Procedure codes: 58554, 55250, 55450, 58600, 58605, 58611, 58661, 58670, 58700, 58720, 58940
• Diagnosis codes: V2622, Z3142

For the procedure codes listed above, a process has now been implemented for sterilization services where if the provider indicates only one side was removed by using the RT/LT modifier, the modifier can be used to indicate the member is not sterile. Providers are advised to resubmit affected claims using the appropriate modifier.

For the diagnosis codes listed above, the requirement to attach a form has now been removed. These fixes will now allow claims billed for any of the codes listed above to bypass the error for which it was previously denied. Claims affected by this issue were reprocessed by DXC on 9/29/17 for dates of service from 3/1/17 to present.

Hysterectomy claims billed for the following codes were denied for EOB 0675 - "Required hysterectomy form is missing or incomplete. Please resubmit electronic claim with correct attachment."

• Procedure codes: 58545, 58546, 58940-58960, 59120, 59151

For the procedure codes listed above, the requirement to attach a form has now been removed. This fix will now allow claims billed for any of the codes listed above to bypass the error for which it was previously denied. Claims affected by this issue were reprocessed by DXC on 9/29/17 for dates of service from 3/1/17 to present.

Issue resolved 9/21/17

 

Resolved 8/23/17: Non-EPSDT Denials for Clinics with CRNA or Podiatrist as Rendering Providers
Clinic claims for non-EPSDT services were incorrectly denying for EOB 0678 – "Billing Provider Type and Specialty is not allowable for the Rendering Provider" when a Certified Registered Nurse Anesthetist (CRNA) or a Podiatrist was listed as the rendering provider. Clinic providers are allowed to bill non-EPSDT services for these provider types.

Claims were reprocessed by DXC on 9/1/17.

Issue resolved 8/23/17

 

Resolved 8/23/17: Physician and Osteopath Billing Providers Unable to Enter CLIA Information
There was no field available for Physician and Osteopath providers to input CLIA information. This applied to both the initial enrollment as well as enrollment updates on the Provider Web Portal.  As a result, claims may have denied for EOB 3660 – "The service is not within the scope of the billing provider’s CLIA certification; Please update the MMIS provider records with the correct CLIA number." Providers are now able to update the CLIA information. Individuals within a group do not need to enter a CLIA.

Providers are advised to resubmit the affected claims.

Issue resolved 8/23/17

 

Resolved 8/18/17: Claim Denials for Physician Services for PAR Requirement
Claims for physician services were denying for a Prior Authorization Request (PAR) requirement when billed for any of the following codes: 19370, 19371, 19350, 19380, 19357. PARs are not required for these services.

Claims were reprocessed by DXC on 9/7/17.

Issue resolved 8/18/17

 

Resolved 8/18/17: Claim Denials for Clinic Providers for Procedure Code 99406 for EOB 1381
Claims for clinic providers were denying for procedure code 99406 for smoking cessation. These claims were denying for EOB 1381 - "No billing rule for procedure." Clinic providers are allowed to bill for this code even if the member is not pregnant.

Claims were reprocessed by DXC on 9/1/17.

Issue resolved 8/18/17

 

Resolved 8/11/17: Clinic Claim Denials for EOB 0030 - Same Day Well Child and Sick Child Visit
Clinic claims were denying when a well child visit and a sick child visit had been billed for the same day.  These claims were denying for EOB 0030 – "EPSDT services are not a benefit with office visits."

Procedure codes 99201 – 99215 with modifier 25 should be allowable against procedures codes 96360-96361, 99381-99385, 99391-99395 regardless of modifiers. Procedure codes 96360-96361, 99381-99385, 99391-99395 regardless of modifiers should be allowable against procedures 99201-99215 with modifier 25.

Claims were reprocessed by DXC on 8/18/17.

Issue resolved 8/11/17

 

Resolved 8/10/17: Claim Denials for Radiology Clinic Providers
Radiology providers enrolled as Type 16 – CLINIC were receiving claim denials when submitting claims with the CPT codes in the 70000 range resulting in EOB 1381 – "No billing rule for procedure."

Claims were reprocessed by DXC on 8/11/17.

Issue resolved 8/10/17

 

Resolved 8/3/17: Claim Suspended for EOB 2861 – No Rate on File for the Date(s) of Service
Claims with the following procedure codes were suspending for EOB 2861 – "No Rate on File for the Date(s) of Service."

This issue has been resolved and claims were recycled by DXC on 8/4/17.

Procedure codes have been listed by the affected provider communities below:
DME: E0486, E0635, E0639, E0676, K0462, L8699, S0395
Laboratories: 89259, 81205, 81281, 81287, 81355
Physician Services: 26418, 59898, 69631, 90662, 99100, 99135, 99140, 99288, 01996, G0452, J1050, J3490, J8499, Q2039, S0316, S0613, S4993, S9083, S9088, S9141
Vision: S0590, V2702, V2790

Issue resolved 8/3/17

 

Resolved 8/2/17: Physician Services with Different Rendering Providers for Multiple Visits
Claims with procedure codes 99221-99233 were denying for EOB 0010 – "The number of hospital visits exceeds the guidelines for the procedure billed" when the same service for a member was performed by different rendering providers in an outpatient setting.  

Providers are advised to resubmit affected claims.

Issue resolved 8/2/17

 

Resolved 7/27/17: Clinic Claim Denials for Procedure Code 97162 for Physical Therapy Evaluation
Claims for Clinic providers were incorrectly denying for procedure code 97162. These claims were denying for EOB 1381 - "No billing rule for procedure."

