2015 Provider Manual - Child Health Plan Plus Provider Provider Manual ... Primary Care Provider...

2015 Provider Manual

Child Health Plan Plus (CHP+)State Managed Care Network & Prenatal Care Program

2015 51 21-101 0515A

PROVIDER MANUAL

Table of Contents I. Introduction ................................................................................................................... 4

Important Telephone numbers ................................................................................................................. 4

Important Fax Numbers ............................................................................................................................ 4

Important Websites .................................................................................................................................. 4

Secured Information on coaccess.com ..................................................................................................... 5

II. Primary Care Providers & Specialists ............................................................................... 6

Primary Care Provider Responsibilities ..................................................................................................... 6

Practice Capacity and Acceptance of New Patients.................................................................................. 7

PCP Coverage ............................................................................................................................................ 7

Specialist Responsibilities ......................................................................................................................... 7

Specialist Coverage ................................................................................................................................... 8

Credentialing and Re-credentialing .......................................................................................................... 8

Effective Communication with Limited English Proficient (LEP) Persons & Sensory-Impaired Speech-

Impaired Persons ...................................................................................................................................... 9

Non-Discrimination Policy ....................................................................................................................... 10

Confidentiality ......................................................................................................................................... 10

Fraud and Abuse ..................................................................................................................................... 11

Rights and Responsibilities for Members with Special Needs ................................................................ 13

Appointments and Service Standards ..................................................................................................... 14

Medical Record Documentation ............................................................................................................. 15

Utilization Management Program .......................................................................................................... 16

Alternative Treatments ........................................................................................................................... 17

Servicing Members with Special Healthcare Needs ............................................................................... 17

Advance Directives .................................................................................................................................. 17

Quality Management Program ............................................................................................................... 18

Essential Community Providers (ECP) ..................................................................................................... 19

III. Claims Submission ........................................................................................................ 20

Please submit claims to: ......................................................................................................................... 20

Timely Filing ............................................................................................................................................ 20

Provider Responsibilities ......................................................................................................................... 20

Table of Contents

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Have questions? Call us at 303-751-9051 or 800-414-6198 (toll free) Visit us on the web at chpplusproviders.com

Colorado Access Responsibilities ............................................................................................................ 21

Required Formats.................................................................................................................................... 21

Electronic Claims ..................................................................................................................................... 21

CMS 1500 ................................................................................................................................................ 22

CMS 1450 ................................................................................................................................................ 22

Procedure Coding .................................................................................................................................... 22

Diagnosis Coding ..................................................................................................................................... 22

Non-Clean Claims .................................................................................................................................... 23

Resubmissions ......................................................................................................................................... 23

ClaimCheck ............................................................................................................................................ 24

IV. Provider-Carrier Disputes (Claim Appeals) ..................................................................... 25

Submission Process ................................................................................................................................. 25

Processing Timeframes ........................................................................................................................... 25

V. Coordination of Benefits & Subrogation ........................................................................ 27

Filing a Claim for Members with Secondary Coverage ........................................................................... 27

Secondary Benefit Calculation Lower of Logic .................................................................................... 27

Authorizations and Coordination of Benefits ......................................................................................... 28

VI. Providers Reimbursement ........................................................................................... 29

Primary Care Providers ........................................................................................................................... 29

Specialty Care Reimbursement ............................................................................................................... 29

Reproductive Health Services ................................................................................................................. 31

Emergency/Urgent Care Services ........................................................................................................... 31

Anesthesia Billing .................................................................................................................................... 31

Immunizations ........................................................................................................................................ 31

Dental Services ........................................................................................................................................ 32

Hold Harmless ......................................................................................................................................... 32

VII. Member Grievances & Clinical Appeals ......................................................................... 33

VIII. Authorizations & Referrals ............................................................................................ 39

Prior Authorization List ........................................................................................................................... 39

Submitting an Authorization Request ..................................................................................................... 39

Table of Contents

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Authorization Categories ........................................................................................................................ 40

Types of Utilization Review Determinations ........................................................................................... 41

General Authorization Rules ................................................................................................................... 42

Continuity of Care and Transition of Care for Members ........................................................................ 49

Continuity of Care and Transition of Care for Existing Members ........................................................... 50

IX. Pharmacy Services ........................................................................................................ 51

Prescription Copays ................................................................................................................................ 51

Mail Order Service .................................................................................................................................. 51

X. Behavioral Health ......................................................................................................... 52

Outpatient Treatment ............................................................................................................................. 52

Medication Management ....................................................................................................................... 52

Day Treatment ........................................................................................................................................ 52

Case Management .................................................................................................................................. 52

Inpatient Services .................................................................................................................................... 52

Substance Abuse ..................................................................................................................................... 53

Behavioral Health Services That are not Covered .................................................................................. 53

XI. Enrollment Procedures & Membership ......................................................................... 55

Income Test ............................................................................................................................................. 55

Presumptive Eligibility (PE) ..................................................................................................................... 55

Terms of Eligibility ................................................................................................................................... 56

Pre-HMO Enrollment Period ................................................................................................................... 57

HMO Enrollment ..................................................................................................................................... 57

Membership Identification ..................................................................................................................... 58

Verifying Eligibility and PCP Assignment ................................................................................................. 58

Cancellation of Members Coverage ....................................................................................................... 58

The States Child Health Plan Plus Managed Care Network ................................................................... 58

XII. Benefits & Copayments ................................................................................................ 59

Out of Pocket Limit ................................................................................................................................. 59

Copayments ............................................................................................................................................ 59

Covered Services/Benefits ...................................................................................................................... 59

I.

PROVIDER MANUAL

I. Introduction This manual applies to providers in the State Managed Care Network administered by Colorado Access.

Unless otherwise noted, policies in this manual apply to both CHP+ and the CHP+ Prenatal Care

Program.

NOTE: Colorado Access maintains a separate provider manual for the CHP+ HMO product.

IMPORTANT TELEPHONE NUMBERS

Customer Service (Claims, Eligibility, Authorizations) -

Local: .......................................................................................................... 303-751-9051

Toll Free: .................................................................................................... 800-414-6198

TTY/TDD: .................................................................................................... 720-744-5126

Toll Free TTY/TDD: ..................................................................................... 888-803-4494

Grievances and Appeals -

Local: .......................................................................................................... 720-744-5134

Toll Free: .................................................................................................... 877-276-5184

Child Health Plan Plus Administrative Offices -

Toll Free: .................................................................................................... 800-359-1991

Delta Dental -

Toll Free: .................................................................................................... 800-610-0201

IMPORTANT FAX NUMBERS

Authorization (Physical Health) Fax -

Local: .......................................................................................................... 303-755-4135

Toll Free: .................................................................................................... 877-232-5976

Authorizations (Behavioral Health) Fax -

Local: .......................................................................................................... 720-744-5127

Provider Contracting Fax -

Local: .......................................................................................................... 303-755-2368

Quality Management Fax -

Local: .......................................................................................................... 303-369-5741

IMPORTANT WEBSITES

chpplusproviders.com The CHP+ provider site is designed specifically for State Managed Care Network

providers. Important provider information, as well as member information can be located on the site.

http://www.chpplusproviders.com/

Introduction

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aap.org The American Academy of Pediatrics website provides recommended childhood and

adolescent immunization and well child visit schedules.

coaccess.com The Colorado Access website contains important information for members and

providers. Provider information available in the For Our Providers section of the website includes:

Important provider updates

Provider manuals

The provider directory

HIPAA information

Secured information:

o Online eligibility verification

o Online claim status

o Colorado Access prior authorization list

SECURED INFORMATION ON COACCESS.COM

Some of the information available on the site, including online eligibility verification, online claim status,

and the Colorado Access Prior authorization list, requires a username and password. To access the

secured information, click the Provider Logon link located in the For Our Providers section and enter

your Colorado Access website username and password.

