OCTOBER 2023
At Colorado Access, we are committed to caring for you and your success as you serve our members. Our monthly Provider Update highlights essential information and resources to support you as a contracted provider with us.
Colorado Department of Regulatory Agencies (DORA) Licenses Changes
The PHE ends May 11, 2023. The renewal process for the more than 1.75 million people covered by either Health First Colorado (Colorado’s Medicaid program) or Child Health Plan Plus (CHP+) starts in May. The Colorado Department of Health Care Policy and Financing (HCPF) estimates that 30% of enrolled people will not need to take any action to remain covered, while the other 70% will need to submit eligibility verification.
HCPF also estimates that more than 325,000 people will no longer qualify for Health First Colorado and CHP+ coverage. People who no longer qualify can apply for insurance through the state’s official marketplace, Connect for Health Colorado, online or by calling their customer service line at 855-752-6749.
As more updates become available, we will continue to share what this means for you and for our members.
Licensure data issues by DORA for enrollments, revalidations, or maintenance request applications in the Department of Health Care Policy & Financing (HCPF) provider web portal previously had to be entered manually, which led to errors that increased application returns and processing times. Changes include automatic verification and auto-population.
Learn more in the HCPF September 2023 provider bulletin.
Gender-Affirming Care Policy Updates
This policy was updated on August 30, 2023, to align coverage with the most recent standards of care and allow members easier access to gender-affirming services. Learn more in the Gender-Affirming Care Billing Manual. If you have any questions, email Chris Lane at [email protected].
Share With Your Patients – Health First Colorado Listening Sessions
HCPF is hosting listening sessions for Health First Colorado members and family members who are impacted by the criminal justice system. They want to hear about member experiences and gather feedback to help identify gaps in services and needs of this community. Staff members will ask questions about experiences enrolling in Health First Colorado and using Health First Colorado benefits.
Both virtual and in-person sessions will be offered. Members can join as many sessions as they want. There will also be opportunities to give anonymous feedback.
Upcoming Virtual Sessions
- Wednesday, October 25th, 9:00 a.m.
- Wednesday November 8th, 9:00 a.m.
Upcoming In-Person Sessions
Longmont: Monday, October 16th, 12:00 p.m.
Limon Community Center South Room
477 D Ave, Limon, CO 80828
Evergreen: Thursday, October 26th, 2:00 p.m.
ECHO
27888 Meadow Drive, Evergreen, CO 80439
Commerce City: Friday, October 27th, 9:00 a.m.
Salud Family Health
6255 Quebec Parkway, Commerce City, CO 80022
Durango: Thursday, November 2nd, 10:00 a.m.
Ft. Lewis College Center for Innovation
835 Main Avenue Suite 225, 2nd floor of the main mall
Durango, CO 81301
Alamosa: Friday, November 3rd, 10:00 a.m.
Adelante Family Resource Center
600 Hunt Ave, Alamosa, CO 81101
Auxiliary aids and services for individuals with disabilities, as well as language services for individuals whose first language is not English may be provided on request. Members who need these services should email Hannah Hall at [email protected] or the civil rights coordinator at [email protected] at least one week before the session they are attending to arrange for these services.
National Institute of Mental Health (NIMNH) Spanish-Language Mental Health Resource
To honor Hispanic Heritage Month (September 15th through October 15th), NIMH is highlighting Spanish-language mental health materials for patients, their families, health professionals, and the public. Click here to view the materials and order print versions for free.
Verify Member Eligibility
You are required to verify member eligibility and the member's Managed Care Organization (MCO), if applicable, for each date of service, through the Provider Web Portal. Verification must be done within 365 days of the date of service. You may not bill the member if eligibility is not determined within this timeframe. Check the Provider Rates and Fee Schedule webpage before billing.
All codes must be reviewed for medical necessity, prior authorization coverage standards, and rates before they can be reimbursed. More information:
New procedure codes for Explanation of Benefits (EOB) 0000 – “This claim/service is pending for program review” – may be under review for 30 to 60 days.
Physician-Administered Drugs (PAD) need a National Drug Code (NDC) assignment and can take up to 90 days to be implemented.
The Colorado interChange is updated with billing codes based on the Centers for Medicare & Medicaid Services (CMS) release of deletions, changes, and additions. Any claims in a suspended status will be released and processed after the update is complete.
Claims with services requiring ordering, prescribing, or referring (OPR) providers will post EOB 1997 – “The referring, ordering provider, and attending type is invalid for the service. The service is not within the scope of the provider type.” – if the ordering provider is not enrolled with Health First Colorado as of October 2023. This is not a claim denial. Claims submitted for services or items that require an OPR can be found on the Billing Manuals webpage.
If you need more benefit information, contact the appropriate MCO after the member is assigned. Benefits through Child Health Plan Plus (CHP+) may vary from the Health First Colorado Title XIX benefit plan.
If you have any questions, contact the Provider Services Call Center.
Prescriber Tool Alternative Payment Model (APM)
The first program year of the Prescriber Tool APM officially began this month. This is a risk-free program to support provider engagement with the Prescriber Tool, specifically the Real-Time Benefits Inquiry module. Participating providers will be eligible for an incentive payment to share in pharmacy cost savings.