Claims were reprocessed by DXC on 8/4/17.

Issue resolved 7/27/17

 

Resolved 7/20/17: Claim Denials for Procedure Code J3121 for EOB 1381
Claims for Clinic and Non-Physician Practitioner Group providers were incorrectly denying for procedure code J3121. These claims were denying for EOB 1381 - "No billing rule for procedure."

Claims were reprocessed by DXC on 7/26/17.

Issue resolved 7/20/17

 

Resolved 7/20/17: Clinic Claims Not Deducting Co-Pays
Co-pays on claims billed by clinic providers were not being deducted appropriately.

This issue was resolved in three parts, with the first fix occurring on 7/12/17, and the remaining two fixes occurring on 7/20/17.

DXC reprocessed affected claims and recouped funds in several stages, on dates 8/25, 9/1, 9/8, 9/15 and 9/22.

Issue resolved 7/12/17, 7/20/17

 

Resolved 7/13/17: Provider Web Portal Error – Not Allowing Duplicate ICD Procedures on a Claim
A Provider Web Portal error message was displaying when a provider attempted to add duplicate ICD surgical procedures on an Institutional claim, even if the dates of the procedure were different. The error message stated, "Surgical Procedure Code already exists in the list."

Providers were previously advised that if they have a batch biller they could submit claims via batch.

Issue resolved 7/13/17

 

Resolved 7/12/17: Professional and Outpatient Claim Denials for EOB 0101 – Duplicate Service
Professional and Outpatient claims were incorrectly denying for EOB 0101 – "This is a duplicate service."  However, this is a valid denial in the case of duplicate laboratory codes.

Claims were reprocessed by DXC on 7/21/17.

Issue resolved 7/12/17

 

Resolved 7/5/17: Provider Web Portal Issue - Vaccines for Children
When submitting a service detail line for a vaccine in the Provider Web Portal, providers were required to enter a dollar amount even though vaccines should not require this amount.

In addition, there was an existing known issue where the NDC for the DTaP vaccine was is not available in the Provider Web Portal.

As a workaround until the issue was resolved, providers were instructed to submit a vaccine detail line or a detail line that contains the NDC for DTaP via paper or batch claim.

Providers are advised to resubmit affected claims.

Issue resolved 7/5/17

 

Resolved 6/7/17: Suspended Claims Due to Manual Pricing for Hepatitis B Vaccine (90746)

Claims with procedure code 90746 were suspended for EOB 0653.

Claims were reprocessed by DXC on 6/15/17.

Issue resolved 6/7/17

 

Resolved 6/15/17: Clinic Claim Denials for Procedure Code J9267 - EOB 1381
Procedure code J9267 was denying for EOB 1381 – "no billing rule for procedure". Claims were reprocessed by DXC on 7/10/17.

Issue resolved 6/15/17

 

Resolved 3/31/17: Vaccines for Children Overpaying
For CPT 90686, system was paying the admin and Flu vaccine. The vaccine should pay at zero. System will no longer pay vaccine incorrectly. Adjustment to recoup not yet scheduled.

Issue resolved 3/31/17

Resolved 3/23/18: Claim Denials for Procedure Codes 11042, 11720, 11721, 11740, 20550, 20551, 97597, and G0127 for EOB 1030 with Place of Service (POS) 12, 13, 14 or 33
Procedure codes 11042, 11720, 11721, 11740, 20550, 20551, 97597, and G0127 were denying for EOB 1030 - "The place of service code is invalid for procedure code. Correct the place of service code" when billed with POS codes 12, 13, 14 or 33. The Department and DXC have resolved this issue.

Claims were reprocessed by DXC on 3/23/18.

Issue resolved 3/23/18

 

Resolved 8/23/17: Non-EPSDT Denials for Clinics with CRNA or Podiatrist as Rendering Providers

Clinic claims for non-EPSDT services were incorrectly denying for EOB 0678 – "Billing Provider Type and Specialty is not allowable for the Rendering Provider" when a Certified Registered Nurse Anesthetist (CRNA) or a Podiatrist was listed as the rendering provider. Clinic providers are allowed to bill non-EPSDT services for these provider types.

Claims were reprocessed by DXC on 9/1/17. 

Issue resolved 8/23/17

 

Resolved 4/20/17: EOB 1381 - No Billing Rule for Procedure for Prosthetics

Claims for prosthetics for podiatry services submitted with the following codes, prior to 4/20/17, were denying for EOB code 1381:

L1904, L1940, L1970, L2275, L2280, L2330, L2340, L2820, L3000, L3020, L3030, L3060, L3100, L3150, L3201, L3216, L3221, L3260, L3320, L3480, L4361, and L4396.

DXC reprocessed all affected claims on 5/10/17. Providers were previously advised that if they wished to resubmit for payment sooner they may do so.

Issue resolved 4/20/17

Resolved 1/18/18: Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030

Some claims for vaccine procedure codes were denying for Explanation of Benefits (EOB) 1552 -"This procedure is age restricted. Member's age does not fall within the approved range." and EOB 1030 - "The place of service code is invalid for procedure code." The Department and DXC reviewed and assigned the appropriate place of service and age ranges.

Claims were reprocessed by DXC on 3/2/18.