If you need a Colorado Access website username and password, please follow these instructions:

Download the Web Based Applications Request Form located online at: coaccess.com/for-

providers

Fax the completed application to 303-755-2368, or email it to [email protected]

http://www.aap.org/http://www.coaccess.com/http://www.coaccess.com/http://www.coaccess.com/for-providershttp://www.coaccess.com/for-providersmailto:[email protected]

PROVIDER MANUAL

II. Primary Care Providers & Specialists Each member of Child Health Plan Plus (CHP+) and the CHP+ Prenatal Care Program must choose a

participating primary care provider (PCP) who is a:

Family and general practitioner

Internist, or

Pediatrician

PRIMARY CARE PROVIDER RESPONSIBILITIES

Primary care providers (PCPs) have the following responsibilities when seeing members of the CHP+ and

the CHP+ Prenatal Care Program:

Providing care and services for all enrolled members

Being accessible (or have call coverage) to members 24 hours a day, 7 days a week

Hours of operation must not be less than those offered to commercial members

Providing services to members according to the CHP+ access standards

Coordinating healthcare services for members, including referring members to specialists

Providing preventive health services and offering provision for special needs

Educating members about healthy lifestyles and prevention of serious illness

Counseling members about appropriate emergency department utilization

Providing culturally appropriate healthcare

Maintaining confidentiality of medical information in compliance with all state and federal

regulatory agencies (including HIPAA), as well as National Committee for Quality Assurance

(NCQA) standards

Maintaining legible and comprehensive medical records for each encounter with a member that

conform to documentation standards

Administrative Responsibilities include:

Participating in the CHP+ quality management and utilization management programs, which

adhere to National Committee for Quality Assurance (NCQA) standards, and the CHP+ contract

standards, which includes the provision of medical records copies upon request for study

purposes

Complying with the State Managed Care Networks credentialing requirements

Maintaining a separate medical record for each CHP+ member

Reporting encounter and claim data to the State Managed Care Network, so that we may have

track service utilization

Authenticate patients identity at every office encounter to prevent card sharing and patient

identity theft

Verifying eligibility and enrollment for every office encounter

Referring members to participating providers

Adhering to the professional code of conduct

Primary Care Providers & Specialists

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PRACTICE CAPACITY AND ACCEPTANCE OF NEW PATIENTS

A PCP may determine how many members the practice will accept and at what point the panel is open

or closed. To request a change in member capacity of open/close your practice, notify the State

Managed Care Network in writing. The change will become effective no later than two business days

from the date we receive the notification.

NOTE: New members are not assigned to providers with closed panels. An individual PCP may not have

more than 2,000 CHP+ members without consent from the State Managed Care Network. The PCP is

responsible for the care of members assigned to the PCP from the date of assignment, whether or not

the PCP has previously provided care to the patient.

PCP COVERAGE

The PCP must assure that coverage is available seven days a week, 24 hours a day for member services.

Access to a qualified healthcare practitioner by telephone coverage either onsite, call sharing, or

answering service is appropriate.

The PCP must notify the State Managed Care Network of the name of the practitioner providing

on-call coverage.

Please notify us by sending us a completed On-Call Coverage Sheet (Appendix A). To ensure

appropriate payment, we must have this information on file.

The call-coverage provider must know and follow the specifications of the authorization process.

Coverage responsibilities include outpatient and inpatient care.

SPECIALIST RESPONSIBILITIES

Contracted specialty care providers have the following responsibilities to CHP+ and CHP+ Prenatal Care

Program members:

Verifying member eligibility on the date of service

Providing specialty consultation care referred by the members PCP or the State Managed Care

Network as necessary.

Obtaining appropriate authorization from the State Managed Care Network before treating a

member.

Coordinating the members care with his or her PCP.

Providing a written consultation report to the PCP within five days of providing service

Maintaining confidentiality of medical information in compliance with all state and federal

regulatory bodies, as well as NCQA requirements.

Maintaining a separate medical record for each CHP+ or CHP+ Prenatal Care Program member.

Maintaining legible and comprehensive medical records for each encounter.


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SPECIALIST COVERAGE

The specialist must assure that coverage is available seven days a week, 24 hours a day for

member services. Access to a qualified healthcare practitioner by telephone coverage either

onsite, call sharing, or answering service is appropriate.

The specialist must notify the State Managed Care Network of the name of the practitioner

providing on-call coverage. Please notify us by sending a completed On-Call Coverage Sheet.

To ensure appropriate payment, we must have this information on file. Contact the State

Managed Care Network at 303-751-9051 or 800-414-6198 (toll free).

The call-coverage provider must know and follow the specifications of the authorization process.

Coverage responsibilities include outpatient and inpatient care.

SECOND OPINION

Members have a right to a second opinion. If members need assistance to arrange a second opinion or

set an appointment, please call 303-751-9021 or 888-214-1101 and ask to speak to a care manager.

CREDENTIALING AND RE-CREDENTIALING

When applicable, providers shall participate with the credentialing and re-credentialing standards and

requirements as set forth in this provider manual and shall submit to the Department, or its designee,

the appropriate credentialing application and other required attachments, as modified from time to

time in accordance with National Committee for Quality Assurance (NCQA) and Colorado Access

standards.

The State Managed Care Network conducts credentialing and re-credentialing of the following

contracted healthcare practitioners, who treat members outside the inpatient setting who fall within its

scope of authority and action:

Allopathic physician (MD)

Osteopathic physician (DO)

Doctor of dental science (DDS) *

Podiatrist (DPM)

Certified nurse midwife (CNM)

Nurse practitioner (NP)**

* Dentists who provide care under the medical benefit program only

** Only nurse practitioners serving as PCPs in rural underserved areas

The applicant will complete the Colorado Unified Credentialing Application available on the Colorado

Access website at: coaccess.com/credentialing. The application includes a current and signed attestation

by the applicant. The applicant will bear the burden of proving that he/she is eligible and qualified for

participation in the State Managed Care Network and shall have the responsibility of producing

adequate information for a proper evaluation of his/her current competence, relevant training, and

experience. The applicant is also responsible for resolving any questions about such qualifications.

http://www.coaccess.com/credentialing


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The applicant has the right to review information obtained by the State Managed Care Network to

evaluate his/her credentialing application to the extent permitted by law. The State Managed Care

Network is not required to allow an applicant to review references, recommendations, or other

information that is peer-review protected. The State Managed Care Network is not required to reveal

the source of information if the information is not obtained to meet credentialing verification

requirements if disclosure is prohibited by law. In the event that credentialing information obtained

from other sources varies substantially from that provided by the applicant, the credentialing

department will notify the applicant of the process to correct erroneous information submitted by

another party.

