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Fiscal Agent Name Change: Effective October 1, 2020, references to the current fiscal agent will now be Gainwell Technologies. Visit the News and Media web page of the Gainwell Technologies website to review the Press Releases.
Validation of Provider Taxpayer Identification Numbers (TIN) Against Internal Revenue Service (IRS) Data Effective April 24, 2019, provider Taxpayer Identification Numbers (TIN) are being validated against IRS data. If a provider’s TIN does not match the IRS data, the provider will receive a letter notifying them that their contract has been put on hold until the TIN is verified. The letter will include what type of IRS documentation is required to verify the TIN and specific instructions on how to submit the required documentation.
Notifications of Expiring Checks on Remittance Advice (RA) Summary Page Effective May 1, 2019, the Summary Page of the RA will be updated to include notifications when a provider has received a paper check which is now expiring or has expired.
Notifications on the status of any uncashed paper checks will be displayed on the RA under one of three categories:
Refer to the example of the RA Summary Page. For more information, refer to the Reading the Remittance Advice (RA) Dated on or after 1/9/2019 Provider Web Portal Quick Guide, located on the Quick Guides web page. Providers should contact the Provider Services Call Center at 1-844-235-2387 with any questions.
When writing a check to refund payment, make the check out to "Colorado Department of Health Care Policy and Financing" and mail it to:
DXC Technology P.O. Box 30 Denver, CO 80201
However, we highly recommend submitting electronically as we will automatically set up an AR balance. To learn how to copy, adjust or void a claim in the Provider Web Portal, reference the Provider Web Portal Quick Guide – Copy, Adjust, or Void a Claim, available on the Quick Guides web page.
Effective 3/1/18, checks made out to other entities (such as ACS, Consultec, DXC, Hewlett Packard, HP, HPE, Xerox, etc.) will be returned. "Colorado Department of Health Care Policy and Financing" is the only pay-to name that will be accepted as of 3/1/18.
The Alternative Benefit Plan (ABP) is an extended plan which must be accompanied by Medicaid State Plan (TXIX) coverage. If the member does not have TXIX coverage, they are not eligible for services and claims will be denied for 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."
Providers should verify coverage under Benefit Details (example shown here) on the Provider Web Portal before rendering services. For detailed, step-by-step instructions on verifying member eligibility, refer to the Provider Web Portal Quick Guide - Verifying Member Eligibility (including Managed Care Assignment Details and Benefit Plan Information) and Co-Pay, available under the Quick Guides section on the Quick Guides web page.
Claim Denials for EOB 2580 - Services Must be Billed to HMO/PHP Listed on Eligibility Inquiry
Claims denied for Explanation of Benefits (EOB) 2580 – "The services must be billed to the HMO/PHP listed on the eligibility inquiry" may have caused confusion for providers billing for medical or mental services rendered to members with a Behavioral Health Organization (BHO) listed on the eligibility inquiry. In the previous MMIS, there was an EOB code for HMO and a separate EOB code for the BHO. The new Colorado interChange system combines these two EOB codes into one. Claims may have been denied for this EOB whether an HMO, Prepaid Health Plan (PHP), or BHO was listed on the eligibility inquiry. To mitigate the confusion, the Department and DXC have updated the description for this EOB code to more clearly define the reason for the denial. The description for EOB 2580 now reads: "The services must be billed to the HMO/PHP/BHO listed on the eligibility inquiry."
If the member has a BHO/Regional Accountable Entity (RAE) listed on the eligibility inquiry, providers should refer to the 2017 Uniform Service Coding Standards Manual to verify that the services are covered under the BHO/RAE. If the services are listed as covered by the BHO/RAE, providers should bill to them.
Resolved 6/24/19: No Error Message in Provider Web Portal for Overlapping License Effective Dates When updating a license, the License panel of the Provider Web Portal did not display an error message when there were overlapping license effective dates on Provider Maintenance requests and Revalidation applications. Users were prevented from progressing through the request or application and the "Effective Date" field was highlighted in red. The License panel now displays the error message, “The Covered Dates overlap an existing record”.
Providers are reminded that a copy of the current license must be submitted as an attachment with the request.
Issue resolved 6/24/19
Outdated Version of Microsoft Edge Browser May Cause Provider Web Portal Errors
Providers should not use older versions of the Microsoft Edge browser, such as version 42.17134, when accessing the Provider Web Portal. Providers should ensure that they have downloaded the most recent version of Microsoft Edge, or that they are using another supported web browser. To see a list of supported web browsers, refer to the Website Requirements page of the Provider Web Portal.
Provider Enrollment Portal Change to Prevent Future Enrollment Effective Date Effective 1/2/19, providers can no longer enter a future enrollment effective date on a new enrollment application. If a provider enters a future date in the Requesting Enrollment Effective Date field on the Request Information Panel, they will receive the following error message, “Requesting Enrollment Effective Date cannot be in the future.” See the example below:
This change applies to providers starting a new enrollment application and providers resuming an application that is still in process. A future enrollment effective date will continue to be allowed for revalidation, since the future date equates to the revalidation date.
Providers can now request an enrollment effective date up to 365 days prior to the current date on their enrollment application from the Request Information Panel by entering the specified date in the Requesting Enrollment Effective Date field. Refer to the example in the Backdating a New Enrollment Application Provider Enrollment Portal Quick Guide, available on the Quick Guides web page.
This change will apply only to providers starting a new enrollment application and providers resuming an application that is still in process. For providers who are already enrolled and approved, an Enrollment Backdate Form, available under the Provider Enrollment & Update Forms drop-down section of the Provider Forms web page, must be completed and mailed to DXC.
Resolved 2/13/20: Provider Web Portal Error when Atypical Providers Add Taxonomy Using the Additional Taxonomies Section The Provider Web Portal displayed an error when Atypical providers attempted to add a taxonomy using the Additional Taxonomies section of the Provider Maintenance Specialty and Contact panel. This error affected current providers that are updating an existing enrollment record, not for new enrollments. Only Atypical providers, such as Home and Community Based Services (HCBS) or Transportation providers, were affected.
Note: If an Atypical provider has an National Provider Identifier (NPI), they must add a taxonomy using the Additional Taxonomies section. If an Atypical provider does not have an NPI, a taxonomy cannot be entered in the Additional Taxonomies section.
Issue resolved 2/13/20
National Provider Identifiers (NPIs) and the Provider Web Portal
Once a provider adds the newly obtained National Provider Identifiers (NPIs) to the enrollment records by completing a Provider Maintenance request, there is no need to re-register the new NPI in the Provider Web Portal. The new NPI will automatically display at Web Portal login once it becomes effective.
Off-campus hospital locations should refer to the Provider Maintenance - Hospital Provider Adding an NPI Provider Web Portal Quick Guide and all other providers should refer to the Provider Maintenance – Adding an NPI Provider Web Portal Quick Guide located on the Quick Guides web page for detailed instructions on adding a new NPI to the enrollment records.
Provider Web Portal Password Change to Require 9 Characters
An upcoming change to the Provider Web Portal password requirements will require all Web Portal users to change their passwords from 8 characters to 9 characters. Once this change goes into effect, Web Portal users will be prompted to reset their password to 9 characters the next time it is about to expire.