Issue resolved 1/18/18

 

Resolved 1/12/18: Claims Denying for CPT 81025 for EOB 1030 with Place of Service (POS) Code 71 (State/Local Health Clinic)
CPT 81025 was denying for EOB 1030 - "The place of service code is invalid for procedure code" when billed with POS 71 (State/Local Health Clinic). This procedure code is separate from vaccine procedure codes denying for EOB 1030 (see separate Known Issue "Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030").

Claims were reprocessed by DXC on 1/19/18.

Issue resolved 1/12/18

Previously Paid Physical and Occupational Therapy Claims Adjustments Denying for EOB 2305 - "Occupational Therapy and Physical Therapy Services Limited to a Maximum of 48 Units"

DXC and the Department initiated a mass adjustment for claims for the Fiscal Year 2017-2018 rate updates. Claims were incorrectly denied for EOB 2305 – “Occupational therapy and physical therapy services limited to a maximum of 48 units.” In the Colorado interChange, if an adjustment denies, it retracts the original paid claim.

This issue has been resolved for adjusted claims billed prior to 8/3/18, and these adjustments were reprocessed by DXC on 8/3/18.

The Department and DXC are continuing to work on a long-term resolution for this issue to address adjusted claims billed on or after 8/3/18. While the initial issue affected only DXC-initiated adjustments, after 8/3/18, this issue affects only some provider-submitted adjustments. Not all provider-submitted adjustments are affected by this issue.

 

Physical and Occupational Therapy Units Displayed in the Provider Web Portal 

The Provider Web Portal displays physical and occupational therapy (PT/OT) total dollars and service units "used" from claims processed in the Colorado interChange system only (claims processed on or after 3/1/17). Dollars and service units used in the legacy MMIS system are not calculated into the amount displayed on the web portal, however, they are still counted towards limits when claims are adjudicated. The amounts displayed on the portal may not reflect the total amount of units the member has used.

---

Resolved 7/27/19: Claims for Services Requiring a Prior Authorization (PA) Denying for Explanation of Benefits (EOB) 0192, 0504, 5110
Some claims for services that require a PA were denying for one of the following EOB codes because the PA on file had units decremented incorrectly:

• EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
• EOB 0504 – “There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier.”
• EOB 5110 – “The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed."

To verify the correct amount of units remaining on a PA, contact the Provider Services Call Center.
 
Claims were reprocessed by DXC on 7/27/19 and any units decremented incorrectly were replaced on the PA.

Issue resolved 7/27/19

 

Resolved 7/24/19: Claims Suspending for Across-the-Board Rate Increase for EOB 2861 - "No Rate on File for the Date(s) of Service”
Fiscal Year 2019-2020 Provider Rate Increases and Adjustments

Health First Colorado (Colorado’s Medicaid Program) provider rate increases were approved during the 2019-2020 legislative session and are effective for dates of service beginning July 1, 2019. The fee schedules located on the Provider Rates & Fee Schedule web page have been updated to reflect the approved 1.0% across-the-board (ATB) rate increase and targeted rate increases and decreases. The updated rates were implemented in the Colorado interChange on 7/24/19.

Claims were previously suspending for EOB 2861 - "No rate on file for the date(s) of service" while rates were being updated in the Colorado interChange. Affected claims were reprocessed by DXC on 7/26/19.

Issue resolved 7/24/19

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

Resolved 10/17/18: Claims for Occupational Therapy Denying for EOB 1599 – “Rendering Provider Type and/or Specialty is Not Allowable for the Service Billed”​
Claims for procedure code 92526 were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed" when billed with either the following provider type combinations:

• Rendering provider type 28 (Occupational Therapist) billed with Billing provider type 48 (Rehabilitation Agency)
• Rendering provider type 28 (Occupational Therapist) billed with Billing provider type 25 (Non-Physician Practitioner- Group)

Claims were reprocessed on 10/26/18.

Issue resolved 10/17/18

 

Resolved 7/25/18: Speech Therapy Claims for Procedure Codes 92507 and 97532 Denying for EOB 1512 – "The Procedure Code/Modifier Combination is Not Payable for the Date of Service" 
Speech therapy claims billed for procedure codes 92507 and 97532 with or without the GN or GP modifiers were denying for EOB 1512 – "The Procedure Code/Modifier Combination is Not Payable for the Date of Service." 
 
Providers were previously advised to not bill modifier GT as a workaround to this issue unless it was the appropriate modifier based on program policy.

Claims were reprocessed on 8/31/18.

Issue resolved 7/25/18

 

Resolved 7/19/18: Physical and Occupational Therapy Claims Paying $0.00
Some physical and occupational therapy claims were paying $0.00.

Claims were reprocessed by DXC on 9/7/18, which resulted in payment or valid claim denials.

Issue resolved 7/19/18

 

Resolved 7/13/18: Medical PAR Revisions, Reconsiderations or PARs with Amended Status Not Showing Fully Approved
Some PAR revisions, reconsiderations or any PAR with Amended status were not showing fully approved in the Colorado interChange.  The line items of the PAR must show approved or approved with revisions in order for the claims to pay.
Updates have been made in the Colorado interChange and eQ Health has resent PARs to the interChange.  If providers encounter PARs that do not show fully approved, they are advised to contact eQ Health. 

Claims were reprocessed by DXC in two stages on 7/6/18 and 7/13/18.

Issue resolved 7/13/18

 

Resolved 4/27/18: Claim Denials for Speech Therapy Procedure Code 92508 for EOB 1030 or 1599
Claims where the billing provider was either type 16 (Clinic - Practitioner) or 48 (Rehabilitation Agency) and the rendering provider was type 27 (Speech Therapist - Individual) were incorrectly denying for speech therapy procedure code 92508 for EOB 1030 - "The place of service code is invalid for procedure code" or EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed."