The applicant has the right to be informed of the status of their credentialing or re-credentialing

application upon request. These rights apply to any applicant who has completed the Colorado Unified

Credentialing Application. For additional information, please contact the credentialing department at

720-744-5100 or 800-511-5010 (toll free) or email [email protected].

CAQH Universal Credentialing DataSource

Colorado Access participates with the CAQH Universal Credentialing DataSource. CAQH is a web-based

tool that enables providers to enter credentialing information online and avoid the hassles of

completing the same paperwork for multiple healthcare organizations. If you would like more

information about registering with the service or completing the UCD application, please visit

coaccess.com/caqh-universal-credentialing-datasource. If you already participate with CAQH, please

designate Colorado Access as an authorized health plan.

EFFECTIVE COMMUNICATION WITH LIMITED ENGLISH PROFICIENT (LEP) PERSONS &

SENSORY-IMPAIRED SPEECH-IMPAIRED PERSONS

The State managed Care Network will take such steps as are necessary to ensure that members,

potential members, family members and designated client representatives (DCR) with limited English

proficiency or who are sensory-impaired/speech-impaired receive information about services, benefits,

consent forms, waivers of rights, financial obligations, consent to treatments, etc., in a language or

format that they understand. Language interpreters and auxiliary aids will be provided without cost to

the individuals being assisted. In determining what type of auxiliary aid is necessary, the State Managed

Care Network will give primary consideration to the request of the individual with disabilities. These aids

and services include, but are not limited to, the following:

Multilingual staff

TTY/TDD

AT&T Language Line

Notices translated into the members primary language

Notices prepared in large print

Reading the contents of notices aloud for members who are unable to ready large print or who

have low literacy levels

mailto:[email protected]://www.coaccess.com/caqh-universal-credentialing-datasource


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Audio tape

Braille

NON-DISCRIMINATION POLICY

State Managed Care Network does not exclude, deny benefits to, or otherwise discriminate against any

person on the grounds of race, color, national origin, gender, sex, religion, creed, sexual orientation,

disability, age, socioeconomic level, health status, participation in any government program (including

Medicaid and Medicare), source of payment, participation in a health plan, marital status, or physical or

mental disability. This includes all State Managed Care Network programs and activities or through a

contractor or any other entity with whom State Managed Care Network arranges to carry out its

programs and activities.

Providers shall not discriminate against any member on the basis of race, color, national origin, gender,

sex, religion, creed, sexual orientation, disability, age, socioeconomic level, health status, participation in

any government program (including Medicaid and Medicare), source of payment, participation in a

health plan, marital status, or physical or mental disability. Nor shall providers knowingly contract with

any person or entity which discriminates against any member on such basis.

State Managed Care Network will not discriminate in its selection process against providers that serve

high-risk populations or who specialize in conditions that require costly treatment. In addition, State

Managed Care Network will not discriminate with respect to the participation, reimbursement, or

indemnification of any provider who is acting within the scope of his or her license or certification under

applicable Colorado State law, solely on the basis of that license or certification.

This statement is in accordance with the provisions of:

Title VI of the Civil Rights Act of 1964

Title VII of the Civil Rights Act of 1964

Section 504 of the Rehabilitation Act of 1973

The Americans with Disabilities Act of 1990 (ADA)

The Age Discrimination Act of 1975

The Age Discrimination in Employment Act of 1976

Title IX of the Education Amendment of 1972

Regulations of the US Department of Health and Human Services issued pursuant to the Acts

NOTE: Other federal laws and regulations provide similar protection against discrimination on grounds

of sex and creed.

CONFIDENTIALITY

The State Managed Care Network abides by federal and state regulations pertaining to confidentiality

standards including requirements of the Health Insurance Portability and Accountability Act of 1996


PROVIDER MANUAL

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(HIPAA). As a provider, it is important for you to follow the State Managed Care Networks expectations

concerning confidentiality of member information and records.

FRAUD AND ABUSE

The State Managed Care Network is dedicated to providing quality healthcare services to members

while conducting business in an ethical manner. The State Managed Care Network supports the efforts

of federal and state authorities in identifying incidents of fraud and abuse. The State Managed Care

Network has mechanisms in place to prevent, detect, report, and correct incidents of fraud and abuse in

accordance with contractual, regulatory, and statutory requirements.

The following definitions are taken from state and federal guidelines:

Fraud: An intentional (willful or purposeful) deception or misrepresentation made by a person with the

knowledge that the deception could result in some unauthorized benefit to himself/herself or some

other person. This includes any act that constitutes fraud under applicable federal or state law.

Abuse/Misuse: Practices that are inconsistent with sound fiscal, business or medical practices, and that

result in an unnecessary cost to the CHP+ program, or in seeking reimbursement for goods or services

that are not medically necessary or that fail to meet professionally recognized standards for health care.

Misutilization: The incorrect, improper or excessive utilization of medical care and services which are

not medically necessary, at the recipients insistence or request.

The State Managed Care Network complies with requirements of the Colorado Attorney General, the

District Attorney, The Department of Health Care Policy & Financing, and other agencies that conduct

investigations.

Colorado Access has a corporate compliance officer who is responsible for reporting suspected

fraudulent claims to the fraud division of the Colorado Division of Insurance and the Colorado Office of

the Attorney Generals Department of Law.

The State Managed Care Network is required to take appropriate disciplinary and enforcement action

against employees, providers, subcontractors, consultants, members, and agents found to have

committed fraud. We are also required to take appropriate corrective actions to prevent further

offenses through systems and process changes. All employees, providers, subcontractors, consultants,

members, and agents of the State Managed Care Network are responsible for reporting potential and/or

suspected incidents of fraud, abuse, misuse, or misutilization, including actual or potential violations of

law or regulation, to the Colorado Access corporate compliance officer (CCO) or staff attorney.

The following methods may be utilized to report such situations:

Contact the CCO directly at 720-744-5465

Call the confidential Corporate Compliance Hotline at 877-363-3065


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Email the CCO at [email protected]

Download and print the Suspected Fraudulent Claim Form located on the Colorado Access

website and forward the completed form to:

Colorado Access

Corporate Compliance Officer

10065 E. Harvard Ave., Suite 600

Denver, CO 80231

Send the information to the dedicated fax line at 303-751-9048, addressed to the corporate

compliance officer

MEMBER RIGHTS AND RESPONSIBILITIES

Members have the right to:

Get information about their healthcare benefits

Be treated fairly and with respect to their dignity and privacy

Not be restrained or left by themselves to make them do something you may not want to do

Get all of the correct benefits from CHP+ HMO

Get health information from their doctor in a way that they understand. This includes finding

out whats going on (diagnosis), taking care of whats going on (treatment), and talking about

what could happen in the future (prognosis)

Get copies of their treatment records and service plans

Ask for their medical records to be changed if they believe they are incorrect or incomplete

Get the right healthcare, from the right providers, at the right time, in the right setting

Have a talk with providers about how to take care of whats going on with their health

regardless of the cost or benefit coverage. This includes any alternative treatments that they

may be able to do yourself

Be a part of deciding what is best to do for their own healthcare

Get a second opinion

Not follow their providers treatment plan. Their provider(s) must tell them what could happen

to their health if you do so

Get family planning services. They must get services directly from any provider licensed or

certified to provide such services. This does not depend on enrollment

Get information on how to stay well and how to help them stay and live healthy

Tell us about any concerns and complaints they have about the care and services they got. CHP+

HMO will look into it and will take the right action

File a complaint or appeal a decision with CHP+ HMO without fear of it being used against them

(retaliation) (See the Grievances and Appeals section)

Expect that their personal health information will be kept in a confidential manner

Have input about the Member Rights and Responsibilities policies

mailto:[email protected]


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Get information about CHP+ HMO, Colorado Access, other CHP+ health plans, services,

providers and doctors, and the rights and responsibilities of members.