Provider Web Portal Error Message When Submitting Claims
Some Provider Web Portal users have experienced an intermittent "Error" message asking them to "try again later" when trying to submit claims. DXC believes a combination of internal factors in the DXC system along with external factors with the user’s network/internet connection is causing the problem. While DXC is still working to resolve this issue, the following steps have proven helpful to several users:
- Clear your browser’s cache - Run a connection speed test - Log out and come back at a later time - even a few minutes may help - Use the system during non-peak hours (peak hours are 7 a.m. to 4 p.m. Monday through Friday). Please note that the Provider Web Portal is down for regularly scheduled maintenance every Wednesday night beginning at 7 p.m. MT. Anticipated downtime is usually less than 2 hours, but could be up to 5 hours. - Try using another browser (Internet Explorer is the recommended browser)
If this does not resolve the issue, please call the Provider Services Call Center (1-844-235-2387) and press the option for "web portal." Please let the agent know you have tried the suggestions above and provide them with your log-on ID, Provider ID, an explanation of what you were doing on the portal at the time of the error and contact information for follow-up.
Provider Web Portal Update to Add “Remove” Link to Service Details Section
Effective 7/31/19, the Provider Web Portal has been updated so providers can remove claim details when adjusting a previously paid claim. A “Remove” link has been added to the Submit Dental Claim, Submit Institutional Claim and Submit Professional Claim screens in the “Service Details” section under the “Action” column. Providers can use the link to remove the applicable claim detail lines before resubmitting the claim.
Refer to Step 3 in the Submitting an Institutional Claim and Submitting a Professional Claim Provider Web Portal Quick Guides located on the Quick Guides web page for more information.
Updated Processing Timeline for Third-Party Liability (TPL) Information Submitted Through the Provider Web Portal Effective 5/22/19, a new weekly automated system process will reduce turnaround time on the processing of TPL information entered in the Provider Web Portal. Additional processing will still be required if a member has multiple active policies on file.
The Effective To date will be automatically updated to 12/31/2299. If the policy is no longer active, providers should update the TPL record with a valid termination date.
Refer to the Adding and Updating Third-Party Liability (TPL) Information - Provider Web Portal Quick Guide, available on the Quick Guides web page, for illustrated, step-by-step instructions on adding and updating TPL information via the portal.
Provider Web Portal Inactivity Setting Update Effective 4/24/19, the Provider Web Portal will allow users 15 minutes of inactivity. If Web Portal is left idle for 15 minutes, the user will be logged out and must go to the login page and enter their credentials to access Web Portal again.
Provider Web Portal Invalid Login Attempt Change Effective 3/11/19, the Provider Web Portal will allow users three login attempts. If the user fails to enter the correct log in and password after three attempts, the account will be locked for 15 minutes before login can be attempted again or credentials can be reset.
Clinical Laboratory Improvement Amendments (CLIA) Certification Effective and End Dates
Providers should not be concerned if the Effective Date displayed on the Provider Web Portal does not match the Effective Date they entered or the date of their most recent certification. DXC updated the Effective Date and End Date for all CLIA licenses in the Colorado interChange as of 8/10/18. The Effective and End Dates for all CLIA licenses are as follows:
Effective Date: 1/1/1900
End Date: 12/31/2299
When updating CLIA Certification information via the Provider Web Portal, providers should enter the Effective Date and End Dates as shown above.
Claims submitted with any other Effective and End Dates on the CLIA license will be denied if the dates of service (DOS) precede the Effective Date.
Currently, the Effective Date and End Date are required fields when providers are updating CLIA Certification information. DXC and the Department are working on updating the Provider Web Portal so the effective dates will be automatically populated.
Effective 11/30/17, the Eligibility page on the Provider Web Portal will require users to complete a CAPTCHA human verification step by identifying which images fit the given description. CAPTCHA (an acronym for "Completely Automated Public Turing test to tell Computers and Humans Apart") is a type of challenge-response test used in computing to determine whether or not the user is human. Requests from scripted code or robots will no longer be allowable. This change is intended to minimize issues and slowness affecting all portal users. Batch submitters must utilize the X12 270 for large eligibility requests.
For information on submitting batch 270 Eligibility, visit the EDI Support web page.
For additional questions on how to use the portal or to verify eligibility, please call the Provider Services Call Center at 1-844-235-2387.
Claim Submissions, Adjustments and Voids Limited to 50 or Less Detail Lines in the Provider Web Portal
The Provider Web Portal does not allow for claim submissions, adjustment or voids with over 50 detail lines. Claims with over 50 detail lines must be submitted, adjusted or voided via the Electronic Data Interchange (EDI) batch process, which allows for up to 999 detail lines per claim.
When viewing a claim with more than 50 detail lines in the Web Portal, the “copy,” “void,” “adjust” and “reconsideration” buttons may be disabled, and the portal user will receive the following error message – “Not all service lines can be displayed due to the size of the claim.” If these buttons are available, and the portal user attempts to copy or adjust a claim with more than 50 detail lines, the claim will be denied for EOB 1330 – “The total claim charge is invalid. Re-calculate and correct the total claim charge.”
DXC and the Department are working to implement a fix within the Web Portal to ensure these buttons are consistently disabled when viewing a batch claim with over 50 detail lines.
Void Button Will Only Appear in the Provider Web Portal if the Paid Claim Has Not Already Been Adjusted/Voided and Has 50 or Less Detail Lines
The void button will only appear in the Provider Web Portal if:
Refer to the Provider Web Portal Quick Guide - Copy, Adjust, or Void a Claim, available on the Quick Guides web page, for more information.
Rendering Provider ID Does Not Return a Single Provider - Provider Web Portal
Symptoms: When entering claims on the Provider Web Portal, providers receive "Rendering Provider ID does not return a single Provider" error message. Cause: Provider is not using the magnifying glass button when an NPI is tied to multiple locations. System does not know which location to use, and generates an error message. Solution: If NPI is tied to multiple locations, providers must use the magnifying glass to select the correct location..
Suspended claims only show up once on the Remittance Advice (RA). The claim won’t appear again on the RA until the claim either denies or pays. Once the claim is finalized, it will be reported on the RA and the 835. Suspended claims are not reported on the 835, only on the RA.
Suspends
EOB 1786 - The date of service date is out of timely filing. Refer to the new billing manual.
Explanation: The claim is outside of the initial timely filing period of 240 days. Claims with a timely filing attachment must be reviewed by DXC.
Estimated Time for Processing: 20 business days
EOB 0101 - Possible duplicate: practitioner to practitioner.
Explanation: This may be a duplicate claim, but not all parameters for an exact duplicate are met, so the claim must be reviewed by DXC to determine if it is a duplicate.
Estimated Time for Processing: 30 days
EOB 4000 - "The client 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."
Explanation: The client has other insurance. Medicaid [Health First Colorado (Colorado's Medicaid Program)] is always the payer of last resort. The claim must be sent to the primary carrier first. Due to a system defect claims must be reviewed to determine if the TPL information was entered on the claim.
Estimated Time for Processing: One week
EOB 6172 - "Multiple Surgery Review"
Explanation: The department and DXC are currently working to implement a more efficient process.
Estimated Time for Processing:30 days
EOB 2013 - "Claim Processed With Closest Elig Span-Deny" OR EOB 2690 – "Claim processed with closest eligibility span."
Explanation: The client is currently not eligible.
Estimated Time for Processing: This claim will be recycled after 15 calendar days. If after the 15 days the client is still not eligible for the DOS, the claim will deny.
EOB 0653 - "Claim requires manual pricing. Please attach invoice for medical services."
Explanation: This claim requires manual processing by DXC to price.
NOTE: If claims are over 60 days from the date of receipt, please notify the DXC Provider Services Call Center at 844-235-2387 so they can be escalated for processing.
Denials
EOB 1473 - "Multiple Provider Locations for Billing Provider Specialty."