Some claims were reprocessed by DXC on 5/4/18. The remainder of the affected claims were reprocessed by DXC on 5/11/18.

Issue resolved 4/27/18

 

Resolved 4/25/18: Claim Denials for Speech Therapy Procedure Code 92507 for EOB 1030 or 1599
Claims where the billing provider is either type 16 (Clinic - Practitioner) or 48 (Rehabilitation Agency) and the rendering provider is type 27 (Speech Therapist - Individual) were incorrectly denying for speech therapy procedure code 92507 for EOB 1030 - "The place of service code is invalid for procedure code" or EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed."

Some claims were reprocessed by DXC on 5/4/18. The remainder of the affected claims were reprocessed by DXC on 5/11/18.

Issue resolved 4/25/18

 

Resolved 3/7/18: Habilitative Therapy Claims Denying for SZ Modifier and/or CPT 97532 and Suspending for Procedure Code G0515
Habilitative therapy claims for CPT 97532 for dates of service after 12/31/17 will deny for either or both of the following EOBs:
•    EOB 3261 - "The procedure code currently is not a benefit for date of service billed.  Refer to the CPT or the HCPCS listing for valid procedure codes."
•    EOB 3181 - "The procedure code is invalid for date of service. Correct the procedure code.  Refer to the CPT or the HCPCS listing for valid procedure codes."
This is due to CPT 97532 being replaced by procedure code G0515, effective 1/1/18. This code was part of the HCPCS 2018 annual update, and HCPCS 2018 procedure codes and the billing rules were loaded into the Colorado interChange system on 3/7/18. Therefore, claims billed for procedure code G0515 will no longer suspend for EOB 0000 - "This claim/service is pending for program review."

Habilitative therapy claims with the SZ modifier for dates of service after 12/31/17 will deny for any of the following EOBs, depending on the position the modifier is in:
•    EOB 3170 - "The first modifier code is invalid for date of service.  Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a listing of valid modifiers."
•    EOB 3171 - "The second modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a list of valid modifiers."
•    EOB 1127 - "The third modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a listing of valid modifiers."
•    EOB 1514 - "The fourth modifier code is invalid for date of service. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS for a list."

This is due to the SZ modifier being replaced by the 96 modifier, effective 1/1/18. Claims billed with the 96 modifier were denying for EOB 0504 – "There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier." These claims were reprocessed on 3/9/18.

The Department is working on a solution to address PARs that cross from 2017 to 2018 for the SZ modifier or CPT 97532. Providers are advised to call eQHealth Solutions for further direction on revising current authorizations to reflect the new codes for dates of service in 2018.

Issue resolved on 3/7/18

 

Resolved 2/14/18: Providers Unable to see Prior Authorization (PA) Modifiers on the Provider Web Portal

Modifiers on the detail lines of the PA records are now viewable on the Provider Web Portal. Physical and Occupational Therapy providers are no longer required to contact eQHealth Solutions, the ColoradoPAR vendor, for this PA information. When providers click the Line # of the detail line in question, Web Portal now displays up to four modifiers in the Modifiers field.

Issue resolved 2/14/18

 

Resolved Issue 8/28/17: Claims Denials for Provider Type 48 for EOB 0182 - Rehab Agency

Rehab Agency claims were denying for some services that should be allowed for this provider type. These claims were denying for EOB 0182 – "Billing Provider Type and/or Specialty is not allowable for the service billed."

Claims were reprocessed by DXC on 8/30/17.

Issue resolved 8/28/17.

Resolved 8/11/17: Clinic Claim Denials for EOB 0030 - Same Day Well Child and Sick Child Visit

Clinic claims were denying when a well child visit and a sick child visit had been billed for the same day.  These claims were denying for EOB 0030 – "EPSDT services are not a benefit with office visits."

Procedure codes 99201 – 99215 with modifier 25 should be allowable against procedures codes 96360-96361, 99381-99385, 99391-99395 regardless of modifiers. Procedure codes 96360-96361, 99381-99385, 99391-99395 regardless of modifiers should be allowable against procedures 99201-99215 with modifier 25.

Claims were reprocessed by DXC on 8/18/17.

Issue resolved 8/11/17

 

Resolved 3/30/17: Outpatient Duplicate Claim Payments

Some outpatient claims were allowing duplicate payments. Duplicate logic has been corrected. Department will wait until 5/1/17 to recoup duplicate payments from providers.

Issue resolved 3/30/17 

Resolved 5/9/19: Clinic Claim Denials for Explanation of Benefits (EOB) 1599

Some clinic claims were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed." when one of the following provider types was the billing provider on the claim:

• Clinic-Practitioner
• Federally Qualified Health Center (FQHC)
• Rural Health Clinic
• Indian Health Services

Claims were reprocessed by DXC 5/17/19.

Issue resolved 5/9/19

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

Resolved 1/18/18: Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030

Some claims for vaccine procedure codes were denying for Explanation of Benefits (EOB) 1552 -"This procedure is age restricted. Member's age does not fall within the approved range." and EOB 1030 - "The place of service code is invalid for procedure code." The Department and DXC reviewed and assigned the appropriate place of service and age ranges.

Claims were reprocessed by DXC 3/2/18.