Ask how we pay the providers and doctors that work with us. They can also ask about any

incentive plans we may pay them.

To make decision regarding medical care and to create an advance directive that, under state

law, must be respected by your provider and Colorado Access

Ask for information on how to be a part of the Member Advisory Board at Colorado Access by

contacting the Office of Member and Family Affairs at 720-744-5610

Ask for information about our Quality Assessment and Performance and Population Health

Outcomes Plan program. They can also ask for our member satisfaction survey results.

MEMBERS HAVE THE RESPONSIBILITY TO:

Use in-network providers and remember to show their Colorado Access ID card

Maintain ongoing patient-provider relationships with the providers who give them care or

coordinate their total healthcare needs

Give their providers complete and honest information about their healthcare status and history

Follow the treatment plan recommended by providers

Understand how to access care in non-emergency and emergency situations, and to know their

out-of-network healthcare benefits, including coverage and copayments

Notify the provider or Colorado Access about their concerns regarding the services or medical

care they receive

Be considerate of the rights of other members, providers, and Colorado Access staff

Read and understand their CHP+ offered by Colorado Access Member Benefits Booklet

Pay all member requirements in a timely manner

Provide Colorado Access with complete and accurate information about other healthcare

coverage and/or benefits they may have or obtain

Work with their provider to understand your healthcare concerns and to develop treatment

goals

RIGHTS AND RESPONSIBILITIES FOR MEMBERS WITH SPECIAL NEEDS

New CHP+ members and members with special needs have some additional rights which include the

following:

Rights:

To keep seeing non-CHP+ doctors up to 60 days after joining CHP+ as long as the doctor works

with the State Managed Care Network to transfer care.

To keep seeing non-CHP+ home health or DME providers up to 75 days as long as the member

and provider work with the State Managed Care Network to transfer care.

Responsibilities:


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To tell the State Managed Care Network and medical providers, including doctors, home health,

and DME providers, that they have enrolled so we can work together to transfer care.

Rights and Responsibilities for Members Who are More Than Three Months Pregnant

Members who are more than three months pregnant have some additional rights, which include the

following:

Right:

To see current providers of prenatal care until after delivery if the provider agrees to accept the

State Managed Care Networks rates

Responsibility:

To tell CHP+ they are pregnant and let CHP+ know who is providing care when enrolled.

APPOINTMENTS AND SERVICE STANDARDS

Member satisfaction is very important to the State Managed Care Network. Excessive wait time for

appointments is a major cause of member dissatisfaction with the healthcare provider and health plan.

The State Managed Care Network has established the following appointment standards for contracted

providers:

NOTE: The State Managed Care Network reserves the right to adjust or modify appointment standards,

based on member and provider needs.

Appointment Standards

Type of Care Standard

Pediatric routine care Scheduled within 2 weeks of request

Adult routine care (ages 18-19) (Non-symptomatic, well care physical exam)

Scheduled within 4 weeks of request

Non-urgent care Scheduled within 1 week of request

Urgent care Scheduled within 24 hours of request

Appointment Standards (Behavioral Health)


Routine care (new requests for service) Available within 7 business days of initial contact by the member

Urgent care Scheduled within 24 hours of initial contact by the member

Emergency services Phone contact within 15 minutes of the initial contact, and face-to-face clinical evaluation within one hour of contact in urban/suburban areas or


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Appointment Standards (Behavioral Health)

within two hours in rural areas

Follow-up care after discharge from a hospital or ATU

Scheduled within 7 calendar days after an inpatient discharge

Substance use disorder (non-emergent, non-urgent)

Scheduled within 2 weeks of request

After Hours and Emergency Care


After-hours care Available 24 hours a day, seven days a week, access to a qualified healthcare practitioner via telephone coverage either onsite, through call sharing, or an answering service

Emergency care Immediately

Access to Interpretive Services


Interpretive services Language assistance is available in the provider office or the member is directed to the Colorado Access customer service department for assistance at 303-751-9051 or 800-414-6198 (toll free)

For providers with 14 employees or less, the State Managed Care Network will pay for oral or other

interpretive services in compliance with federal and state rules and regulations and line of business

contracts.

For providers with 15 employees or more, the State Managed Care Network may pay for oral or other

interpretive services only where the cost to the provider is deemed an undue burden. If such services

are requested by a provider, justification must be provided to the director of the Colorado Access Office

of Consumer and Family Affairs, who will make a determination on a case-by-case basis.

Missed Appointments

Per state requirements, members are not subject to missed appointment fees, even if the cancellation

occurred within 24 hours of the scheduled appointment time.

MEDICAL RECORD DOCUMENTATION

Providers are responsible for maintaining a medical record system that promotes continuity of care for

each patient. Well-documented medical records facilitate communication, coordination and continuity

of care, and effective treatment. The State Managed Care Network has established medical record


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documentation standards based on applicable regulatory and accrediting body standards. These

standards are reviewed periodically and are utilized to assess medical recordkeeping practices of our

network practitioners.

The State Managed Care Network may perform chart reviews to assure compliance with medical record

review standards.

Patients date of birth

Home address of patient

Home or work phone number

All pages contain patient identification

Each entry has providers name or initials either handwritten, electronic, typed, or signature

stamp

Current medication list or medication note

Allergies and adverse reactions prominently displayed

Visit exam coincides with the chief complaint

Each return visit or follow-up plan noted

Each encounter with a physician has documentation of any unresolved problems from a

previous visit or if all problems are resolved

Pediatric patients birth to 19 years; preventive care visits include anticipatory guidance such as

injury prevention, violence prevention, sleep positioning, and nutrition counseling

Each entry is dated

Legible documentation

Individual medical record for each patient or individual sheet or section for each family member

Medical record organized in chronological or reverse chronological order with reports in a

consistent location within the chart

Lab and other diagnostic studies reviewed with results signed or initialed by physician

Documentation or inquiry regarding smoking habits and history of alcohol/substance abuse

IF a consult is ordered, the consultant report or note is received and reviewed

Past medical history including past patient and family history including a history of accidents,

illness, and surgeries

Advance directive

Completed problem list or summary of health maintenance exams listing summarizes significant

illnesses, medical conditions, past surgical procedures or chronic health problems and is

updated as new problems are encountered

UTILIZATION MANAGEMENT PROGRAM

Participation in the State Managed Care Network Utilization Management Program is a contractual

obligation of every network practitioner, provider, and delegate. This includes adhering to policies,

procedures, and standards; identifying and addressing barriers to the provision of quality care; reporting


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grievances and/or quality of care concerns; participating in auditing processes; and providing access to

or copies of clinical records or other documents, as requested by the State Managed Care Network.