Explanation: In general, EOB 1473 is an indication that the system cannot determine which location to look at. If a National Provider Identifier (NPI) is associated with more than one (1) provider type or location address, additional steps are needed to ensure proper claims adjudication. A unique nine (9) digit zip code or taxonomy code is required to identify the correct billing provider ID.
Provider action: Confirm the address, NPI and taxonomy on the claim match the information reported on Provider Maintenance tab on the Provider Web Portal.
EOB 4100 - "Type of Bill Code Invalid."
Explanation: Home Health Claim with an invalid TOB (likely 33x).
Provider action: Refer to the new Home Health Billing Manual for claims submission.
EOB 1454 - "Procedure Code, Revenue Code, or Modifier is Invalid - Home Health"
Explanation: Home Health Claim without the Procedure Code, Revenue Code or Modifier Code. While these are not required fields on the Provider Web Portal, they are required for the claim to process correctly.
Provider action: Refer to the new Home Health Billing Manual for required fields. Don't forget to include all applicable procedure codes for PDN claims.
Example: Private Duty Nursing (PDN) claims will deny if submitted without the procedure code T1000, in addition to the revenue code for PDN.
The procedure code is not a required field in the Provider Web Portal, but page 11 of the Private Duty Nursing Billing Manuals does indicate this is required for the claim.
EOB 1786 - "The date of service is out of timely filing. Refer to the new billing manual."
Explanation: Claims must be submitted within timely filing limits. The Department has extended timely filing limits from 120 days from DOS to 240 days from DOS.
Provider action: Submit the claims and reference the ICN of the last submission within 60 days.
EOB 1381 - "No billing rule for procedure."
Explanation: The claim includes a procedure which is not a defined billing rule for the provider type. The rendering provider is not permitted to render the procedure to Health First Colorado members based on the provider type.
Provider action: Ensure the correct procedure code was submitted on the claim. Refer to billing manual to confirm allowable procedures for the provider type.
If the procedure is allowable for the provider type, contact DXC.
EOB 1030 - "The place of service code is invalid for procedure code. Correct the place of service."
Explanation: The procedure and place of service cannot be billed together. This could be because the procedure can’t be performed at a specific POS (transplant in an office) or the combination is not allowed on the providers billing rule.
EOB 3261 - "The procedure code currently is not a benefit for date of service billed."
Explanation: This is not a covered procedure.
Provider action: Confirm the correct procedure code was submitted on the claim. Refer to billing manual for information on covered procedures.
EOB 2590 - "The client has Medicare. Charges must billed to Medicare before billing Medicaid."
Explanation: This member has other coverage with Medicare. Medicare would be the primary insurance and should be submitted.
Provider action: Rebill the claim after billing Medicare first.
EOB 1010 - "This is a duplicate item that was previously processed and paid"
Explanation: The denied claim was a duplicate of a claim that has already been processed and paid (or denied).
Provider action: Providers who believe this error is returned incorrectly should contact DXC Provider Services (1-844-235-2387) with the interChange Control Number (ICN).
EOB 0678 - "Billing Provider Type and Specialty is not allowable for the Rendering Provider"
Explanation: The claim will deny if the Rendering provider type/specialty do not match or if the expected billing provider type/specialty do not match.
Providers have questions about claims with EOB code 3110 for "the rendering provider is not a group member." While it may be unclear on the remittance advice, notations that affiliations are missing do not cause the claim to deny and are informational only. Currently, the Department is giving providers an extended grace period to make all necessary updates to their affiliations to avoid future claims denials. If EOB code 3110 appears on a claim, providers should check their affiliations and make sure they are up to date, and check other EOB codes to see why the claim denied. Updated affiliations are currently taking up to three weeks for final approval. Providers should not submit duplicate update requests.
Timely Filing Period Extended to 365 Days – Effective 6/1/18
In May 2017, the Department of Health Care Policy & Financing (the Department) temporarily extended the timely filing period from 120 to 240 calendar days. Effective 6/1/18, the timely filing period will be extended to 365 days. This is a permanent change, not a temporary extension.
Please note that this timely filing extension does not apply to pharmacy (point of sale) claims submitted through Magellan; however, Durable Medical Equipment (DME) claims are subject to the updated 365-day timely filing policy.
For all updated timely filing policy details, reference the General Provider Information manual, available on the Billing Manuals web page, and the Timely Filing Frequently Asked Questions (FAQs), located on the Provider FAQ Central web page.
Please note that this is not an all-inclusive list of known issues.
Claims Suspending for HCPCS 2021 Quarterly Update Procedure Codes for Explanation of Benefits (EOB) 0000 - "This Claim/Service Is Pending for Program Review" Claims billed with HCPCS 2021 Quarterly Update procedure codes are suspending for EOB 0000 - "This claim/service is pending for program review." The Colorado interChange will be updated with the 2021 HCPCS Quarterly Update billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual release of deletions, changes and additions.
Once the rates are loaded, claims will be released.
Claim shows as Paid in Provider Web Portal but not on the Remittance Advice
Symptoms: A claim may show as "Paid" (with a Paid date of "0") in the Provider Web Portal, but does not show as "Paid" on the Remittance Advice (RA).Cause:Claim is caught in a pre-payment cycle that checks for errors that may cause problems with the financial cycle. The claim is reviewed before being released, but may take a few weeks to review.
Denials for Duplicate Services DXC is working with the Department to closely review duplicate claims to ensure proper payment.
Claim Denials for EOB 4000 – Member Has Other Insurance Secondary Claims with TPL information were incorrectly 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."
As an interim solution, starting 6/5/17, claims will suspend for review rather than deny. During this time, providers may see the claim temporarily suspend for EOB 4000, but no action is required. Claims will be adjudicated appropriately by DXC. DXC is working on a permanent fix.
In order for claims prior to 6/5/17 to be processed correctly, providers are asked to resubmit any claims denying for 4000 that included TPL information.
Providers Unable to Access Update RTPs
Providers are unable to re-enter an update if it's been RTP'd for additional information.
Submit a new (correct) update request, then call the Provider Services Call Center (1-844-235-2387) to have them deny the original RTP'd update request.
Resolved 12/15/20: Professional Claims Denying for Explanation of Benefits (EOB) 7802 or 7817 Professional claims billed with the following procedure codes and modifiers were denying for EOB 7802 - "The non-payment modifier is not appropriate with the billed procedure code."
AND
Professional claims billed with the following procedure codes and modifiers were denying for EOB 7817 - "The payment modifier is not appropriate with the procedure code billed."
Claims were reprocessed 12/18/20.
Issue 12/15/20
Resolved 12/9/20: Professional Claims Denying for “Unbundling” Explanation of Benefits (EOB) 7804 Some professional claims were denying for EOB 7804 – “Separately billed services must be bundled as they are considered components of the same procedure. Separate payment is not allowed.”
Example: Certified nurse midwives may serve as assistant surgeon during a cesarean section. Both the certified nurse midwife claim and surgeon claim are allowable as long as the detailed rendering providers are different on each claim.
Claims were reprocessed 12/29/20.
Issue resolved 12/9/20
Resolved 10/28/20: Delegate Provider Web Portal Users Unable to Resume Revalidation Application
Provider Web Portal users with delegate access were previously unable to access a previously opened Application Tracking Number (ATN) in order to resume their revalidation application. Only users that were signed in to the Web Portal as the account administrator could access the previously opened ATN and resume the revalidation application.
Issue resolved 10/28/20
Resolved 7/2/20: Claims Suspending for HCPCS 2020 Quarterly Update Procedure Codes for Explanation of Benefits (EOB) 0000 - "This Claim/Service Is Pending for Program Review" Claims billed with HCPCS 2020 Quarterly Update procedure codes were suspending for EOB 0000 - "This claim/service is pending for program review." The Colorado interChange has been updated with the 2020 HCPCS Quarterly Update billing codes based on the Centers for Medicare & Medicaid Services (CMS) release of deletions, changes and additions.