Issue resolved 1/18/18

 

Resolved 7/5/17: Dollar Amount Required Where Not Applicable - Provider Types FQHC, RHC, IHS

Provider types FQHC, RHC and IHS were experiencing a Provider Web Portal issue where they were required to enter a dollar amount above $0.00, even when not applicable for the service provided. The portal did not allow for the service detail line to be itemized at $0.00. These claims were denied. Providers are advised to resubmit affected claims.

Issue resolved 7/5/17.

 

Resolved 4/5/17: CMS 1500 Claims

There was system issue that affected the following provider types, when submitting CMS 1500 claims:

• PT 32 - Federally Qualified Health Center (FQHC)
• PT 61 - Indian Health Services (IHS) FQHC
• PT 45 - Rural Health Clinic (RHC)

A large portion of Procedure codes were not set to pay for the provider types above. The issue was resolved 4/5/17, and providers should resubmit any denied CMS 1500 claims.

Please refer to this email for more detail.

Resolved 7/27/19: Claims for Services Requiring a Prior Authorization (PA) Denying for Explanation of Benefits (EOB) 0192, 0504, 5110
Some claims for services that require a PA were denying for one of the following EOB codes because the PA on file had units decremented incorrectly:

• EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
• EOB 0504 – “There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier.”
• EOB 5110 – “The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed."

To verify the correct amount of units remaining on a PA, contact the Provider Services Call Center.
 
Claims were reprocessed by DXC on 7/27/19 and any units decremented incorrectly were replaced on the PA.

Issue resolved 7/27/19

 

Resolved 7/24/19: Claims Suspending for Across-the-Board Rate Increase for EOB 2861 - "No Rate on File for the Date(s) of Service”

Fiscal Year 2019-2020 Provider Rate Increases and Adjustments

Health First Colorado (Colorado’s Medicaid Program) provider rate increases were approved during the 2019-2020 legislative session and are effective for dates of service beginning July 1, 2019. The fee schedules located on the Provider Rates & Fee Schedule web page have been updated to reflect the approved 1.0% across-the-board (ATB) rate increase and targeted rate increases and decreases. The updated rates were implemented in the Colorado interChange on 7/24/19.

Claims were previously suspending for EOB 2861 - "No rate on file for the date(s) of service" while rates were being updated in the Colorado interChange. Affected claims were reprocessed by DXC on 7/26/19.

Issue resolved 7/24/19

 

Resolved 8/14/18: Speech Therapy Claims for Procedure Code 92523 Denying for EOB 0182 – "Billing Provider Type and/or Specialty is Not Allowable for the Service Billed"
If a speech therapist type 27 is both the billing and the rendering provider on the claim, procedure code 92523 was currently denying for EOB 0182 – "Billing Provider Type and/or Specialty is not allowable for the service billed." The code was currently previously only configured correctly for organizations (group) numbers to bill the code. The individual provider type was added to the Colorado interChange so the claims could be processed.

Claims were reprocessed on 8/17/18.

Issue resolved 8/14/18

 

Resolved 7/25/18: Speech Therapy Claims for Procedure Codes 92507 and 97532 Denying for EOB 1512 – "The Procedure Code/Modifier Combination is Not Payable for the Date of Service" 
Speech therapy claims billed for procedure codes 92507 and 97532 with or without the GN or GP modifiers were denying for EOB 1512 – "The Procedure Code/Modifier Combination is Not Payable for the Date of Service." 
 
Providers were previously advised to not bill modifier GT as a workaround to this issue unless it was the appropriate modifier based on program policy.

Claims were reprocessed on 8/31/18.

Issue resolved 7/25/18

 

Resolved 4/27/18: Claim Denials for Speech Therapy Procedure Code 92508 for EOB 1030 or 1599
Claims where the billing provider was either type 16 (Clinic - Practitioner) or 48 (Rehabilitation Agency) and the rendering provider was type 27 (Speech Therapist - Individual) were incorrectly denying for speech therapy procedure code 92508 for EOB 1030 - "The place of service code is invalid for procedure code" or EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed."

Some claims were reprocessed by DXC on 5/4/18. The remainder of the affected claims were reprocessed by DXC on 5/11/18.

Issue resolved 4/27/18

 

Resolved 4/25/18: Claim Denials for Speech Therapy Procedure Code 92507 for EOB 1030 or 1599
Claims where the billing provider is either type 16 (Clinic - Practitioner) or 48 (Rehabilitation Agency) and the rendering provider is type 27 (Speech Therapist - Individual) were incorrectly denying for speech therapy procedure code 92507 for EOB 1030 - "The place of service code is invalid for procedure code" or EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed."

Some claims were reprocessed by DXC on 5/4/18. The remainder of the affected claims were reprocessed by DXC on 5/11/18.

Issue resolved 4/25/18

National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

• First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
• If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
• Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

---

Resolved 8/28/17: EOB 0182 for Rehab Agency/Therapy Claims

Procedure codes 97161 through 97168 were not added to the clinic billing contract for Non-Physician Practitioner Group and Rehab Agency provider types, and the practitioner billing contract for Physical Therapist and Occupational Therapist provider types.

This was causing claim denials for EOB code 0182.

All denied claims since January 1, 2017, when the codes were opened, were reprocessed by DXC on 8/30/17.

Issue resolved 8/28/17.

