Prenatal Plus Program Outpatient – Fee-For-Service

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The Prenatal Plus Program (PN+) is administered by the Colorado Department of Health Care Policy and Financing (the Department). This manual details information regarding the program's programmatic components and billing requirements. The Department periodically modifies the Prenatal Plus Program benefits and services, therefore, the information in this manual is subject to change, and the manual is updated as new policies are implemented.

For general information about Colorado's Medical Assistance Program, please refer to the Health First Colorado (Colorado's Medicaid Program) Provider Information found on the Billing Manuals web page of the Department's website. The manual provides information about billing the Health First Colorado, reimbursement policies, provider participation, eligibility requirements and other useful information.

 

Program Overview

The Prenatal Plus Program is a case management program for pregnant women who receive Health First Colorado benefits and who are at risk of negative maternal and infant health outcomes. The program gives women access to a care coordinator, a registered dietician, and a mental health professional who work together to help the woman reduce her risk of having a low birth weight baby. Prenatal Plus Program services are in addition to a woman's regular prenatal care services.

  • To be eligible for the program, a woman must meet the following criteria:
    • Be eligible for Health First Colorado;
    • Be pregnant;
    • Be at risk of negative maternal or infant health outcomes due to lifestyle, behavioral, and non-medical parts of the woman's life that could affect her pregnancy (see Eligibility Screening Form).

For more information about the Prenatal Plus Program, please visit the Prenatal Plus Program's web page.

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Reimbursable Services

Reimbursable services include nutrition and psychosocial counseling and support; general education and health promotion; and targeted case management services. With the exception of targeted case management, all services can be offered to members in an individual or group setting.

  • Nutrition counseling and support provided by the registered dietitian may include nutrition screening, education, and counseling. Counseling includes such activities as nutrition care-planning, goal-setting, monitoring, follow-up, and revision of the care plan.
  • Psychosocial counseling and support provided by the mental health professional may include psychosocial health screening, assessment, and counseling. Counseling and support includes such activities as care-planning, goal-planning, monitoring, follow-up, and revision of the care plan.
  • General member education, health promotion, and targeted case management are services offered by the care coordinator. Topics may include basic understanding of the prenatal period, concerns related to childbirth and breastfeeding, and the post-partum period and healthy infancy. Targeted case management helps member gain access to needed medical, education, social, and other services.

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Rules and Regulations

The Prenatal Plus Program is administered by the Department. Rules governing the program are outlined in the Code of Colorado Regulations, 10 C.C.R. 2505 – 10 §8.748. Providers are required to comply with all of the rules and guidance provided by the Department and are encouraged to contact the Department's policy specialist with any questions.

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Required Documentation

Prenatal Plus Program sites utilize three specific forms to implement the program. All of these documents, a more comprehensive program manual, and provider resources and announcements can be found on the Prenatal Plus Program's section of the Department's website at colorado.gov/hcpf. They include:

  • Prenatal Plus Eligibility Screening Form
  • Initial Assessment Form
  • Psychosocial Assessment

While these forms are required, the method and detail of documentation of member's service plans is up to the discretion of the local Prenatal Plus Program staff. Every claim for reimbursement must be supported by clear evidence in the member's record/chart.

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Provider Enrollment and Participation

Providers must be enrolled as a Health First Colorado provider in order to treat a Health First Colorado member and to submit claims for payment to the Health First Colorado.

If interested in becoming a Health First Colorado provider, please refer to the Provider Services Enrollment section of the Department's website. Once enrolled in the Health First Colorado, providers who want to provide Prenatal Plus Program services must submit a Prenatal Plus Program Provider Participation Form as an addendum to the Health First Colorado Provider Participation Agreement. This form is found on the Forms web page of the Department's website.