Claims were released by DXC on 7/2/20.
Issue resolved 7/2/20
Resolved 3/13/20: Upcoming Reprocessing of Third Party Liability (TPL) Recoupments
The reprocessing of multiple claims identified for recoupment by Health Management Systems (HMS), the Department's Third Party Liability (TPL) vendor, had been delayed within Colorado interChange. These claims identified the member as having commercial insurance or third party liability for the member which should be billed primary.
DXC has reprocessed affected claims and recouped funds.
Issue resolved 3/13/20
Resolved 1/17/20: Provider Web Portal Claims Submitted on 1/16-1/17/2020 Suspending for Member Information Review Claims submitted through the Provider Web Portal on 1/16/2020 and 1/17/2020 were suspending for review of the member’s information, such as date of birth.
Claims were released from suspense 1/17/20 by DXC. The updated status of claims can be found on the Remittance Advice (RA).
Issue Resolved 1/17/20
Resolved 1/15/20: Claims Suspending for HCPCS 2020 Procedure Codes for Explanation of Benefits (EOB) 0000 - "This Claim/Service Is Pending for Program Review"
Claims billed with a HCPCS 2020 procedure code were suspending for EOB 0000 - "This claim/service is pending for program review." The Colorado interChange was updated with the 2020 HCPCS billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual release of deletions, changes and additions.
Claims were released from suspense 1/17/20 by DXC.
For more information, refer to the Healthcare Common Procedures Coding System (HCPCS) Updates for 2020 Special Provider Bulletin.
Issue resolved 1/15/20
Resolved 12/3/19: Professional and Outpatient Claims Suspending for Explanation of Benefits (EOB) 0000
Some professional and outpatient claims were suspending for EOB 0000 – “Adjustment was initiated by provider.“
Claims were released from suspense on 12/3/19.
Issue resolved 12/3/19
Resolved 12/3/19: Reset Provider Web Portal Passwords Not Working
Providers who successfully reset their Provider Web Portal password on or after 11/19/19 were reporting issues when trying to log in with their new password. Providers who did not need to reset their password on or after 11/19/19 were not impacted and were able to successfully log in to the Provider Web Portal.
As a workaround until the issue was resolved, providers were advised to verify member eligibility by calling the Provider Services Call Center at 1-844-235-2387 via the Interactive Voice Response system or by speaking with a call center representative.
Resolved 10/23/19: Provider Web Portal Error When Attempting a Provider Enrollment Update
Provider Web Portal users may have received an error message when attempting an enrollment update stating, “Error: A failure occurred during a database insert. Location Name must be less than or equal to 30 characters in length,” when the name entered in the Doing Business As (DBA) field exceeded 25 characters.
Portal users receiving this error message were advised to contact the Provider Services Call Center at 1-844-235-2387 for workaround instructions.
Issue resolved 10/23/19
10/23/19: Members Incorrectly Enrolled in Denver Health
Some members were being enrolled in Denver Health incorrectly. As an interim solution, impacted members were advised to contact Maximus (303-839-2120, or 888-367-6557; TTY 888-876-8864) to speak with an agent who confirmed their eligibility information and then initiated a correction as appropriate.
Resolved 6/19/19: Provider Web Portal Error When Updating an Electronic Remittance Advice (ERA) X12 835 from the Manage Accounts Link
Providers were receiving an error message when updating an ERA X12 835 report in the Provider Web Portal from the Manage Accounts link. The error message read “There has been a problem with your transaction, please try again later.” As a workaround until this issue was resolved, providers could update the ERAs X12 835 report in the portal through the EFT/ERA (835) Enrollment link.
Issue resolved 6/19/19
Resolved 6/19/19: Provider Web Portal Error When User Copied Claim and Updated Service Detail Information
The Provider Web Portal displayed an error message when a portal user using one National Provider Identifier (NPI) for multiple locations copied a claim, updated the service detail information, and then clicked “Save.”
The error message stated: “There has been a problem with your transaction, please try again later. If you were submitting a claim please check to see if your claim has been processed prior to resubmitting.”
Resolved 3/1/19: All Providers that Bill Medicare:
COBA Claims for Members with QMB Only Were Not Automatically Crossing Over
Some claims for services provided to members that have Qualified Medicare Benefits (QMB) only, with no Title XIX coverage, were not automatically crossing over from COBA to the Colorado interChange.
Issue resolved 3/1/19
Resolved 2/27/19: Claim Resubmissions Denying for Timely Filing
Some claims resubmitted after a previous adjustment were incorrectly denying for Explanation of Benefits (EOB) 1786 – “The date of service date is out of timely filing” in the following scenario:
Claims were reprocessed by DXC 4/5/19.
Note: Claims that are still within 365 days and have been adjusted can be resubmitted without the adjustment ICN.
Issue resolved 2/27/19
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 2/1/19: Prior Authorization (PA) Letters Unavailable in the Provider Web Portal PA letters from 1/8/19 to 1/31/19 were unavailable in the Provider Web Portal. The missing PA letters are now available in the Web Portal. Letters from 1/8/19 to 1/24/19 were posted in the Web Portal on 2/2/19. Letters from 1/25/19 to 1/31/19 were posted in the Web Portal on 2/6/19.
As a workaround until this issue was resolved, providers were advised to contact the Provider Services Call Center at 1-844-235-2387 and request that the call center representative look up the PA number. Providers could then search that PA number in the Provider Web Portal in order to view and save PA information. After logging into the Provider Web Portal, select the “Care Management” option from the menu, then select the “View Status of Authorizations” option on the Care Management page. Providers can view all of their PAs on the Prospective Authorizations tab or search for specific PAs on the Medical/Dental tab.
If the provider is listed as the billing or rendering provider on the PA, they do not need to know the PA number to search for it. Only the following search criteria is required:
• At least one field in the “Authorization Information” section; or • At least one field in the “Provider Information” section; or • Member ID or Last Name, First Name and Birth Date in the “Member Information” section
Issue resolved 2/1/19
Resolved 1/23/19: Claims Suspending for HCPCS 2019 Procedure Codes for EOB 0000 – “This Claim/Service Is Pending for Program Review” Claims billed with a HCPCS 2019 procedure code were suspending for EOB 0000 - “This claim/service is pending for program review.” The Colorado interChange has been updated with the 2019 HCPCS billing codes based on the Centers for Medicare & Medicaid Services (CMS) annual release of deletions, changes and additions.
Claims were reprocessed by DXC on 2/1/19.
Issue resolved 1/23/19
Resolved 7/5/18: Provider Web Portal Error When Attempting to View Crossover and Secondary Claims Provider Web Portal users may have experienced an error when attempting to view crossover and secondary claims for some members. The error message stated: "There has been a problem with your transaction, please try again later. If you were submitting a claim please check to see if your claim has been processed prior to resubmitting."
Issue resolved 7/5/18
Resolved 6/13/18: Retroactive Updates to Eligibility Spans The Colorado interChange was not processing some retroactive changes to a Health First Colorado (Colorado’s Medicaid Program) and Child Health Plan Plus (CHP+) member’s eligibility span. The Colorado interChange is now receiving the changes from the CBMS eligibility system. This issue has now been resolved.
If a member still believes an update to their eligibility information is necessary, the process is the same as it would have been with the Xerox legacy system; the member must call the Health First Colorado Member Contact Center to initiate the correction. In some cases, the member may be redirected to the county technician if additional information is needed to fulfill the eligibility requirements.