 

Resolved 6/1/17: Denied IP/OP Claims with Mental Health or Substance Use Diagnosis - EOB 2580

Inpatient/outpatient claims using a diagnosis from a mental health diagnosis group or substance use disorder group were incorrectly denying for EOB 2580 – "The services must be billed to the HMO/PHP listed on the eligibility inquiry."

These claims have been reprocessed.

Issue resolved 6/1/17

 

Resolved 5/1/17: Incarceration Indicator on Member Eligibility 

Some members were incorrectly showing as "incarcerated" in the Colorado interChange system. This issue was fixed, but in some very limited cases, members may still be listed incorrectly as incarcerated in the system.

Pharmacists should call Magellan at 1-800-424-5725 to confirm whether the system is incorrectly showing someone as incarcerated.

Issue resolved 5/1/17

Resolved 2/28/18: Claims Voided via the Provider Web Portal Denying for Atypical Providers for EOB 1960 – "No Provider Billing Indicator Found"
Providers who do not use an NPI (atypical providers) were not able to successfully void a claim using the Provider Web Portal.  While the portal may have displayed a message stating that the claim was successfully voided, the system was erroneously creating the claim without the billing provider ID, causing claim denials for EOB 1960 - "No Provider Billing Indicator Found. Please make sure the billing provider has been revalidated and that you are using the correct billing provider service location."

For questions, please contact Provider Services Call Center (1-844-235-2387).

Issue resolved 2/28/18

 

Resolved 1/25/18: Claim Denials Non-Emergent Medical Transportation (NEMT) Procedure Codes A0431, A0430 and A0140 for EOB 1030 - "Place of Service Code is Invalid for Procedure Code"
Claims were denied for NEMT procedure codes A0430 and A0431 when billed with place of service (POS) 42 for EOB 1030 - "The place of service code is invalid for procedure code. Correct the place of service code. Refer to the Provider Manual or Help Screens for valid place of service codes."

Claims were denied for NEMT procedure code A0140 when billed with POS 41 for EOB 1030 - "The place of service code is invalid for procedure code. Correct the place of service code. Refer to the Provider Manual or Help Screens for valid place of service codes."

Claims were reprocessed by DXC on 2/2/18.

Issue resolved 1/25/18

 

Resolved 9/14/17: Claim Denials for Non-Emergent Medical Transportation Providers for EOB 4000 – Member Has Other Insurance

Claims for Non-Emergent Medical Transportation Providers were denying for EOB 4000 – "The member has other insurance. Bill the charges to the other insurance before billing Medicaid. Complete the other insurance payment information fields on the claim and retain a copy of the explanation of benefits."

Claims were reprocessed by DXC on 9/22/17.

Issue resolved 9/14/17

 

Resolved 4/17/17: NEMT Providers Termed

On Friday 4/14, many NEMT providers were incorrectly terminated and were either unable to log onto the web portal and/or received incorrectly denied claims.

Issue resolved 4/17/17, please refer to this email for more detail. 

Resolved 7/27/19: Claims for Services Requiring a Prior Authorization (PA) Denying for Explanation of Benefits (EOB) 0192, 0504, 5110
Some claims for services that require a PA were denying for one of the following EOB codes because the PA on file had units decremented incorrectly:

• EOB 0192 – “Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim.”
• EOB 0504 – “There is no PA on file for the procedure with the billed modifier. Check the approved PA and verify the procedure and modifier.”
• EOB 5110 – “The prior authorization does not match the services billed on your claim. Please correct services or submit a new prior authorization for the services billed."

To verify the correct amount of units remaining on a PA, contact the Provider Services Call Center.
 
Claims were reprocessed by DXC on 7/27/19 and any units decremented incorrectly were replaced on the PA.

Issue resolved 7/27/19

 

Resolved 6/14/18: Claim Denials for Eye Surgery Codes 66982 & 66984 for EOB 0101 or 1010

Claims for eye surgery procedure code 66984 were denying for EOB 0101 – "This is a duplicate service." or EOB 1010 – "This is a duplicate item that was previously processed and paid." when:

• 66984 was billed with modifier 54; AND
• A separate claim for eyeglasses was billed with modifier 55

Claims for 66982 billed with modifier 54 were also denying for EOB 0101 or EOB 1010; however, the issue was resolved for 66982 on 12/10/17.

Claims for both 66982 and 66984 were reprocessed by DXC on 6/15/18.

Issue resolved 6/14/18

 

Resolved 2/23/18: Claims Denying for Vision Providers for Codes V2025, V2626 and 92015
Vision providers claims were denying for V2025, V2626 for EOB 1381 - "No billing rule for procedure"

92015 was denying for EOB 3280 - "The client’s age is invalid for this procedure code.  Verify the client’s birth date/procedure code."

Claims were reprocessed by DXC on 3/30/18.

Issue resolved 2/23/18

 

Resolved 1/11/18: Vision Claims Denying for EOB 3280 – "The client’s age is invalid for this procedure code"

Vision claims billed with the 55 modifier were incorrectly denying for EOB 3280  - "The clients age is invalid for this procedure code.  Verify the clients birth date."

Claims were reprocessed on 1/19/18.

Issue resolved on 1/11/18

 

Resolved 8/3/17: Claim Suspended for EOB 2861 – No Rate on File for the Date(s) of Service
Claims with the following procedure codes were suspending for EOB 2861 – "No Rate on File for the Date(s) of Service."

This issue has been resolved and claims were recycled by DXC on 8/4/17.

Procedure codes have been listed by the affected provider communities below.