Prenatal Plus Program providers must be enrolled in the Health First Colorado as one of the following Provider Types:

  • Clinic
  • Federally Qualified Health Center
  • Rural Health Center
  • Non-Physician Practitioner Group
  • Physician
  • Nurse Practitioner
  • Certified Nurse-Midwife
  • Physician's Assistant

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Billing Information

Refer to the General Provider Information manual for general billing information.

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Prenatal Plus Program Procedure Codes and Modifiers

The Prenatal Plus Program's services are billed using one procedure code and a combination of modifiers. The code and modifiers are explained in the tables below.

Procedure Code Description
H1005 Prenatal care, at-risk enhanced service package

 

Modifier(s) Description
52 Reduced services
TF Intermediate level of care
TG Complex/high tech level of care
TH Obstetrical treatment/services, prenatal or post-partum

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Prenatal Plus Billing Packages

The billing options for the Prenatal Plus Program are described in the table below.

Package Type Procedure Code Required Modifier(s) Condition(s) Under Which Code Can Be Billed
Partial H1005 TH and 52 Member enrolls at 28 or more weeks gestation and receives 1-4 contacts, at least one of which must be a face-to-face contact; OR
Member enrolls in the first or second trimester (prior to 28 weeks) and receives 1-4 contacts, at least one of which must be a face-to-face contact, but withdraws from the program before delivery OR does not meet the criteria for the other package categories.
Partial Plus H1005 TH and TF Member enrolls at 28 or more weeks gestation and receives 5-9 contacts; OR

Member enrolls in the first or second trimester (prior to 28 weeks) and receives 5-9 contacts, but withdraws from the program before delivery OR does not meet the criteria for the Full package categories.
With appropriate documentation, one telephone call can be counted as a contact.
Calls to reschedule an appointment or to make an appointment with a member cannot be considered a contact.
Full H1005 TH Member enrolls at 27 or fewer weeks gestation;
A minimum of one case conference is held; AND
Member receives a total of ten (10) contacts over the course of the pregnancy and through the end of the second month following the month in which the member delivered.
With appropriate documentation, one telephone call can be counted as a contact.
Calls to reschedule an appointment or to make an appointment with a member cannot be considered a contact.
Full Plus H1005 TH and TG Member enrolls at 27 or fewer weeks gestation; A minimum of one case conference is held; AND
Member receives a minimum of eleven (11) contacts over the course of the pregnancy and through the end of the second month following the month in which the member delivered.
With appropriate documentation, one telephone call can be counted as a contact.
Calls to reschedule an appointment or to make an appointment with a member cannot be considered a contact.

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Claims Submission and Timely Filing

Prenatal Plus Program claims must be submitted directly to the Health First Colorado for processing within 120 days after the last date of service. The last date of service is either the delivery date or the last date of contact for those who withdraw from the program. Providers should bill completed packages as soon as possible after the delivery date, even if the member may be seen for additional visits. Please see the Timely Filing section of this manual for more information.

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Other Insurance Coverage

Occasionally, Prenatal Plus Program members have primary insurance coverage in addition to being eligible for Health First Colorado coverage. In these cases, claims for services must first be submitted to the primary insurance company. If the primary insurance company denies the claim, the claim can be submitted to the Health First Colorado for processing, along with a copy/date of the denial.

If the member is covered by one of the Health First Colorado's managed care organizations, a denial is not necessary before billing for Prenatal Plus services covered by Health First Colorado.

Please refer to the Health First Colorado Provider Information found on Billing Manuals web page of the Department's website for more information on the payer of last resort.

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Billing more than once in a nine-month period

The Colorado interChange System allows for one billing per member in a nine-month period using Prenatal Plus billing codes. However, the following exceptions may be made:

  • A member is seen for an initial pregnancy, subsequently has either a miscarriage or an abortion, and becomes pregnant again within a nine-month period. In this case, the provider may bill for the second pregnancy within the nine-month period.
  • A member receives a Partial or Partial Plus package from one provider, then moves from the area and re-enrolls with a new provider. In this case, the first provider may bill a Partial or Partial Plus package, and the second provider may bill either a Partial, Partial Plus, Full or Full Plus package depending on the level of services provided (i.e., if all requirements for a Full package have been met, the provider can bill a Full package).