Issue resolved 6/13/18
Resolved 4/6/18: Paper Claim Adjustment or Void Denials for EOB 0100 - "Denied as Duplicate Claim" Claim adjustments (reason code 7) or voids (reason code 8) submitted on paper were previously denying for EOB 0100 - "Denied as duplicate claim" because the system was not processing them as an adjustment or void, but as an original claim. These claims were being held for processing until the issue was resolved. Providers are advised to resubmit affected claims.
Providers are reminded that if they are submitting more than 5 claims a month and have not signed up for paper claim submission then they must submit all adjustments electronically.
Issue resolved 4/6/18
Resolved 4/5/18: Third-Party Liability (TPL) Information on Adjusted Claims Not Matching TPL Information Submitted on Original Claim Adjustments to claims originally filed with TPL information were not calculated correctly, causing for the TPL information on the adjustment to not match the TPL information on the original claim.
Affected claims were reprocessed by DXC in three stages, on 5/25/18, 6/1/18 and 6/15/18.
Issue resolved 4/5/18
Resolved 3/7/18: Claims Suspending for HCPCS 2018 Procedure Codes Claims were suspending when billed for HCPCS 2018 procedure codes for EOB 0000 - "This claim/service is pending for program review." Claims were reprocessed by DXC on 3/9/18.
Issue resolved 3/7/18
Resolved 2/28/18: Changes to Rendering or Referring Provider on Service Detail Line Not Saving
A Provider Web Portal error was occurring where the provider was attempting to change the rendering or referring provider on the Service Detail line of a claim after the initial entry, but the portal did not save the change.
The following workaround was given until the issue was resolved: If the provider wished to modify the entry, the line should have been removed and re-entered. The line could be removed by clicking Remove in the Action column or clicking the Reset button at the bottom of the window.
Issue resolved 2/28/18
Resolved 2/28/18: Third Party Liability – Carrier Not Listed When adding Third Party Liability to a claim in the Provider Web Portal, providers were previously unable to type in the carrier name if the member’s carrier wasn’t one of the options available. Providers were previously unable to submit the claim correctly via the web portal and had to submit on paper or batch.
Providers can now submit the TPL carrier on the web portal or continue to submit on batch. Paper claims do not need to be sent. For TPL carriers not listed, select the Other Carrier option, which now includes the Effective From date as a required field.
Resolved 2/8/18: Provider Enrollment Portal Duplicate Record Error Message An issue was identified on 2/8/18 where providers attempting to submit a new application or submit a disenrollment were receiving an error message stating "A failure occurred during a database insert. A duplicate record cannot be saved." This issue has now been resolved.
Issue resolved 2/8/18
Resolved 1/25/18: Professional Crossover Claims Denying for EOB 1178 – "Service is not reimbursable for Date(s) of Service" Beginning Jan 11, 2018, professional crossover claims were denying for EOB 1178 - "Service is not reimbursable for Date(s) of Service."
Claims were reprocessed by DXC on 1/26/18.
Issue resolved 1/25/18
Resolved 1/10/18: Claim Denials due to Bypass Modifiers for the National Correct Coding Initiative (NCCI) Update Claims were denying due to the bypass modifiers not being setup correctly in Colorado interChange. The Department and DXC have made adjustments to the system that reflect the current NCCI Policy and billing documentation.
Providers are advised to resubmit affected claims.
Issue resolved 1/10/18
Resolved 5/22/19: Multi-Surgery Claims for Ambulatory Surgery Center (ASC) Some ASC claims paid more than one line between 6/1/17 and 5/22/19.
Affected claims were reprocessed and overpaid funds were recouped by DXC on 8/9/19. Recoupments will appear on Remittance Advices beginning Monday, 8/12/19.
Issue resolved 5/22/19
Resolved 12/14/18: Ambulatory Surgical Claims Denying when Billed with POS Code 24 (Ambulatory Surgical Center) for EOB 1030 Ambulatory Surgical Center claims for the following procedure codes 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.”
Issue resolved for procedure codes 60220 and 21365 on 11/28/18. Issue resolved for procedure codes on 01991 and 01935 on 12/14/18.
Resolved 11/14/18: Ambulatory Surgical Center Provider Claim Denials for EOB 0182 – “Billing Provider Type and/or Specialty is Not Allowable for the Service Billed” Ambulatory Surgical Center (provider type 44) claims for the following procedure codes were denying for EOB 0182 – “Billing Provider Type and/or Specialty is not allowable for the service billed.”
Issue resolved 11/14/18
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 3/16/18: Claim Denials for Ambulatory Surgical Center Providers for Procedure Code 67808 for EOB 0182 – Billing Provider Type and/or Specialty Not Allowable for Service Billed Claims for Ambulatory Surgical Center providers were denying for procedure code 67808 for EOB 0182 – “Billing Provider Type and/or Specialty is not allowable for the service billed.”
Claims were reprocessed by DXC on 3/23/18.
Issue resolved 3/16/18
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.
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:
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
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. Please be aware this rate increase does not apply to CMHS clients.
Ending the service line: As you know we have asked for PAR revisions to be completed, ending the line September 30, 2017, and beginning the new line October 1, 2017. We know that may not be possible for providers who have billed past September 30, 2017. We have informed provider agencies that they have the option to seek the higher reimbursement; if they do they will need to coordinate with you to do so.
Note that claims for all impacted dates of service must be voided by providers in order for revisions to be performed. The following steps must take place to adjust the rate and PAR:
1) Provider will contact the case manager by November 30, 2017, indicating they wish to get the higher rate. 2) Agree on the time period the case manager can complete the revision.
3) The provider will void the claims, using the instructions from the Provider Web Portal Quick Guide - Copy Adjust or Void a Claim. 4) Case manager will complete the revision of both the PAR and PETI, reflecting the correct dates and new rates. A screenshot of the work completed shall be sent to the provider. 5) Provider will rebill all impacted claims.
CMHS clients/PARs: As the CMHS rate has not been increased (CDASS exception beginning December 1, 2017), we ask that you do not perform any revisions to the PARs for all other services. If you have a new client, or must complete a CSR, the new rate will be populated for the provider. You may use the increased rate on both the PETI and PAR. The Department will notify all CMAs once we receive federal approval of the CMHS rates.
Categorical clients: In order for providers to receive the higher rate, both the PAR and PETI must be revised. The system pulls the rate from the PETI, rather than the PAR. This means you must complete a revision of the PETI and PAR for all categorical clients.
Resolved 12/16/20: Case Managers/Transition Services Claims Suspending for Explanation of Benefits (EOB) 5765 - Targeted Case Mgmt-Trans Svcs (TCM-TS) is Limited to 240 Units per Transition
Case managers/transition services claims were suspending for using procedure code T1017 for EOB 5765 - "Targeted Case Mgmt-Trans Svcs (TCM-TS) is limited to 240 units per transition."
Claims were reprocessed on 12/18/20.
Issue resolved 12/16/20
Resolved 3/7/20: Prior Authorization Revisions for Procedure Codes T2031 and T2033 Case managers were temporarily unable to revise PAR lines with codes T2031 (Alternative Care Facility) and T2033 (Supported Living Program). This may have allowed claims to pay higher than the approved daily rate that is listed on the PAR. This may have potentially caused the total approved dollars to be exhausted before the end of the certification period, and before all units are utilized.
No action is necessary for case managers or providers at this time. Issue resolved 3/7/20
Resolved 9/4/19: Member’s Gross Income Populating as “0” in Post-Eligibility Treatment of Income (PETI) Worksheet PETI worksheets were populating “0” in the member’s gross income field.