ALTERNATIVE TREATMENTS

The State Managed Care Network does not prohibit or restrict providers from advising members about

any aspect of his or her health status or medical care, advocating on behalf of a member, or advising

about alternative treatments regardless of whether such care is a covered benefit.

SERVICING MEMBERS WITH SPECIAL HEALTHCARE NEEDS

The State Managed Care Network has an obligation to ensure appropriate services and accommodations

are made available to members with special healthcare needs. Services must be provided in a manner

that promotes independent living and facilitates member participation in the community.

Members with special healthcare needs may be allowed to have direct access/standing referral to their

specialist as needed for their care. If you have a member who may need a longstanding referral, contact

the State Managed Care Network for assistance.

The State Managed Care Network providers and vendors must respond within 24 hours to any

diminishment of a clients capacity to live independently (e.g. a broken wheelchair). The provider and/or

vendor shall deliver medically-necessary covered services that will restore the members ability to live

independently as soon as possible.

If a provider is unable to accommodate the special healthcare needs of a member, the provider can call

the customer service department at 303-751-9051 or 800-414-6198 (toll free) for help to find a provider

capable of delivering these services.

ADVANCE DIRECTIVES

An advance medical directive is a written instruction of care, such as a living will or medical durable

power of attorney, relating the provision of health care when or if the individual is incapacitated.

Medical providers have the responsibility to provide information about advance medical directives, and

to assist members with completing advance medical directive forms, as appropriate. If the member has

an advance medical directive, it is the responsibility of the member to provide medical providers or the

facility with a copy.

Types of Advance Medical Directives:

Living Will A living will tells medical providers not to use artificial life support of the member becomes

terminally ill. Copies of living will forms should be available at healthcare facilities, doctors offices,

office supply stores, on the Internet, and through the Guardianship Alliance of Colorado. For further

information call the Guardianship Alliance of Colorado at 303-423-2898.


PROVIDER MANUAL

18


Medical Durable Power of Attorney (also called a Health Care Proxy) A medical durable power of

attorney is a person the member chooses to make healthcare choices for the member if the member

cannot speak for himself or herself.

Cardiopulmonary Resuscitation (CPR) Directive A CPR Directive directs paramedics, doctors,

medical staff, or others to not try to resuscitate a member if his/her heart or breathing stops.

Hospitals, skilled nursing facilities, and home health agencies must maintain written policies and

procedures concerning advance medical directives. These policies must specify how and when a

directive can be changed, as well as procedures for providers to give information to the client regarding

implementation of the advance medical directive.

Providers shall document in the members medical record if the individual has executed an advance

medical directive. The presence or absence of an advance medical directive is not a provision of care and

providers cannot discriminate against an individual based on advance medical directive status.

If possible discrimination or coercion is suspected, a member or a provider (on behalf of a member) can

file a grievance. If the provider cannot execute or implement an advance medical directive on the basis

of conscience, the provider is to issue a written or other appropriate form of statement of limitation to

the member (or designated client representative).

QUALITY MANAGEMENT PROGRAM

The State Managed Care Network utilizes preventive healthcare and care management programs and

promotes quality monitoring using nationally recognized standards.

Continuous monitoring of quality indicators provides both the evaluation of individual outcomes and the

development of comparative performance and outcome norms. Health Plan Effectiveness Data

Information Set (HEDIS) indicators are used to evaluate performance and health status outcomes.

The State Managed Care Network quality management program complies with state and federal

regulatory requirements and follows applicable National Committee for Quality Assurance (NCQA)

Standards for Managed Care Organization. Operational components include:

Quality management and improvement through selection of appropriate clinical, cost, and

service indicators

Continuous monitoring, feedback and studies

Utilization management

Credentialing and re-credentialing

Satisfaction surveys

Monitoring use of available preventive health services and improvement of utilization

Medical records and standards and review

Grievances and quality of care investigation


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19


Network adequacy and access monitoring

The operation of a comprehensive, integrated program requires all participating primary care clinics,

medical groups/IPAs, and other contracting network ancillary and inpatient facility providers to actively

monitor quality of care. Equally important is the active monitoring of appropriate service utilization. Our

mutual goal is to improve the health status of CHP+ members.

ESSENTIAL COMMUNITY PROVIDERS (ECP)

Colorado Access encourages all of our contracted providers to become designated as an essential

community provider (ECP) with the Department of Health Care Policy and Financing (HCPF). Essential

community providers are providers that historically serve medically needy or medically indigent patients

and demonstrate a commitment to serve low income and medically indigent populations who

compromise a significant portion of our patient population. The ECP designation will apply to providers

participating in Medicaid/CHP+, and the Colorado Health Benefit Exchange (COHBE).

ECPs are currently defined in Colorado State Statute 25.5-5-403 (2) as a health care provider that:

Has historically served medically needy or medically indigent patients and demonstrates a

commitment to serve low income and medically indigent populations who make up a significant

portion of its patient population or, in the case of a sole community provider, serves the

medically indigent patients within its medical capability; and

Waives charges or charges for services on a sliding scale based on income and does not restrict

access or services because of a clients financial limitations

In order to become designated, please visit colorado.gov/hcpf and complete the application form. If

your application is approved, you will be included in the current list of essential community providers,

which can be accessed from the same website. The above website offers supplemental information

regarding this designation as well as other resources, such as FAQs.

https://www.colorado.gov/hcpf

PROVIDER MANUAL

III. Claims Submission

PLEASE SUBMIT CLAIMS TO:

CHP+ Claims

PO Box 17470

Denver, CO 80217-0470

Provider Carrier Disputes/Claims Appeals

PO Box 17189

Denver, CO 80217-0189

Colorado Access acts as the administrative services organization for the State Managed Care Network.

All claims for services rendered to members enrolled in CHP+ are processed by Colorado Access, with

the exception of non-accident related dental claims, which are processed by Delta Dental, and pharmacy

benefits, which are managed by Caremark. CHP+ participating providers must follow the State Managed

Care Networks claims filing procedures. All explanations of benefits (EOBs) and payments will be issued

by Colorado Access.

TIMELY FILING

Unless otherwise stated in your contract, CHP+ providers must submit claims within 180 calendar days

from the date on which services were rendered.

