Batch billing systems usually extract information from an automated accounting or patient billing system to create a group of claim transactions. Providers are asked to notify the Department's fiscal agent if the member or the member's representative (e.g., attorney) requests detailed copies of bills for medical services paid by the Health First Colorado program. A recouping restriction is an established guideline in Colorado interChange that limits or prevents the automatic recovery of all monies owed on an AR when there are available provider funds. Services must be ordered by a licensed physician (MD or DO) or advanced practice nurse (APN). There is a monthly Co-pay maximum for Health First Colorado members. Information in this section applies only to Medicare benefit coordination. Telephone requests cannot be accepted. Issue Medical Identification Cards (MIC Card) to eligible members. This document provides a link to the Pharmacy billing instructions. Providers are not required to accept all Health First Colorado members. The State approves using HCPCS codes when submitting claims for services billed in the following formats: Providers should use the most current CPT version. If providers receive payment from a third party, they must return any Health First Colorado payment. If a zero payment is incorrect, the provider must submit a claim adjustment. The sort order within each claims section is by the following five fields: Last Name, First Name, Middle Name, Medicaid ID and ICN. Following the last transaction in the Claim Adjustments section, the total number of adjustments is indicated as well as the net result, payment, or recovery for all adjustment transactions. For example, a household with a monthly income of $900 would pay no more than $45 in co-pays for that month. Providers bill usual and customary charges for all FFS services and Co-pay is automatically deducted during claims processing. Each RA page carries a heading with the following information: Claim detail information is reported under a number of headings according to the type of claim submitted and the adjudication status of the claim. The Health First Colorado program must submit copies of audit information for audit and review upon request. Additional testing may be required in the future to verify any changes made to the Colorado interChange have not affected provider submissions. Updates and revisions to HCPCS listings are documented in the Provider Bulletins. This manual describes policies for commercial health insurance coverage, Medicare coverage, and other liability programs such as accident coverage and victim compensation. Charges for services are the member's responsibility until eligibility is established. 447.56(f). Claims that are duplicates will be denied as such. Health First Colorado claims instruct providers to identify services that are related to accidents. Adjustment Amount - This is the amount paid on the adjusted claim. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented. Providers should always ask the member about other insurance coverage. LOUISIANA MEDICAID PROGRAM ISSUED: 01/01/21 REPLACED: 09/11/18 CHAPTER 25: HOSPITAL SERVICES SECTION: TABLE OF CONTENTS PAGE(S) 5 Page 1 of 5 Table of Contents HOSPITAL SERVICES . A Health First Colorado State ID number is assigned to a newborn when the case manager establishes and approves eligibility. Avoid Billing Issues – Laboratory Services; Avoid Denial of National Drug Code (NDC) Claims ; Billing for Off-Label or Unproven Indication; Breast Pump Coverage for GEHA Benefit Plans; CDC Best Practices for Your Fight Against the Flu; Clarification: Prior Authorization and Site of Service Review; Colorado - You’re Invited. Kaiser Permanente of Colorado Claims Administration P.O. It is important that the CWCCI site use the diagnostic test date as the PE start date. The provider may send a personal check payable to the State of Colorado for the total claim payment amount. Providers should read information carefully to ensure that they apply appropriate policies to the correct services and programs. QMB-only members are financially responsible for services that are not covered by Medicare. When EFT is interrupted, payments are made by State warrant (paper check). Some Co-pay exemptions are processed automatically and others require the provider to complete specific information on the claim transaction or form. Approval of the Prior Authorization Request (PAR) does not guarantee Health First Colorado payment. Benefit Policies Outpatient Behavioral Health Services are a group ofservices designed to provide medically necessary behavioral health services to certain Health First Colorado members in order to restore these individuals Providers cannot bill members for the difference between commercial health insurance payments and their billed charges when Health First Colorado does not make additional payment. Note: Any existing agreement between the provider and the Department regarding specific accounts receivables owed will be honored regardless of these recouping restrictions. Providers may also request to receive the HIPAA 835 Health Care Claim Payment Advice for receiving claim payment information. Failure to respond to a revalidation request or requirement may result in provider suspension or termination.
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