Provider FAQs

Per member.

No. Providers must be contracted as a primary care provider (PCP) in the Accountable Care Collaborative (ACC) program before they can receive attributions. Providers must meet specific criteria to be considered for PCP contracting and have a signed agreement with the regional organization serving their region.

All behavioral health providers must go through our credentialing process. CHP+ HMO providers must also go through our credentialing process. All providers, including behavioral health providers and PCPs, must be validated by the Department of Health Care Policy and Financing (HCPF) and enrolled as a Medicaid provider.

If you have been successfully revalidated, you do not need to do so again. Click here to learn more about validation.

No. The only exception to this would be bed-based care (inpatient, residential, acute treatment unit or intensive outpatient).

Yes, we have regularly scheduled webinar trainings. You can also request an in-office training with your provider relations representative.

Yes, these sessions will be available in a primary care setting without a covered diagnosis. Sessions provided and billed by a behavioral health practitioner to Colorado Access can also be provided without a covered diagnosis.

In ACC Phase II, members will be attributed to the brick and mortar service location, rather than the group Medicaid billing ID. This means that all Primary Care Providers (PCPs) must ensure they are billing HCPF utilizing site IDs and that each site is contracted with their regional organization. All claims submissions must adhere to Colorado Medicaid billing guidelines as outlined in the Billing Manuals. Specifically, claims must be submitted using the proper service location ID and address where services are rendered. For guidance on how to add a NPI for a service location, see Provider Web Portal Quick Guide: Provider Maintenance – Adding a National Provider Identifier (NPI) | Colorado Department of Health Care Policy & Financing.
The state will use four different methodologies to ensure all members are attributed to a PCP site location.

• Member selection:  ACC members have the option of choosing a different PCP at any time by calling the state’s enrollment broker.
• Claims history: If an ACC member has a demonstrated claims history with a practice over the last 18 months, the system will automatically attribute the member to that location. The system first looks at paid Evaluation and Management (E&M) claims, then other types of claims are considered.
• Family connections: If member has no utilization with a PCP in the past 18 months, the system will attribute the member to the PCP with which a family member is attributed. This occurs only if the PCP is appropriate. Example: a parent will not be attributed to a child’s PCP if that PCP is a pediatrician. Family relationships will be assumed when a member shares last name, street address, city and ZIP code.
• Proximity: If neither a member nor a family member has a utilization history with a PCP, the system will determine the closest appropriate PCP within the member’s region and attribute to that location.

Using Emdeon the Payment Manager, enrolled providers can download PDF versions of Explanation of Payments (EOPs) that were previously mailed in hardcopy with a VCC or conventional check format. Please call 855-886-3863 to learn more.

Complete and submit a Clinical Staff Update Form. Note: submission of this form is to initiate the process for adding a provider and there may be additional steps required for approval to provide services to our members. Please contact your provider relations representative for the provider’s effective date.

We’re glad you’re interested in becoming a contracted provider! Please visit our Become a Provider page for specific information on how to become a Colorado Access provider.

The default payment method is through a Virtual Credit Card (VCC). Click here for information on other payment options and how to request a change.

On the date of service, please check the state web portal to confirm eligibility. If the state web portal is showing that a child is eligible for Child Health Plan Plus (CHP+) on the date of service, a copy of that printout can be used as proof of eligibility regardless of future retro-enrollment activities. Please use our eligibility web portal here to confirm the member is covered under the CHP+ offered by Colorado Access program; you may also.

Eligibility can be checked in two locations:

• Our provider portal

Complete Synagis prior authorization form and fax to Navitus at 855-668-8551. You will receive a fax indicating approval or denial of prior authorization determination is made. If request is approved, fax order for Synagis to Lumicera Specialty Pharmacy at 855-847-3558. If you wish to have a home health agency administer Synagis to your patient, please indicate that the medication will be shipped to the patient’s home on your order. Upon receipt of Synagis order indicating that medication will be shipped to patient’s home, Lumicera will fax a home health request to Colorado Access utilization management (UM) team to set up the services. Our UM team will work to set up a home health agency to visit the patient’s home and administer the medication.

Thank you for keeping us updated regarding address changes! Complete and submit a Provider Address Change Form. Note: when changing your remit address, please include a copy of your current W9.

The first step is to complete and submit a Provider Logon ID Request Form. If you are having problems with your username/password, please email ProviderNetworkServices@coaccess.com. Note: you must have the most current version of Adobe to complete and submit this form electronically through the website.

Updates and information on integrated care billing can be found on our website, in the provider newsletter, and on the Colorado Department of Health Care Policy and Financing’s (HCPF) website.

Behavioral health and CHP+ providers can submit claims electronically through a number of clearinghouses. For more information about EDI claims, click here. All physical health claims will be submitted to the state.

Behavioral health and CHP+ paper claims can also be mailed to:
Colorado Access Claims
PO Box 17470
Denver, CO 80217-0470

Effective July 1, 2018, there is a new Department of Health Care Policy & Financing (HCPF) billing requirement for behavioral health services provided in primary care clinics, FQHCs, RHC, Indian Health Center and non-physician practitioner groups as follows:
1. The first six behavioral health visits provided in a primary care setting must be billed directly to Health First Colorado (Colorado’s Medicaid Program).
2. The following CPT codes are included in this new billing requirement: 90791, 90792, 90832, 90834, 90837, 90846 and 90847.
3. Claims for these CPT codes that go beyond six visits billed to HCPF require a prior authorization from Colorado Access.

In accordance with the Department of Health Care Policy & Financing, if a provider is not enrolled or validated with the state, reimbursement for any services rendered to CHP+ and/or Medicaid members may be denied.