As a work around until this issue was resolved, case managers were advised to enter the member’s gross income in the appropriate field and then click “calculate.” Case managers could use the member’s gross income from the latest PETI worksheet to enter in the new worksheet.
Issue resolved 9/4/19
Resolved 9/4/19: Incorrect Benefit Plan Reflected in Post-Eligibility Treatment of Income (PETI) Worksheet PETI worksheets created prior to implementation of “PETI by Program” on 7/3/19 were displaying “PACE” under the Current Benefit Plan.
Case managers were advised that they did not need to correct the Current Benefit Plan. If necessary, case managers should have been able to end any of the older PETI worksheets.
Resolved 6/12/18: Retroactive Updates to Eligibility Spans in the Bridge
The Colorado interChange was not processing some retroactive changes to a member’s eligibility span, which was contributing to issues of Home and Community Based Services (HCBS) member eligibility mismatches between the Colorado Benefits Management System (CBMS) and the Bridge.
This issue is resolved, and the Colorado interChange is receiving the changes from the CBMS eligibility system. The Bridge will reflect retroactive updates to HCBS member eligibility spans. This update will help with the finalization of HCBS Prior Authorization Requests (PARs).
Case managers should take the following steps to finalize any impacted Prior Authorizations (PAs):
There could be instances where the data in CBMS does not match the data in the Bridge. If an eligibility does not appear in the Bridge after two business days, but has been confirmed as processed by the county technicians, please email HCPF_BPA-CBMSMismatch@state.co.us with the necessary CBMS screenshots documenting member eligibility.
Although this change will help resolve PA issues, case managers are still responsible for communicating with the county regarding members’ financial and functional eligibility.
Issue resolved 6/12/18
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 anesthesia services rate decreases which were not applied to the initial rounds of reprocessing. Refer to page 610 of the Colorado Register, published on 5/10/19, for more information on the anesthesia rate decrease, effective 7/1/19.
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 6/1/18: Anesthesia Units Rounding
Prior to 6/1/18, anesthesia policy reimbursed claims based on 15-minute time units where any fractional unit of service was rounded up to the next 15-minute increment.
Effective 6/1/18, providers should bill for exact minutes; refer to the May 2018 Provider Bulletin – Anesthesia (B1900416) for guidance on rebilling and adjusting affected claims.
Issue resolved 6/1/18
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.
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, available on the Quick Guides web page.
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 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.
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).
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 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
Some Durable Medical Equipment (DME) supply claims billed with the RR modifier are denying for EOB 7802 – “The non-payment modifier is not appropriate with the billed procedure code.” A resolution to this issue is in process. Affected claims will be reprocessed.
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 1/13/21: Durable Medical Equipment (DME) Supply Claims Billed with TW Modifier Denying for Explanation of Benefits (EOB) 7802
Some Durable Medical Equipment (DME) supply claims billed with the TW modifier were denying for EOB 7802 – “The non-payment modifier is not appropriate with the billed procedure code.”
Claims were reprocessed 1/19/21.
Issue resolved 1/13/21
Resolved 1/13/21: Durable Medical Equipment (DME) Supply Claims Billed with RB or RA Modifiers Denying for Explanation of Benefits (EOB) 7802 Some Durable Medical Equipment (DME) supply claims billed with the modifiers RB or RA were denying for EOB 7802 – “The non-payment modifier is not appropriate with the billed procedure code.”
Resolved 1/13/21: Durable Medical Equipment (DME) Supply Claims Billed with NU Modifier Denying for Explanation of Benefits (EOB) 7802
Some Durable Medical Equipment (DME) supply claims billed with the NU modifier were denying for EOB 7802 – “The non-payment modifier is not appropriate with the billed procedure code.”
Resolved 10/21/20: Outpatient Claims Receiving Explanation of Benefits (EOB) 3054 - “EVV Record Required and Not Found” When Submitted After Professional Claim
Some providers who submitted a professional claim followed by an outpatient claim via the Provider Web Portal were receiving a response of EOB 3054 - “EVV Record Required and Not Found.”
This issue primarily impacted Hospital – General and Nursing Facility providers; however, other provider types may also have been affected, including:
While these outpatient claims were posting EOB 3054, claims payment was not impacted and reprocessing was not needed.
No action is required from providers.
Resolved 9/30/20: Geographic Rates Updated for Durable Medical Equipment (DME) Codes Subject to Medicare Upper Payment Limit (UPL)
Effective for claims with dates of service on or after 1/1/20, geographic rates for DME codes subject to the Medicare Upper Payment Limit (UPL) were implemented in the Colorado interChange on 9/30/20.
The Durable Medical Equipment fee schedule for 2020 has been posted under the Durable Medical Equipment, Upper Payment Limit drop-down section located on the Provider Rates & Fee Schedule web page.
Claims with dates of service from 1/1/20 - 5/31/20 were reprocessed on 10/30/20. Claims with dates of service from 6/1/20 - 9/30/20 were reprocessed on 11/6/20 and 12/15/20.
Issue resolved 9/30/20
Resolved 3/16/20: Durable Medical Equipment (DME) Claim Denials for EOB 5110
Claims billed for procedure code A4225 were incorrectly denying for 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.” This procedure code does not require a prior authorization. Providers should resubmit affected claims.
Issue resolved 3/16/20
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
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.
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 7/26/19: 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.
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.
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 11/8/18: Supply Provider Claim Denials for Procedure Code A9900 for EOB 1178 - “Service is Not Reimbursable for Date(s) of Service” Supply provider (type 14) claims for code A9900 were denying for EOB 1178 - “Service is not reimbursable for Date(s) of Service.” Claims were reprocessed by DXC on 11/23/18.
Issue resolved on 11/8/18
Resolved 10/31/18: Supply Claim Denials for EOB 1178 - “Service is Not Reimbursable for Date(s) of Service” Professional claims billed by a Pharmacy provider (type 09) were denying for EOB 1040 - “A billing provider contract could not be assigned to this claim.” This issue affected all claims for durable medical equipment or supply.
Claims were reprocessed by DXC on 11/2/18.
Issue resolved 10/31/18
Resolved 10/19/18: Across the Board Rate Increase for Manually Priced Codes for Dates of Service 7/1/17 - 6/30/18 DXC has completed reprocessing for all claims with manually priced durable medical equipment (DME) procedure codes for dates of service 7/1/17 – 06/30/18. Adjusted claims that would result in denial and recoupment of the original payment were not processed. If providers have claims that still need to be reprocessed, providers should resubmit claims with the invoice or quote from the manufacturer. For any claims that are over 365 days old, providers must rebill and then report the claims to hcpf_dme@state.co.us for further resolution on timely filing denials. Include the National Provider Identifier (NPI) and total volume of claims in the email. Issue resolved 10/19/18
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 eQHealth has resent PARs to the interChange. If providers encounter PARs that do not show fully approved, they are advised to contact eQHealth.
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.
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 12/12/20: Behavioral Health Claims Billed by Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs) or Indian Health Services (IHS) - FQHC Denying for Explanation of Benefits (EOB) 2029
Some outpatient behavioral health claims billed by FQHC, RHC or IHS-FQHC providers were denying for EOB 2029 – “The Services Must Be Billed to The Members RAE.”
Claims were reprocessed 12/21/20.
Issue resolved 12/12/20
Resolved 4/13/20: Federally Qualified Health Center (FQHC) Claims Using Procedure Code 90791 Were Denying for Explanation of Benefits (EOB) 2028 FQHC Claims using procedure code 90791 were denying for EOB 2028 - "Behavioral health revenue 900 requires behavioral health procedure code"
Claims were reprocessed on 4/17/20.