Should your claim be denied for timely filing, upon appeal, Colorado Access will accept the following

documents as proof of timely filing:

Another health plans explanation of benefits (EOB)

An electronic/EDI claim submission acceptance report

PROVIDER RESPONSIBILITIES

Providers rendering services to members of CHP+ and the CHP+ Prenatal Care Program have the

following responsibilities in relation to billing for these services:

Verify the members eligibility prior to submitting the claim

Ensure that the appropriate authorization requirements have been met

Verify that place of service codes are correct

Verify that diagnosis and/or procedure codes match the service provided

Complete all required data elements including NPI on electronic claims

Leave non-required data fields blank (do not enter N/A)

Use only black or dark red ink on any handwritten paper claims

Use only good quality toner, typewriter, or printer ribbons for paper claims

Do not use highlighters to mark claims or attachments

Bill original claims within 180 days or as specified by contract (whichever is less)

Claims Submission

PROVIDER MANUAL

21


Bill a members primary payer as applicable, prior to submitting claims to the State Managed

Care Network

Attach all required documentation to the claim

If several claims require the same attachment, a photocopy of the attachment must be

submitted with each claim

Do not submit continuation claims or interim bills

Submit claims timely to ensure timely payment for services

Submit paper claims to the appropriate address

COLORADO ACCESS RESPONSIBILITIES

As administrator of the State Managed Care Network, Colorado Access has the following responsibilities

with respect to the provider:

Provide information about requirements for filing claims

Notify new providers of standard forms, instructions, or requirements upon acceptance into the

plan

Notify providers of changes in standard forms, instructions or requirements within 15 calendar

days

Determine whether sufficient information has been submitted to allow proper consideration of

the claim

Provide appropriate explanations for denied claims

Approve, deny, or settle clean paper claims within 45 calendar days of receipt

Approve, deny, or settle clean electronic claims within 30 calendar days of receipt

Approve, deny, or settle all other claims within 90 calendar days

REQUIRED FORMATS

Providers are required to submit complete claims for all services rendered to members of CHP+ and the

CHP+ Prenatal Care Program. Electronic submission of claims is preferred. However, we will accept

paper claims in CMS 1500 and CMS 1450 (UB04) formats.

In order to process claims in a timely, accurate manner, we ask providers to observe standard reporting

requirements.

ELECTRONIC CLAIMS

The State Managed Care Network accepts electronic/EDI claims through direct submission or through

the use of a clearinghouse. For more information on direct submissions of electronic/EDI claims, please

contact [email protected].

The use of clearinghouses provides quick and efficient submission of electronic/EDI claims that are

compliant with current guidelines. Colorado Access accepts electronic/EDI claims from the

mailto:[email protected]

Claims Submission

PROVIDER MANUAL

22


clearinghouses listed below. If you use one of the clearinghouses noted below, please advise the

clearinghouse to direct your claims to the appropriate payer ID for each clearinghouse listed.

ENS: enshealth.com (Payer ID: coacc)

Emdeon (formerly known as WebMD): emdeon.com (Payer ID: 84129)

HealthFusion (formerly known as Quadramed): healthfusion.com (Payer ID: coacc)

Safe Software Healthcare (formerly known as Scinet): sagehealth.com (Payer ID: coacc)

Relay Health (formerly known as NDC): relayhealth.com (Payer ID: coacc)

SSI Group: thessigroup.com (Payer ID: coacc)

S&S Datalink: sasdatalink.com (Payer ID: coacc)

PNC Bank (formerly known as Healthcare Admin Tech): pnc.com (Payer ID: coacc)

If you would like information on direct EDI claim submission, or for additional information about EDI

claims, visit the Colorado Access website coaccess.com, or email [email protected].

CMS 1500

Providers must file all claims for professional/non-facility services, including laboratory services

performed by an independent laboratory on the CMS 1500 claim form.

CMS 1450

Providers must submit all hospital and facility claims, including those for laboratory services performed

by a hospital to CHP+ members on the CMS 1450 (UB04) claim form.

PROCEDURE CODING

We use the Health Care Financing Administration Common Procedures Codes (HCPCS) to identify

services provided to eligible recipients. HCPCS codes include CPTTM codes. In order to ensure that claims

are processed promptly and accurately, please follow these guidelines:

Use the most current CPTTM (Current Procedural Terminology) revision

Be aware that not all codes are covered benefits under the State Managed Care Network

When we receive billed codes that are considered obsolete, the claim will be denied and written

notification will be sent on an Explanation of Benefits (EOB).

DIAGNOSIS CODING

We require providers to enter the appropriate diagnosis code on each claim submitted. We will only

accept those codes published in the International Classification of Diseases, 9th Revision, Clinical

Modification (ICD-9 codes). The provider must enter ICD-9 codes clearly on the claim form and include

all digits and characters.

Some procedures are appropriate only when specific conditions are present (i.e. 99381 99387 is valid

only with Diagnosis Code V20.2). We require providers to ensure the diagnosis entered is appropriate

for the services provided and is supported by the patients medical record.

http://www.enshealth.com/http://www.emdeon.com/http://www.healthfusion.com/http://www.sagehealth.com/http://www.relayhealth.com/http://www.thessigroup.com/http://www.sasdatalink.com/http://www.pnc.com/http://www.coaccess.com/mailto:[email protected]

Claims Submission

PROVIDER MANUAL

23


Confidential Diagnosis Coding

Please enter AIDS or AIDS-related diagnosis codes on the claim form as with any other diagnosis or

condition. While federal and state statutes provide stringent penalties for failure to keep AIDS-related

information confidential, these statutes are not intended to prevent accurate and appropriate

submission of claims.

Federal and state statutes prohibit disclosure of information regarding application for or receipt of

public assistance. However, this information may be disclosed for purposes of administering a public

assistance program. Claims submitted for services rendered to CHP+ members include information

necessary to process claims, calculate costs and project future funding. In sharing information for these

purposes, we do not jeopardize the privacy of the member.

NON-CLEAN CLAIMS

In accordance with Colorado State Senate bill SB02-013, effective July 1, 2002, if a submitted claim

requires additional information in order to be paid, denied, or settled the claim will not be considered a

clean claim. Such claims will be paid, denied, or settled according to the following schedule:

Within 30 calendar days of receiving the claim, we will identify the claim as non-clean and

include written explanation of payment (EOP) codes and follow-up instructions to the provider

on the voucher as to how to resolve the claim.

If, within 30 calendar days of our request, a provider fails to submit requested additional

information, we may deny the claim.

Where all additional information necessary to resolve the outstanding claim has been provided

during the 30 calendar day period, the claim will be paid, denied, or settled (absent fraud)

within 90 calendar days after the date that the claim was first received.

According to law, the State Managed Care Network and the CHP+ Prenatal Care Program are

exempt from paying interest and penalties on claims.

RESUBMISSIONS

Providers may resubmit denied claims for reprocessing within 180 days of the date of service or 90 days

from the date of the last denial recorded on a voucher.

Resubmission Process

Send a photocopy of the original claim, clearly marked Resubmission on the face of the claim

or newly completed claim form. The resubmission must be newly dated and signed with an

authorized signature. Attach a copy of the voucher listing the originally submitted claim as

denied.

If one or more items on an original claim have been paid and other items denied, a legible

photocopy of the original claim may be used to resubmit denied lines.

Correct the appropriate information clearly and accurately.

Claims Submission

PROVIDER MANUAL

24


Adjust total charges to reflect the amount being resubmitted.

Mail all resubmitted claims to the claims address listed in this manual.

We will research the resubmission and adjudicate the claim according to the newly resubmitted

information. Once adjudicated, the claim will appear on your voucher with a corresponding EOP code

outlining the reason for payment or denial.

Late or Additional Charges

When billing late or additional charges for previously submitted claims, please resubmit the entire claim.

Do not submit the missing lines or additional lines separately. For example, if an inpatient claim was

submitted without the laboratory fees, the new/corrected claim must include the laboratory fees AND

the original claim lines.