If a member leaves the program and then re-enrolls with the same provider during the same pregnancy, the provider must request that the claim for the previously billed service package be voided out of the interChange. Billing for the new service package can be done once the criteria for the new package are met. An agency cannot bill the Health First Colorado for two separate packages for the same member during the same pregnancy.

 

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Deactivate Participation in the Prenatal Plus Program

Prenatal Plus Program sites can end participation in the program at any time. Instructions can be found on the Prenatal Plus Program's web page.

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Other Covered Maternity Services Not Part of the Prenatal Plus Program

The following services are available to pregnant women but must be billed in addition to Prenatal Plus Program claims:

  • Clinical prenatal and postpartum care, labor, and delivery
  • Depression screenings
  • Non-emergent medical transportation (transportation to and from Health First Colorado services)
  • Prenatal vitamins
  • Substance use counseling and SBIRT services
  • Tobacco cessation counseling and medications
  • Family Planning Counseling

 

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Contact Information

Please contact the Department's fiscal agent, DXC Technology (DXC) with billing inquiries.

The Department's Prenatal Plus Program policy specialist at 303-866-2844 can be contacted for all other inquiries.

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Patient's Relationship to Insured Conditional Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070117 for July 1, 2017.

Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Conditional Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional  
18. Hospitalization Dates Related to Current Service Not Required  
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges
Conditional Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional CLIA
When applicable, enter the word "CLIA" followed by the number.

Prior Authorization
Not Required
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Practitioner claims must be consecutive days.

Single Date of Service: Enter the six digit date of service in the “From” field. Completion of the “To field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
04 Homeless Shelter
11 Office
12 Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room Hospital
25 Birthing Center
26 Military Treatment Center
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Transportation – Land
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility – MR
60 Mass Immunization Center
61 Comprehensive IP Rehab Facility
62 Comprehensive OP Rehab Facility
65 End Stage Renal Dialysis Trtmt Facility
71 State-Local Public Health Clinic
99 Other Unlisted
24C. EMG Not Required  
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Conditional Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.
52 - Reduced services
TF - Intermediate level of care
TG - Complex/high tech level of care
TH - Obstetrical treatment/services, prenatal or post-partum
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.

Anesthesia Services
Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period.

Anesthesia time begins when the anesthetist begins member preparation for induction in the operating room or an equivalent area and ends when the anesthetist is no longer in constant attendance. No additional benefit or additional units are added for emergency conditions or the member's physical status.

The fiscal agent converts reported anesthesia time into fifteen minute units. Any fractional unit of service is rounded up to the next fifteen minute increment.

Codes that define units as inclusive numbers
Some services such as allergy testing define units by the number of services as an inclusive number, not as additional services.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV - Available- Not Used
S2 - Under Treatment
ST - New Service Requested
NU - Not Used

Family Planning (unshaded area)
If the service is Family Planning, enter "Y" for YES or "N" for NO in the bottom unshaded portion of the field.
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider's name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
"Signature on file" notation is not acceptable in place of an authorized signature.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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CMS 1500 Prenatal Plus Claim Example

CMS 1500 Prenatal Plus Claim Example

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.

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Prenatal Plus Revisions Log

Revision Date Addition/Changes Made by
12/1/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive. HPE (now DXC)
12/27/2016 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
5/22/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
2/9/2018 Removed NDC supplemental qualifier - not relevant for Prenatal Plus providers DXC
6/25/2018 Updated billing and timely to point to general manual HCPF
12/21/2018 Clarification to signature requirements HCPF
3/18/2019 Clarification to signature requirements HCPF
01/22/2020 Converted to web page HCPF
9/14/2020 Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table HCPF