If the provider is validated for Medicaid with the state, contracting and credentialing takes approximately 8-10 weeks.

The state will send a letter notifying members of their primary care provider (PCP) assignment, how to change their PCP, and what regional organization they are in based on their PCP assignment. The information is also included in the Member Handbook.

In order to be reimbursed for your services from a regional organization, you must have contracts with regions in which your patients are assigned.

Yes. Claims using codes not included in the list of short-term behavioral health codes should be sent to the regional organization for payment. Please refer to the Billing and Coding manual for guidance on CPT/HCPCS coding practices and documentation requirements.

Members will not be attributed to behavioral health providers. Members will be attributed to the region in which their primary care provider (PCP) is located, which will determine their regional organization. The behavioral health provider will need to be contracted with the members’ regional organization to be reimbursed by the regional organization.

You must have a contract with each regional organization where you have a location. You also need a Medicaid site ID. You will bill the Department of Health Care Policy & Financing (HCPF) with that site ID. If you have questions, please call us Monday through Friday from 8 a.m. to 5 p.m.

We’re sorry you’re having issues with your contract and we’d be happy to help. Please contact your provider relations representative. You may also email us at ProviderNetworkServices@coaccess.com.

If you disagree with the way we processed a claim, you should submit a claim appeal (provider carrier dispute) form and all supporting documents in writing to:

Appeals and Adjustments
Colorado Access
PO Box 17189

Denver, CO 80217-0189
Please note: An incomplete form or incomplete documentation may delay the appeal or result in a denial. If you have questions about an appeal, or would like to learn the status of your appeal, please call us. For additional information, please review the “Provider Carrier Disputes” (Claim Appeal) section of your provider manual.

Yes, they can.

Yes, prior authorization is required for certain procedures. To see services that require prior authorization, please consult our Master Authorization List on the Provider Toolkit.

Synagis is covered for eligible patients through the Colorado Access pharmacy benefit. The specific criteria for approval can be found here. Prior authorization forms should be faxed to Navitus at 855-668-8551.

For applicable provider groups doing integrated care, the first six sessions billed using short-term behavioral health codes (90791, 90792, 90832, 90834, 90837, 90846, and 90847) will now be sent to Health First Colorado as fee-for-service claims instead of the being sent to the Behavioral Health Organization (BHO) for payment.  After six sessions, providers must receive a prior authorization from their regional organization to have additional short-term behavioral health services paid under the capitated behavioral health benefit.

Physical health claims will continue to be paid by the state. Primary care providers (PCPs) that receive medical home payments by contracting with us will be receiving those per member per month (PMPM) payments from Colorado Access instead of the state, via our claims processing vendor, Change Health. Behavioral health providers will be paid by submitting their claims to the regional organization to which their member is assigned.

No changes have been made to restrict a member’s ability to seek care from another provider. Providers with multiple sites should note that patient attribution will be to the site they most frequently utilize for primary care but the patient is not required to only receive care from their attributed site.

We request that our network providers adhere to state and federal standards for appointment availability for members. If you are unable to provide an appointment within the required timeframes, listed below, please refer the member to our customer service department for assistance finding the care they need in a timely manner.

For Child Health Plan Plus (CHP+), we cover:

• Physical health
• Behavioral health
• Pharmacy benefits
• Vision benefits

Click here to learn more.

CHP+ members also have access to dental benefits through DentaQuest.

For Health First Colorado, we cover:

• Physical health
• Behavioral health
• Dental benefits

Click here to learn more.

An Episode is currently defined as a 12-month period beginning with the first date of service.

You must first initiate a contract with us before we can begin the credentialing process. A contract contains the terms for the provision of health care services for our members. During the credentialing process, a provider’s credentials, including their licensure, DEA certification, education and board certification, are primary source verified. The credentialing process must be complete before we can finalize and execute a contract. For more information on the contracting and credentialing process, visit this page.

Applicable provider types can bill six sessions using applicable codes within a 12-month period without a covered diagnosis. They must meet medical necessity, be provided by a Medicaid enrolled masters level or higher licensed behavioral health provider, follow CPT coding practices and documentation requirements, and be available in a primary care setting.

Federal regulations by the Centers for Medicare & Medicaid Services (CMS) require that all Medicare, Medicaid and CHP+ providers undergo enhanced screening and revalidation.

The following provider types can bill short-term behavioral health codes: primary care clinic, federally qualified health centers, rural health centers, Indian Health Center, and/or a non-physician practitioner group.

This depends on the type of coverage the member has:

• For members of Child Health Plan Plus (CHP+) offered by Colorado Access, refer to the Members Benefits Handbook or call us at 800-511-5010 Monday through Friday from 8 a.m. to 5 p.m.
• For Health First Colorado, visit the Health First Colorado (Colorado’s Medicaid Program) website or call us at 800-511-5010 Monday through Friday from 8 a.m. to 5 p.m.

You may check the status of a Colorado Access claim through our provider portal or call us for additional assistance.

To determine whether a code requires prior authorization for either Medicaid or CHP+ members, please consult our Master Authorization List on the Provider Toolkit.

The Colorado state statute prohibits providers (Medicaid or non-Medicaid) from billing Medicaid and CHP+ members for covered services. Providers who do this may be reported to the Department of Health Care Policy & Financing Program Integrity Unit.

To find out more information about why a claim was denied, you can review the denial on our provider portal. If you have further questions, please call us and we’d be happy to help.

All procedures for prior authorization (including procedures for IOP SUD) will remain the same. Providers can complete the prior authorization request form and fax the form, plus all relevant clinical information, to the fax number listed on the prior authorization form.

Yes, each regional organization is responsible for the utilization management of core behavioral health services and will authorize services. You can call us at 800-511-5010.