CLAIMCHECK

To assist in processing physician payments, we use ClaimCheck software. The following EOP codes

will appear on vouchers to alert you of ClaimCheck edits:

QA Procedure code denied as incidental to anesthesia

QB1 50% reduced reimbursement for multiple surgeries

QD1 ClaimCheck duplicate procedure

QE1 Procedure code denied as exclusive procedure

QG1 Claim check age edit

QI1 Procedure code denied as incidental

QO1 - ClaimCheck obsolete code edit

QR1 - ClaimCheck bundled code

QS1 - ClaimCheck gender code edit

QT1 - ClaimCheck assistant surgery edit

QU1 - ClaimCheck unbundled code

QV1 - ClaimCheck visit edit

PROVIDER MANUAL

IV. Provider-Carrier Disputes (Claim Appeals) A provider or a provider representative may access the provider-carrier dispute process to submit a

written request for a resolution of a dispute regarding an administrative, payment or other issue not

related to an action.

SUBMISSION PROCESS

In accordance with DOI regulations, we require provider-carrier disputes to be submitted in writing.

Information may be submitted in a brief letter or on our Non-Clinical Adjustment Request form

(Appendix D).

All necessary information should be submitted within 90 calendar days from the date of the voucher on

which the disputed claim appears to the following address:

Provider-Carrier Disputes

PO Box 17189

Denver, CO 80217-0189

Necessary information for purposes of a provider-carrier dispute includes the following:

1. Each applicable date of service

2. Member/patient name

3. Member identification number

4. Provider name

5. Provider tax identification number

6. Dollar amount in dispute, if applicable

7. Provider position statement explaining the nature of the dispute, and

8. Supporting documentation where necessary (e.g., medical records, proof of timely filing, State

Web Portal eligibility screen prints verifying reasonable attempts to capture member eligibility

on date of service)

After we receive a dispute in writing, providers or their representatives may present the rationale for a

dispute in person, upon request. When a face-to-face meeting is not practical, we will provide

alternative methods of communication such as teleconference.

PROCESSING TIMEFRAMES

Upon receipt of a provider-carrier dispute, we will review, record, investigate, resolve, and provide

appropriate and timely notifications in accordance with applicable state and federal rules and

regulations.

We will issue a written confirmation to the provider or the providers representative within 30 calendar

days of receiving a complete dispute resolution request. We will resolve provider-carrier disputes and

issue written notification of the outcome within 60 calendar days of receipt of the initial request for

resolution and upon receiving all necessary information. We may choose to use electronic means to

Provider-Carrier Disputes (Claim Appeals)

PROVIDER MANUAL

26


send required notification to providers including email or fax. Both parties may agree to an extension

beyond the 60 calendar days from receipt of all necessary information timeframe established by this

policy in order to resolve a dispute. Should a provider be dissatisfied with the State Managed Care

Network resolution regarding a provider-carrier dispute, providers can direct written correspondence

to:

Health Plan Manager

Child Health Plan Plus

Department of Health Care Policy & Financing

1570 Grant St.

Denver, CO 80203

PROVIDER MANUAL

V. Coordination of Benefits & Subrogation Children or expectant women with other insurance are, by law, not eligible for CHP+ or the CHP+

Prenatal Care Program. Exceptions to this rule include school accident insurance, dental insurance, and

Medicare.

The following guidelines apply concerning other insurance coverage:

A child or expectant woman cannot be covered by a creditable health insurance policy, including

individual non-group policies.

If a child or expectant woman is currently covered by an employer-based group health insurance

policy where the employer pays more than 50% of the cost, he/she must be uninsured for 90

days prior to his/her enrollment in CHP+ or the CHP+ Prenatal Care Program.

If a parent or guardian of an applicant child has access to the State of Colorado health benefits

plan, the child is not eligible for CHP+.

A child or expectant woman cannot be eligible for or enrolled in Medicaid

It is important that providers make their best effort to identify and notify the State Managed Care

Network whenever they have reason to believe a member may be entitled to or known to have

coverage under any other insurance plan. This includes a commercial insurance policy, Medicaid, or

Medicare. Providers can find the Notification of Other Insurance form online at

chpplusproviders.com/materials.asp. Please download and complete this form and fax to 303-893-1780.

FILING A CLAIM FOR MEMBERS WITH SECONDARY COVERAGE

The following steps apply when submitting claims for members with primary coverage such as accident-

related insurance:

Providers must submit a hard copy of the CMS 1500/CMS 1500 or UB04/CMS 1450 along with a

copy of the Explanation of Benefits (EOB), denial notice (including all denial reason wording),

benefits exhausted statement or a copy of the check/voucher used for claim payment from the

other insurance/Third Party Resource (TPR).

o The State Managed Care Network does not consider refusals of payment due to claim

preparation errors or failure to provide sufficient processing information as proof of

denial.

o If an EOB applies to more than one claim, a copy of the EOB must be attached to each

claim submission.

Complete the appropriate TPR data fields/form locators on the claim form submitted to the

State Managed Care Network. Claim TPR data fields/form locators are specific to third party

insurance or Medicare; they cannot be used interchangeably.

Submit the claim within 180 calendar days from the TPRs denial date or processing date.

SECONDARY BENEFIT CALCULATION LOWER OF LOGIC

The State Managed Care Network calculates secondary benefits in the following manner:

http://www.chpplusproviders.com/materials.asp

Coordination of Benefits & Subrogation

PROVIDER MANUAL

28


The CHP+ benefit allowance is compared to the primary payment.

If the primary payment is equal to or greater than the CHP+ benefit allowance, the State

Managed Care Network will not make a payment.

If the primary payment is less than the CHP+ benefit allowance, the State Managed Care

Network will pay the difference between the two amounts. However, payment will not exceed

the other insurances (including Medicare) coinsurance, deductible, and/or copay.

The State Managed Care Network does not automatically pay the other insurances (including

Medicare) copayments, coinsurance, and/or deductibles.

NOTE: Providers cannot bill members for the difference between the primary payers payments and

their billed charges when the State Managed Care Network does not make additional payments.

AUTHORIZATIONS AND COORDINATION OF BENEFITS

The State Managed Care Network authorization rules apply only when the plan is considered the

primary payer. If the State Managed Care Network is considered the secondary payer, benefits will be

coordinated without need for prior authorization by the State Managed Care Network. A provider

should request authorization for services anytime he/she believes the State Managed Care Network will

be primarily responsible for payment of these services. This includes:

When services are not a covered benefit of the primary payer.

When benefits are exhausted by the primary payer.

When the primary payer does not have an adequate network to provide the covered service.

PROVIDER MANUAL

VI. Providers Reimbursement

FEE SCHEDULE

The CHP+ fee schedule is based on the Colorado Adjusted Centers for Medicare and Medicaid Services

(CMS) Resource Based Relative Value Scale (RBRVS). CHP+ uses two separate conversion factors to

calculate reimbursement:

Medical/Surgical/Laboratory

Anesthesia

Payment of 35% of billed charges will be made for those services or procedures which are by report,

unlisted, or have not been assigned a unit value by RBRVS.

PRIMARY CARE PROVIDERS

All primary care providers (PCPs) will be reimbursed at the fee-for-service rate for services provided to

members of CHP+ and the CHP+ Prenatal Care Program.