On October 2, 2023, a form was released where you can update your contact information and opt-out of the program. This information will be used to distribute provider-facing dashboards in December. You must participate in the program to access these dashboards. Opting out of this program means that you will not have a dashboard developed for you. If you opt-out, you will have the opportunity to opt-in before the next program year starts.
Learn more here. You can also email [email protected] to learn more.
Certificate of Medical Necessiry (CMN) Changes for Oxygen
The Medical Services Board (MSB) has removed the requirement for a CMN for long-term oxygen therapy. CMNs will not be required on long-term oxygen therapy claims with a date of service on or after October 30, 2023. If you have any questions, please email [email protected].
Emergency Medicaid Services (EMS) Billing
The EMS benefit plan is limited and does not cover all services, but it does cover services necessary to treat an emergency medical condition, family planning services, and services related to family planning for people who qualify. To be reimbursed, claims must follow billing guidance from the Inpatient/Outpatient (IP/OP) Billing Manual and the Family Planning Benefit Expansion for Special Populations Billing Manual to indicate that a covered service is intended for emergency or family planning purposes.
New Resource for Providers Managing Chronic Pain Treatment
Many Home and Community-Based Services (HCBS) Health First Colorado members have not been able to get adequate pain management services. A new pilot program offers expanded pain consultation services and training to every primary care provider who wants support to manage chronic pain treatment for HCBS members.
The pain management team for this program includes a physician pain consultant and a pharmacist (pharmD) who support physical and behavioral health with pain management best practices. The Department of Health Care Policy and Financing (HCPF) is also offering care coordination support for these HCBS members to resolve recurring issues, like problems with prior authorization, delays in care, and other issues that care coordination teams.
As part of a partnership with the University of Colorado School of Pharmacy, free Continuing Education (CE) and Continuing Medical Education (CME) accredited sessions are offered to providers who want to learn more about pain treatment.
To learn more, please email Judy Shepard, the chronic pain referral coordinator for the pharmacy office, at [email protected].
Free Chronic Pain Treatment Trainings
The Chronic Pain Centers of Excellence will be providing two free one-hour virtual trainings for Health First Colorado primary care providers for managing chronic pain treatment. Included topic are risk factors, risk assessment, risk mitigation, screenings, and patient cases. This series is offered in addition to consultations for complex cases.
Continuing Education Credits
Registered Nurses and Advanced Practice Registered Nurses (ARPNs) – Nursing (Nursing Continuing Professional Development (NPCD) credit – will include pharmacology hours)
The University of Colorado College of Nursing is approved with distinction by the Colorado Nurses Association as a provider of nursing continuing professional development and an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. This offering for a maximum of 2.0 contract hours (2.0 pharmacology contact hours) is provided by the University of Colorado College of Nursing Office of Continuing Education.
Pharmacists and Pharmacy Professionals – Pharmacy (CPE Credit)
The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education (CPE). Each training is accredited for 1.0 contact hour for knowledge-based continuing pharmacy education. After evaluations are completed for each training, credit will be uploaded to the CPE monitor within 48 hours.
Physician Assistants, Physicians, and ARPNs – Medicine (American Academy of Family Physicians (AAFP)
The AAFP has reviewed the Chronic Pain Centers of Excellence Educational Series Best Practices in Managing Chronic Pain and deemed it acceptable for AAFP credit from October 12, 2023 to January 4, 2024. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Speech Therapy and Prior Authorization Requests (PARs)
On August 23, 2023, there was a speech therapy stakeholder engagement about the footnote in the 2023 long bill mandating 12 speech therapy sessions before prior authorization is required. This change will take effect in December 2023, and applies to services for both adults and children. A specific date will be announced later.
Services are limited to five units per day, which equates to one session on one date of service. Adult members enrolled in the Alternative Benefit Plan have separate limits of 12 sessions for habilitative and rehabilitative services. Outpatient speech therapy services must have an order from physicians (MD/DO), physician assistants, nurse practitioners, or an individualized family service plan for early intervention speech therapy, even when a PAR is not required.
Before seeing a member, please verify their remaining sessions to determine whether they utilized any sessions within the rolling calendar year. The allowed number of sessions will lower when you submit a claim for payment. The claims system can only provide the units that have been reported, so the utilization count could change at any time when a new claim is reported. There is no guarantee of payment based on the utilization information provided in the eligibility verification response. If you believe that the member will need more sessions, it’s best to request a PAR before the 12 sessions are exhausted.
If a claim is denied due to a claims processing issue, you must submit a retrospective PAR to the utilization management vendor for those, and any potential additional, units.
Read more here. If you have any questions:
On claims and sessions, contact the Provider Services Call Center.
On speech therapy policy, email Devinne Parsons at [email protected].
On PAR, email the utilization management team at [email protected].