Issue resolved 4/13/20
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
Claims were reprocessed by DXC 5/17/19.
Issue resolved 5/9/19
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 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.
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:
One of the following issues may apply:
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 11/14/20: Home & Community-Based Services Children's Habilitation Residential Program (HCBS CHRP) Waiver Claims Denying for Explanation of Benefits (EOB) 4758
Some HCBS CHRP claims were denying for EOB 4758 - "Billing Provider Type/Specialty Restriction on Procedure Coverage Rule."
Affected claims were reprocessed on 11/20/20
Issue resolved 11/14/20
Resolved 8/3/20: Alternative Care Facility (ACF) Claims Suspending for Explanation of Benefits (EOB) 3051 or EOB 3090 – Provider Under Review – Suspend All Claims Due to rate changes implemented 7/1/20, some ACF providers had all claims with dates of service on or after 7/1/20 temporarily put in a suspended status through the month of July 2020. Claims suspended for EOB 3051 - "Rendering provider under review - suspend all claims" or EOB 3090 - "Billing provider under review - suspend all claims."
This allowed for Post-Eligibility Treatment of Income (PETI) Prior Authorization Request (PAR) rate adjustments on all affected PARs for procedure code T2031, Alternative Care Facility (ACF).
Providers were encouraged to continue to submit claims during this time, however, procedure code T2031 should have been billed on a separate claim from all other procedure codes.
Some claims that included the T2031 procedure code were released from suspense on 8/7/20, and those with dates of service on 7/1/20 were released from suspense on 8/14/20. Targeted rate updates have been completed on the PARs. Claims that did not include the T2031 procedure code may have been reviewed and released before 7/31/20, if possible.
Affected providers received an email communication to notify them of this issue.
Issue resolved 8/3/20
Resolved 5/21/20: Eligibility Impacting Foster Care Members Waiver Benefits
If there is an eligibility break for members with Foster Care Eligibility spans, providers should contact their case managers as case managers can now manage Home & Community Based Services (HCBS) waiver eligibility for these members.
Issue resolved 5/21/20
Resolved 5/27/20: Home & Community Based Services (HCBS) Alternative Care Facility (ACF) for Elderly, Blind or Disabled (EBD) and Community Mental Health Services (CMHS) Waiver Claims for T2031 Denying for EOB 1010 and 0101 Some HCBS ACF for EBD and CMHS waiver claims for procedure code T2031 billed with the U1 or UA modifiers with or without the TU modifier (enhanced rate for COVID-19) were denying for EOB 1010 – “This is a duplicate item that was previously processed and paid” or EOB 0101 – “This is a duplicate service.” The Colorado interChange was allowing one line item to process for payment but was denying the other line item as a duplicate.
Claims were reprocessed by DXC 5/28/20.
Issue resolved 5/27/20
Resolved 5/27/20: Home & Community Based Services (HCBS) Developmental Disabilities (DD) Waiver Level 7 Claims for T2016 Denying for EOB 2384 HCBS DD waiver claims for procedure code T2016 billed with the following modifier combinations with or without the TU modifier (enhanced rate for COVID-19) were denying for EOB 2384 – “Residential Habilitation Services and Support DIDD benefit limited to 1 unit per day.” The Colorado interChange was allowing one line item to process for payment but was denying the other line item as benefit limited to one per day.
Issue resolved 5/9/20
Resolved 4/13/20: Procedure Code T1019 Was Denying for Explanation of Benefits (EOB) 2029
Procedure code T1019 was denying for EOB 2029 - "Services must be billed to members RAE"
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 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:
Issue resolved 5/17/19
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.”
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.
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 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
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.
Resolved 10/8/20: Claims for Pediatric Home Health Services Submitted with Revenue Codes 421, 431 or 441 Denying for Prior Authorization (PA) Some pediatric home health UB-04 claims for members aged 18 to 20 submitted with revenue codes 421, 431 or 441 were incorrectly denying 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.”
Claims with dates of service on or after 1/1/20 were reprocessed on 10/8/20.
Issue resolved 10/8/20
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.”
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 eQHealth has resent PARs to the interChange. If providers encounter PARs that do not show fully approved, they are advised to contact eQHealth.
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 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
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:
Resolved 7/1/20: Claim Denials for Newborn Services
Claims were denying when a male baby is receiving gender-specific services such as circumcision, and the claim was submitted with the mother's Health First Colorado Provider ID. This was due to the mother's gender not matching the baby's. This was affecting claims where the gender-specific or age-specific service is identified by either procedure or diagnosis codes.
This could have caused 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 for dates of service prior to 7/1/20; 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.
Refer to the July 2020 Provider Bulletin (B2000450) for issue resolution details. Claims will be reprocessed by DXC.
Resolved 4/29/20: COVID-19 Update to 3M Enhanced Ambulatory Patient Grouping (EAPG) Grouper
Issue resolved 4/29/20
Resolved 4/15/20: New HCPCS Codes for Specimen Collection for 2019 Novel Coronavirus (COVID-19) New HCPCS codes G2023 and G2024 (used to identify and reimburse specimen collection for COVID-19 testing) have been released for dates of service on or after March 1, 2020, for an independent laboratory provider type only. The Colorado interChange has been updated to receive and process claims for these codes.
Issue resolved 4/15/20
Resolved 3/25/20: Colorado interChange Update to Receive New ICD-10 Code for COVID-19
The Colorado interChange has been updated to receive and process claims billed with the new ICD-10 code for the diagnosis of COVID-19 U07.1 for dates of service on or after April 1, 2020.
Issue resolved 3/25/20
Resolved 3/25/20: Colorado interChange Update to Receive New CPT Code for Laboratory Testing for COVID-19 The Colorado interChange has been updated to receive and process claims billed with new CPT code 87635 for the laboratory testing of the novel coronavirus (COVID-19) for dates of service on or after March 13, 2020.
Resolved 3/20/20: New Healthcare Common Procedure Coding System (HCPCS) Codes for 2019 Novel Coronavirus (COVID-19) Laboratory Tests
The Colorado interChange has been updated to receive and process claims billed with new HCPCS codes U0001 and U0002 for dates of service on or after February 4, 2020. Providers who test members for the 2019 Novel Coronavirus (COVID-19) using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel may bill using code U0001. Providers may use code U0002 to bill for non-CDC laboratory tests for COVID-19. Billing with these specific codes will allow for better tracking of the public health response for COVID-19.
Billing with these specific codes will allow for better tracking of the public health response for COVID-19. Rates for U0001 and U0002 can be found on the Provider Rates & Fee Schedule web page under Health First Colorado Fee Schedule drop-down.
Issue resolved 3/20/20
Resolved 2/26/20: Long Term Acute Care (LTAC), Rehabilitation (Rehab) and Spine/Brain Injury Treatment Specialty Hospital Hospitals Changed to Per Diem Reimbursement
Effective 7/1/19, Long Term Acute Care (LTAC) Hospitals and Rehabilitation (Rehab) hospitals changed from All Patient Refined – Diagnosis Related Groups (APR-DRG) reimbursement to per diem reimbursement. Colorado interChange was updated to reflect the change on 2/26/20, and claims submitted after 2/26/20 will process accordingly.
Instructions to re-bill claims that spanned the implementation date of 7/1/19, were uploaded to the Inpatient Hospital Per Diem web page and the Inpatient/Outpatient (IP/OP) Billing Manual on 4/24/20. Please re-bill qualifying claims according to directions provided.