DME: E0486, E0635, E0639, E0676, K0462, L8699, S0395
Laboratories: 89259, 81205, 81281, 81287, 81355
Physician Services: 26418, 59898, 69631, 90662, 99100, 99135, 99140, 99288, 01996, G0452, J1050, J3490, J8499, Q2039, S0316, S0613, S4993, S9083, S9088, S9141 
Vision: S0590, V2702, V2790

Issue resolved 8/3/17

 

Resolved 7/3/17: Claim Denials for Contact Lens Service Codes for EOB 0192 - PA Required 

Claims for the following HCPCS/CPT service codes were denying incorrectly for EOB 0192 – "Prior Authorization (PA) is required for this service. An approved PA was not found matching the provider, member, and service information on the claim." This is was due to a system error, as these codes do not require a prior authorization. This issue was primarily affecting Physician and Optician provider types.

• V2520
• V2521
• V2530
• 92310

Providers were previously instructed to submit claims as necessary in order to meet the requirements for timely filing.

Providers are now advised to resubmit affected claims.

Issue resolved 7/3/17

 

Resolved 5/12/17: Optician Claims for Vision Supplies Denying for EOB 0653

Claims for vision supplies, like eye glasses, were denying due to missing vision codes for EOB 0653 – requires manual pricing. These codes were loaded on 5/5/17 and claims were reprocessed by DXC on 5/12/17.

Issue resolved 5/12/17

National Drug Codes Not Appearing in Provider Web Portal Search

Certain National Drug Codes (NDCs) are not appearing when using the search option in the Provider Web Portal. Due to this, providers were unable to submit their claims via the web portal.

If providers suspect a certain NDC to be unavailable in the Provider Web Portal, they are advised to take the following steps:

• First, providers should enter the entire 11-digit NDC to be sure the code is truly unavailable.
• If the code does not appear after searching with the entire 11-digit NDC, providers should email the missing NDC to Colorado.SMAC@state.co.us
• Codes are updated on a monthly basis, so providers are advised to attempt the search again after the 15th of each month.

---

Resolved 7/6/18: Claim Denials for Injections Procedure Codes Q9985, Q9986, Q9989, C9485 and C9489 for EOB 3180 – Procedure Code is Invalid
Claims for procedure codes C9485, C9489, Q9985, Q9986 and Q9989 were previously denied for EOB 3180 – "The procedure code is invalid. Correct the procedure code. Refer to the CPT or the HCPCS listing for valid procedure codes." Please see below for the resolution and reprocessing status of each procedure code affected by this issue:

• C9485 - Issue resolved on 12/22/17. Claims were reprocessed by DXC on 2/9/18.
• C9489 - Issue resolved on 12/22/17. Claims were reprocessed by DXC on 2/9/18.
• Q9986 - Issue resolved on 4/6/18. Claims were reprocessed by DXC on 4/27/18.
• Q9985 - Issue resolved on 7/6/18. Claims were reprocessed by DXC on 7/13/18.
• Q9989 - Issue resolved on 7/6/18. Claims were reprocessed by DXC on 7/13/18.

 

Resolved 12/22/17: Women’s Health/Family Planning Claims Denying for Q9984 (Kyleena) for EOB 3180
Procedure code Q9984 (Kyleena) was not being processed for payment. This was causing claim denials for EOB 3180 – "The procedure code is invalid. Correct the procedure code. Refer to the CPT or the HCPCS listing for valid procedure codes."
 
This procedure code is part of the quarterly HCPCS update.  The Department and DXC are currently working on getting the quarterly HCPCS update codes loaded into the Colorado interChange system.

Claims were reprocessed by DXC on 1/5/18.

Issue resolved 12/22/17

 

10/25/17: Delivery, Antepartum and Postpartum Care Claims Denied for EOB 1030 when the Place of Service (POS) is 12 (Home)
Claims for procedure codes 59400, 59409, 59410, 59610, 59612, 59614, 59425, 59426, and 59430, billed with Place of Service (POS) 12 – Home, were incorrectly denying for Explanation of Benefits (EOB) 1030 - "Place of Service restriction on proc billing rule." Home births may be performed by physicians and certified nurse-midwives carrying malpractice insurance that covers home births.
 
Affected claims were reprocessed by DXC 10/27/17.

Issue resolved 10/25/17

 

Resolved 9/22/17: Claims Denials for OB Services for EOB 0260
Claims were previously denying for EOB 0260 – "The OB services are billed incorrectly. Refer to the OB billing instructions in the Provider Manual."
 Claims were reprocessed on 10/19/17.
 Issue resolved 9/22/17

 

Resolved 9/21/17: Claim Denials for Hysterectomy and Sterilization Services for EOBs 6700 and 0675
Claims were previously denying for certain procedure codes for hysterectomy and sterilization services.

Sterilization claims billed for the following codes were denied for EOB 6700 – "Required sterilization form is missing or incomplete. Please resubmit electronic claim with correct attachment."

• Procedure codes: 58554, 55250, 55450, 58600, 58605, 58611, 58661, 58670, 58700, 58720, 58940
• Diagnosis codes: V2622, Z3142

For the procedure codes listed above, a process has now been implemented for sterilization services where if the provider indicates only one side was removed by using the RT/LT modifier, the modifier can be used to indicate the member is not sterile. Providers are advised to resubmit affected claims using the appropriate modifier.

For the diagnosis codes listed above, the requirement to attach a form has now been removed. These fixes will now allow claims billed for any of the codes listed above to bypass the error for which it was previously denied. Claims affected by this issue were reprocessed by DXC on 9/29/17 for dates of service from 3/1/17 to present.