Updated COVID-19 Vaccine Codes
As of September 11, 2023, COVID-19 vaccines are only reimbursable with these Common Procedural Terminology (CPT) product codes, and the corresponding administration code (90480):
91304
91318
91319
91320
91321
91322
As of September 12, 2023, all other COVID-19 vaccine and administrative codes are closed in accordance with existing Emergency Use Authorization (EUA) or Biologics License Application (BLA) from the US Food and Drug Administration (FDA). Also as of September 12, 2023, COVID-19 vaccines for Health First Colorado members under age 19 are now part of the Vaccines for Children (VFC) program. If you are enrolled with Health First Colorado, you must also enroll with the VFC program in order to get reimbursed for administering COVID-19 vaccines to pediatric Health First Colorado members.
As of April 27, 2023, the age range for CPT code 90677 is six weeks and older. Affected claims must be reprocessed. View all reimbursement rates and age ranges here.
Get Higher Reimbursements for Providing Behavioral Health Services in Non-English Languages
We are excited to introduce a new program that will allow you to earn enhanced reimbursements for providing behavioral health services in non-English languages. Eligible outpatient providers can now bill a 10% increased rate on direct outpatient behavioral health services offered in a member’s identified language. Federally qualified health centers, community mental health centers, and inpatient hospitals do not qualify for this incentive.
This incentive is the first of its kind, and it recognizes the additional effort, training, and expertise needed to deliver culturally and linguistically appropriate care.
This program is exclusive to us, Colorado Access, and does not apply to any other Regional Accountable Entity (RAE) services that use an interpreter.
To learn more, talk to your assigned provider network manager, or find who to contact here.
Public Health Emergency (PHE) Unwind – Temporary Extension
On August 30, 2023, HCPF received new guidance from CMA that requires a change to the ex parte process for renewals. In the past, all members of a household that gets Health First Colorado or CHP+ benefits were reviewed at the same time through ex parte automatition, but CMS is now requiring ex parte automation reviews on an individual basis. This means that each person in the household will now be reviewed and approved separately.
This new system means significant changes to the current eligibility system and will be implemented in a phased approach. HCPF has added a temporary renewal extension for all members who are due for renewal in September and October 2023 until they can implement a short-term system change in mid-October to bring them into compliance with the new CMS ex parte guidance.
HCPF is also working on a strategy to renew coverage for members who were disenrolled if their household did not properly complete and submit the required renewal application. HCPF will communicate the strategy when it’s finalized, and will notify members who are eligible to have their coverage renewed.
Ongoing 60-Day Renewal Extension for Vulnerable Populations
With additional flexibility from CMS, HCPF is providing a 60-calendar-day extension to complete the renewal process for vulnerable populations, such as those in long-term care, members on waivered services, and buy-in recipients who have not returned their renewal packet on time during the COVID-19 unwind. This extension allows for additional outreach to these vulnerable members when they’re due for renewal. It also gives extra time for the members to return their information and for the counties to process it.
This extension has been in effect since September 5, 2023, and will continue through the rest of the unwind period, through June 2024. It does not affect members who have already submitted their renewal packet or who have already completed the renewal process. If a member has already turned in their renewal packet and needs to submit additional information, the county may grant additional time through a Good Faith Extension.
We have up-to-date PHE unwind flyers and brochures in English, Spanish, Amharic, Arabic, Burmese, Russian, and Somali that can help you and your staff best inform and support the Health First Colorado and CHP+ members you work with. Please consider keeping them on display on your desks and in your reception areas and having them available for distribution at events. You can request these free materials to be delivered to your office through our new online ordering system. They will be delivered about a week after you submit your online order.
MOVEit Transfer Application Data Breach
On May 31, 2023, Progress Software found a problem with its MOVEit Transfer application. As a third-party vendor contracted with HCPF, IBM used MOVEit to move HCPF data files as part of the normal course of business. Progress Software publicly announced that the problem was the result of a cybersecurity incident that impacted more than 2,000 organizations around the world, including IBM. No HCPF or State of Colorado systems were affected.
On June 13, 2023, a HCPF investigation identified that certain HCPF files containing certain Health First Colorado and CHP+ member and provider information on the MOVEit application were accessed on or about May 28, 2023. This may include full names, Social Security or taxpayer identification numbers, Medicaid or Medicare ID numbers, dates of birth, home addresses and other contact information, demographic or income information, clinical and medical information (such as diagnosis/condition, lab results, medication, or other treatment information), and health insurance information.
Learn more here.
Provider-Carrier Disputes (Claim Appeal) Form Update
We have revised our provider-carrier dispute (claim appeal) form to add a request for additional information, such as an email address, to help us communicate claim determinations in a more timely manner. You can find the revised form on our website under the “Claims” heading.
For the fastest response time, please submit your provider-carrier dispute (claims appeal) on our provider portal. We will also accept submissions with the revised form by mail or email.
Member Survey
We conduct a biannual member survey to get feedback from members and better understand their experience, connect them to resources in real-time, and design improvements based on survey results. This survey is administered by our customer service team during routine member phone calls.
Our most recent member survey focused on how we can improve the member experience; explored how members self-describe their race, cultural, and ethnic identity without the limitations of typical demographic selection choices; and investigated how race and ethnicity affect their health care. Click here to read more about our survey results and methodology.