Some CHP+ members must pay a copayment when they receive services. The patients card shows what

his/her copayment is according to the type of service. PCP offices should collect these copayments for

all office visits that the office would ordinary generate a charge except for:

Emergency transport/ambulance services

Inpatient hospitalization and services

Skilled nursing

Outpatient/ambulatory surgery

Laboratory/X-ray services

Preventive care services (e.g. immunizations, well-child checkups, and health maintenance

visits)

Durable medical equipment

Audiology services

Maternity care

Ancillary Services Performed by the PCP

Ancillary services such as lab tests or x-rays, which are performed by the members PCP or billed through

the PCP office, will be reimbursed on a fee-for-service basis at the rates set forth in the CHP+ fee

schedule.

SPECIALTY CARE REIMBURSEMENT

Copayments for Specialty Care

Providers Reimbursement

PROVIDER MANUAL

30


Some CHP+ members must pay a copayment when they receive services. The patients card shows what

his/her copayment is according to the type of service. Specialty care provider offices should collect these

copayments for all office visits that the office would ordinarily generate a charge except for:

Emergency transport/ambulance services

Inpatient hospitalization and services

Skilled nursing

Outpatient/ambulatory surgery

Laboratory/x-ray services

Preventive care services (e.g. immunizations, well-child checkups, and health maintenance

visits)

Durable medical equipment

Audiology services

Maternity care

All services are reimbursed at the current CHP+ fee schedule.

Laboratory Services

Laboratory services are reimbursed at the rates set forth in the CHP+ fee schedule. Claims for lab

services should be billed on a CMS 1500 or a UB04.

Hospital-based Charges

Radiology services and hospital facility charges for emergency room, surgery, and other hospital-based

charges.

Hospital-based services covered by CHP+ are reimbursed as established by the individual providers

contract with CHP+. Hospital services should be billed on a UB04.

Physical, Occupational, and Speech Therapies

If services such as physical therapy, occupational therapy or speech therapy are hospital based and

billed on a UB04, CHP+ will reimburse those services using the same formula that is applied for other

hospital-based services. If professionals in freestanding facilities provide these services and bill on a CMS

1500, they will be reimbursed at the rates set forth in the CHP+ fee schedule.

Chiropractic Care

Care provided by a chiropractor is not a covered benefit under the CHP+ State Managed Care Network

plan.


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31


REPRODUCTIVE HEALTH SERVICES

The State Managed Care Network will reimburse providers of reproductive health care services at the

rates set forth in the CHP+ fee schedule. Reproductive health care services include, but are not limited

to:

Annual gynecological exams

Family planning services

Other specialty care related to reproductive health care

Most reproductive health care services can be provided without parental consent according to

Colorado Statute 13-22-105 and are considered confidential

EMERGENCY/URGENT CARE SERVICES

Valid procedure codes must be used when medical services are rendered in the office or consult room of

a hospital where no facility fee is charged, rather than sending the member to an emergency room in

and urgent or emergent situation outside normal office hours. After-hours care/office services is care

requested outside a providers normal or published office hours, such as between 10:00 p.m. and 8:00

a.m., or services requested when a providers office is closed on weekends and holidays.

These procedure codes should not be used for routine care that can wait until regular office hours.

These codes only apply to emergency and urgent care. Benefits for routine or preventive services

provided in the emergency department are not within the meaning of emergency services.

The applicable copay requirements for emergency services remain in place, and the CHP+ members are

responsible for paying the copay.

ANESTHESIA BILLING

When billing for anesthesia services, please use Anesthesia Services Codes (procedure codes 00100-

01999) in field 24-D. Time units must be entered in field 24-G one unit equals 15 minutes. When

calculating reimbursement on anesthesia claims, the State Managed Care Network does pay for time

and units. However, the State Managed Care Network pays for the actual time administered. One unit is

equal to 15 minutes. Please see the example below:

Step 1: Actual time divided by 15 equals X

Step 2: The base factor is added to X. This total equals Y.

Step 3: The relative value (conversion factor) is multiplied by Y.

This total is the payment amount.

IMMUNIZATIONS

Primary care providers (PCPs) are required to provide immunizations to CHP+ members who have

chosen their practice as their PCP.


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32


Immunizations administered to CHP+ members are reimbursed on a fee-for-service basis at

100% AWP.

Payment on immunization claims for CHP+ members will reflect reimbursement for both the

vaccine and administration.

Please bill administration fees using CPT codes 90471 (immunization administration) or 90472

(immunization administration; each additional does).

Immunizations for work and travel are not a covered benefit of CHP+.

Flu shots given to members of the State Managed Care Network are covered.

NOTE: CHP+ members are not eligible for the Vaccines for Children Program.

DENTAL SERVICES

Delta Dental provides coverage to CHP+ members for non-accident-related dental services. Please call

Delta Dental at 800-610-0201 with questions or concerns regarding non-accident-related dental

benefits.

The State Managed Care Network provides coverage for certain accident-related dental services, dental

anesthesia, inpatient admission for dental care (including room and board, coverage does not include

charges for the dental services), and treatment of cleft palate and cleft lip conditions. All dental services

and supplies are subject to preauthorization guidelines and plan provisions.

HOLD HARMLESS

Providers contracted with the State Managed Care Network agree that in no event, including, but not

limited to, nonpayment by the State Managed Care Network and the CHP+ Prenatal Program, insolvency

or breach of the provider contract, will the provider bill, charge, collect a deposit from, seek

compensation remuneration, or reimbursement from, or have any recourse against CHP+ members or

persons other than CHP+, acting on its own behalf, for services provided pursuant to the provider

contract. This provision will not prohibit collection of copayments in accordance with the terms of the

members Evidence of Coverage or collection of payment for non-covered services, except as otherwise

expressly prohibited by the provider contract.

Providers contracted with the State Managed Care Network agree that:

This provision will survive the termination of the provider contract regardless of the cause giving rise to

termination and shall be construed to be for the benefit of the member. This provision supersedes any

oral or written contrary agreement now existing or hereafter entered into between a provider and any

member or person acting on his/her own behalf.

PROVIDER MANUAL

VII. Member Grievances & Clinical Appeals Please let us know if you are not happy with Child Health Plan Plus (CHP+) State Managed Care Network,

our providers, your services, or any decisions that are made about your treatment.

You have the right to express a concern about anything you are not happy with.

You also have a right to appeal. This means you can ask for a review of a CHP+ SMCN action or

decision about what services you get.

Call our Grievance and Appeals department at 303-751-9051 or 800-414-6198 (toll free), or TTY

for the deaf or hard of hearing at 888-803-4494.

You will not lose your Medicaid benefits if you express a concern, file a grievance or an appeal. It is the

law.

WHAT IS A DESIGNATED CLIENT REPRESENTATIVE (DCR)?

A DCR is someone you choose to talk for you when you have a concern or appeal about your mental

health services. It could be a provider, an advocate, a lawyer, a family member, or any other person you

trust. A DCR can also be the legal representative of a deceased members estate.

If you decide to use a DCR, you must sign a form with the name, address, and phone number of your

DCR. This is so we can contact him or her during the investigation or appeal process. This person will not

see your medical records or get information about

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