Hysterectomy claims billed for the following codes were denied for EOB 0675 - "Required hysterectomy form is missing or incomplete. Please resubmit electronic claim with correct attachment."

• Procedure codes: 58545, 58546, 58940-58960, 59120, 59151

For the procedure codes listed above, the requirement to attach a form has now been removed. This fix will now allow claims billed for any of the codes listed above to bypass the error for which it was previously denied. Claims affected by this issue were reprocessed by DXC on 9/29/17 for dates of service from 3/1/17 to present.

Issue resolved 9/21/17

 

Resolved 8/18/17: Women’s Health Family Planning Claims J7297 and J7302 Denying - EOB 1178
Procedure codes J7297 (Liletta) and J7302 (Mirena) were not being processed for payment. This was affecting obstetrics claims returning EOB 1178 – "Service not reimbursable for DOS (dates of service)."

Both procedure codes were part of the 2016 HCPCS update, which was completed on 7/12/17.

Procedure code J7302 (Mirena) is not a valid procedure code after 12/31/2015. Procedure code J7298 should be used in its place.

The issue pertaining to J7302 (Mirena) was resolved on 7/12/17 and the affected claims were reprocessed by DXC on 7/14/17.

The issue pertaining to J7297 (Liletta) was resolved on 8/18/17. Providers are advised to resubmit affected claims for J7297 (Liletta).

Issue resolved 7/12/17 (J7302 – Mirena)
Issue resolved 8/18/17 (J7297 – Liletta)

 

Resolved 3/19/17: Accommodation Units for Babies
Claims were suspending for Edit 3033 (Inpatient Units/Covered/Non-Covered Days Conflict). Providers billed the mom’s and baby’s accommodation units correctly and also submitted the Value Code 80 Covered Days accurately. However, the calculation for EOB 3033 was not excluding the baby’s accommodation units as it should.

Affected claims have been recycled by DXC. No further action required.

Issue resolved 3/19/17

Resolved 11/28/18: Diagnostic Radiology Claims for Procedure Code A9552 Denied for EOB 0653 - Claim Requires Manual Pricing
Claims for procedure code A9552 were denying for EOB 0653 – “Claim requires manual pricing. Please attach invoice for medical services.”
 
Claims were reprocessed by DXC on 11/30/18. After reprocessing, many of these claims denied appropriately for duplicate claims. Check previous Remittance Advices (RAs) for payment.
 
Issue resolved 11/28/18

 

Resolved 11/28/18: Pathology Claims with Procedure Code 88112 Denying for EOB 4211
When billed with a TC modifier or no modifier, procedure code 88112 was denying for EOB 4211 - “Modifier is invalid for procedure code. Read the procedure description. Refer to the Provider Manual, Help Screens, CPT or HCPCS listing for valid modifiers.” Per policy, procedure code 88112 can be billed with a TC or 26 modifier, or no modifier indicating the global procedure. The Department and DXC have resolved this issue.

Claims were reprocessed by DXC 11/30/18.

Issue resolved 11/28/18

 

Resolved 10/29/18: Claims Billed with Certain ICD-10 Diagnosis Codes Denied for EOB 1530 – “No Billing Rule for Diagnosis”
The majority of new ICD-10 diagnosis codes which became effective 10/1/18 were loaded to the Colorado interChange in September 2018, however approximately 360 ICD-10 codes effective 10/1/18 were loaded at a later date on 10/29/18. As a result, claims billed for any of those 360 codes between 10/1/18 and 10/29/18 were denied for EOB 1530 – “No billing rule for diagnosis.”

Claims were reprocessed by DXC on 11/30/18.

Issue resolved 10/29/18

 

Resolved 7/13/18: Claims Billed for the Professional Component for Radiology and Imaging Services Denying for EOB 1010 – "This Is a Duplicate Item that was Previously Processed and Paid"
Professional claims billed with modifier 26 may have denied for EOB 1010 – "This is a duplicate item that was previously processed and paid" if the separate hospital claim (modifier TC) was paid first.

It was previously announced in the June 2018 Provider Bulletin (B1800417) that the TC modifier will no longer be required on outpatient institutional claims (UB-04) for procedure codes that allow a technical and professional component split. The technical component, not the global service, will be assumed for these codes when billed on the UB-04 claim.

Affected claims were reprocessed by DXC on 7/13/18.

Issue resolved 7/13/18

 

Resolved 3/23/18: Claim Denials for CPT Codes 92925 and 77085 for EOB 1030 with Place of Service (POS) 22
CPT 92925 was denying for EOB 1030 - "The place of service code is invalid for procedure code"  when billed with POS 22 (Outpatient Hospital); however, the issue was resolved on 2/28/18. Claims for 92925 were reprocessed on 3/13/18.

Claims for CPT 77085 billed with POS 22 were also denying for EOB 1030. The Department and DXC have resolved the issue.

Claims for 77085 were reprocessed 3/23/18 by DXC.

Issue resolved 3/23/18

 

Resolved 3/15/18: Incorrect Radiology and Imaging Rates Listed on Fee Schedule

The technical and professional fees for radiology and imaging codes billed with the TC and 26 modifiers were incorrect on the HCPCS Rate Updates Information and Resources fee schedule and in Colorado interChange.

Claims were reprocessed on 4/6/18 and 4/13/18 by DXC.

Issue resolved 3/15/18