Issue resolved 2/26/20
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:
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: Hospital Claims Denials for Part-B Only for EOB 0103 - "This is a Duplicate Item That was Previously Processed and Paid"
Claims may have suspended for a possible conflict when billed for a member that has Part B only Medicare coverage. Either the claim with 11X or 12X may have denied depending on when the claim was received. As a result, claims may have denied for EOB 0103 - "This is a duplicate item that was previously processed and paid."
Claims were reprocessed by DXC on 10/23/19.
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.
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 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 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.
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.
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 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 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 10/21/20: COVID-19 Laboratory Procedure Codes U0002 and 87635 Included as Clinical Laboratory Improvement Amendments (CLIA) Waived Tests
Effective 4/1/20, procedure codes U0002 and 87365 have been updated as Clinical Laboratory Improvement Amendments (CLIA) waived tests. Laboratory providers with a valid CLIA Certificate of Waiver (COW) may bill codes U0002 and 87635 with the QW modifier when billed with diagnosis code U07.0.
Affected claims with dates of service on or after 3/20/20 were reprocessed on 10/27/20.
Issue resolved 10/21/20
Resolved 6/1/20: COVID-19 Laboratory Procedures Codes U0003 and U0004 Paid Incorrectly
New COVID-19 procedure codes U0003 and U0004 for laboratory claims with dates of service 3/18/20 - 6/1/20 were paid without being reviewed for Clinical Laboratory Improvement Amendments (CLIA) certification requirements.
Claims were reprocessed by DXC on 6/12/20. Reprocessed claims which did not meet CLIA certification requirements were denied and funds were recouped. Recoupments appeared on Remittance Advices beginning 6/15/20.
Issue resolved 6/1/20
Resolved 4/15/20: New HCPCS Codes for Specimen Collection for 2019 Novel Coronavirus (COVID-19) New HCPCS codes G2023 and G2024 (used to identify and reimburse specimen collection for COVID-19 testing) have been released for dates of service on or after March 1, 2020. The Colorado interChange has been updated to receive and process claims for these codes.
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.
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:
1/18/18: Claim Denials for Vaccine Procedure Codes for EOB 1552 and EOB 1030
Issue resolved 1/18/18
Nurse Home Visitor Program (NHVP) Claims Billed with HD or TD Modifiers Denying for Explanation of Benefits (EOB) 7802 Some Nurse Home Visitor Program (NHVP) claims for the following procedure codes billed with the HD or TD modifiers are denying for EOB 7802 – “The non-payment modifier is not appropriate with the billed procedure code.”
A resolution to this issue is in process. Affected claims will be reprocessed.
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 7/8/20: Behavioral Therapy Claims for Procedure Code 96110 EP Are Not Paying Correct Rate
Claims with a date of service on or after 6/1/20 for procedure code 96110 with modifier EP were not paying at the correct rate.
Claims were reprocessed by DXC on 7/17/20.
Issue Resolved 7/8/20
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 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."
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.
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.
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.
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 3/1/19: Nursing Facility Claim Denials for Explanation of Benefits (EOB) 0101 - "This is a Duplicate Service" Some nursing facility claims were incorrectly denying for EOB 0101 – “This is a duplicate service.” The Department’s policy allows for the discharging facility to bill through the discharge date and the admitting facility to bill for the admit date, which can allow the same date to appear on both claims. Claims were reprocessed by DXC 3/8/19.
Issue resolved 3/1/19.
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 2/13/20: 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 have reflected the total amount of units the member has used.
Providers are still 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.
Issue Resolved 2/13/20
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
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.”
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:
Claims were reprocessed on 10/26/18.
Issue resolved 10/17/18
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.
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
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.
Fiscal Year 2019-2020 Provider Rate Increases and Adjustments
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:
Claims were reprocessed by DXC on 3/1/19.
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 2/14/19: 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.
Issue resolved 1/31/19
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 8/24/20: Duplicate Payments for Some Pharmacy Claims
Some pharmacy claims submitted between 5/2/20 and 8/23/20 received duplicate payments. Not all pharmacies were affected by this issue.
Claims will be reprocessed by DXC Technology and funds will be recouped in the coming months. A future communication will be sent the week prior to the recoupment. This information will appear on the Remittance Advice. Providers are encouraged to not submit voids directly.
Contact Magellan at COMedicaidSupport@magellanhealth.com with any questions or concerns regarding this upcoming recoupment.
Issue resolved 8/24/20
Resolved 2/25/20: 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 were 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.
Issue resolved 2/25/20
Resolved 1/13/21: Physical Therapy Claims for Procedure Codes 20560 & 20561 Billed with GP, 96 or 97 Modifiers Denying for Explanation of Benefits (EOB) 7802 Some physical therapy claims for procedure codes 20560 and 20561 billed with the GP, 96 or 97 modifiers were denying for EOB 7802 – “The non-payment modifier is not appropriate with the billed procedure code.”
Affected claims were reprocessed 1/15/21.
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:
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."
2/14/18: Providers Unable to see Prior Authorization (PA) Modifiers on the Provider Web Portal
Resolved 10/28/20: Claims Denying for Evaluation & Management (E&M) Services and Procedure Code 99050 for Explanation of Benefits (EOB) 7801 - "Content of Service of Another Procedure on Current/Previous Claim" When Billed with Other E&M Services
Professional claims for procedure code 99050 (services provided in the office when the office is normally closed after-hours) were previously denying when billed with other E&M services for EOB 7801 - "Service is denied because it is content of service of another procedure on the current and/or previous claim."
Claims were reprocessed on 10/30/20.
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 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.
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.”
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.
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:
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 8/9/18: Claims Denials for 90791, 90832, 90834, 90837, 90846, 90847 and 90792 for EOB 0182
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 7/6/18: 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:
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.
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."
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.
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."
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.
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 1/12/18: 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").
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 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:
Claims were reprocessed by DXC 3/2/18.
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”
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 1/6/21: Non-Emergent Medical Transportation (NEMT) Claims Billed with Modifier 77 Denying for Explanation of Benefits (EOB) 7802 Some Non-Emergent Medical Transportation (NEMT) claims for the following procedure codes billed with modifier 77 were denying for EOB 7802 – “The non-payment modifier is not appropriate with the billed procedure code.”
Claims were reprocessed 1/7/21.
Issue resolved 1/6/21
Resolved 2/10/20: Non-Emergent Medical Transportation (NEMT) Claims Denials for Procedure Code A0425 - Explanation of Benefits (EOB) 1599
Non-Emergent Medical Transportation (NEMT) claims for procedure code A0425 were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed."
Claims were reprocessed by DXC on 2/21/20.
Issue resolved 2/10/20.
Resolved 5/16/19: Non-Emergent Medical Transportation (NEMT) Claim Denials - Explanation of Benefits (EOB) 1599 Non-Emergent Medical Transportation (NEMT) claims for procedure codes A0426, A0428, A0130, T2001, T2005, T2049 and S0209 were denying for EOB 1599 - "Rendering Provider Type and/or Specialty is not allowable for the service billed." Claims were reprocessed in two stages. NEMT provider claims that denied between 4/16/19 and 5/15/19 were reprocessed 5/17/19. Transportation provider claims denials were reprocessed 5/24/19. Issue resolved 5/16/19
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.
Resolved 10/28/20: Vision Claim Denials for Explanation of Benefits (EOB) 7817 - “Payment Modifier Not Appropriate” When Billed with Modifier 55
Professional claims for adult glasses and contact lens procedure codes were denying when submitted with modifier 55 for EOB 7817 - “The payment modifier is not appropriate with the procedure code billed.”
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:
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 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
DME: E0486, E0635, E0639, E0676, K0462, L8699, S0395Laboratories: 89259, 81205, 81281, 81287, 81355Physician 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 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).