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Colorado Access

August 2018


Table of Contents

The Navigator Newsletter!

Welcome to the provider newsletter from Colorado Access. We'll continue to send you important updates throughout the year.

New and Noteworthy

New Inbound Claim Rules

We are implementing a new EDI front-end validation process to ensure that inbound claims are meeting the standard HIPAA validation rules and to increase auto-adjudication rates. With this change, we will be applying stricter front-end transaction validation, which may result in an increase in rejections on your 277CA reports. Your clearinghouse may contact you with items that have been rejected that need to be corrected. Please work with your clearinghouse in this effort.

Important Information for Primary Care & Behavioral Health Providers

The Department of Health Care Policy and Financing (HCPF) is working hard to keep providers informed of the changes and requirements for the next phase of the Accountable Care Collaborative (ACC 2.0). We encourage you to check in regularly here for more information.

Provider Help Guide for EDI Rejections

We recently made changes to the system to require providers to send “cleaner” claims. These tips are intended to help you understand the front-end rejections that may be occurring because of these changes.

Failure to correct these issues will result in a rejection of your claims

Tips for Getting Your Claims Accepted:

  • 1. You must use the correct/up-to-date NDC code
  • 2. Do not use a diagnosis code on a professional claim unless you point to it from the service line
  • 3. Zip codes:
    • “99999” is not a valid zip code for provider or member.
  • Zip extensions:
    • “9999” and/or “1234” are not valid provider zip extensions
    • “1234” is a valid member zip extension. For members, “1234” is for “Unknown”
  • 4. Do not add an additional facility or provider information (i.e. Rendering or Facility) if it is the same as the billing provider (this includes both NPI number and provider addresses)
  • 5. For behavioral health CMS1500 claims, there must be a valid behavioral health modifier in the 1st modifier position (effective date-of-service January 1, 2018 forward)
  • 6. Verify that your condition code is accurate
  • 7. Do not include a description on service-line procedure codes unless the procedure code is “non-specific,” then you must. See example two below for further explanations.

What Will You See On Your Rejection Reports If Claims Are Rejecting for The Items Above?

Examples:

  • 1. Incorrect or incomplete zip code: “Acknowledgement/returned as unprocessable claim – the claim/encounter has been rejected and has not been entered in the adjudication system. Entity’s postal/zip code. Usage: this code requires use of an entity code”
  • What does this really mean? You need to review your policy for entering valid zip codes and zip+4 extensions. Remember that “1234” is valid for a member zip extension but not for a provider zip extension.
  • 2. Non-Specific Procedure Code Descriptions
    • Non-specific procedure codes require a description: Codes such as S9445 and S5151 (and other procedure codes, listed as “non-specific”) require a description. If you leave a description off of a “non-specific” procedure code, it will cause a rejection.
    • Regular procedure codes require no description: Do not include a description for a regular procedure code as it will cause a rejection.
  • What does this really mean? Determine not to use a procedure code description unless you know that it is a “non-specific” procedure code. Look up your codes when necessary – it could mean the difference between a rejected or accepted claim.
  • 3. Invalid Condition Codes or NDC (National Drug Codes): We are validating code sets. If you send codes that are invalid, it will cause a claim rejection. This is not an issue that can be resolved on the payer side, so providers must be diligent to update their software or code set sources to avoid claim rejections due to invalid codes.
  • What does this really mean? Verify your code (CPT, NDC, Value Code, Condition Code, Diagnosis Code, etc.) before using it. You may also need to update your billing software or code sets, these are updated and do change so you must be up to date. It’s also a good idea to ask your billing software vendor, “do we have the latest code sets?”
  • 4.Diagnosis Code Pointers: This is a difficult error because it refers to the EDI 837 Claim file. However, this 837 Claim file is produced from your system, which has the ability to connect a procedure code to a diagnosis code.
  • What does this really mean? This problem will not be ignored and it will cause a claim rejection if you do not connect the procedure code to the diagnosis code on a professional claim. Ask your software vendor for exact directions on how to use professional procedure-to-diagnosis code pointers.
  • 5. Missing Modifier: For Medicaid behavioral health professional health care claims, you must use at least one modifier per the Uniform Service Coding Standards Manual, found here.
  • What does this really mean? A procedure code modifier, when used correctly, allows providers to more accurately document and report the services rendered. For example: 90837 is for individual psychotherapy. A 90837 procedure code, with the “HE” qualifier clarifies that this is for a Mental Health Program, which is acceptable. Use a modifier when billing behavioral health!

If you have questions about these changes, please contact your provider relations representative.

Thank you for helping us make claim processing successful!

HCPF’s August Provider Bulletin is available now

More provider information and updates from HCPF can be found here in the August issue HCPF’s Provider Bulletin.

Physical Health (RAE)

ACC 2.0 Attribution Tips and Reminders

As we enter the new ACC 2.0 contract, we’ve received a lot of feedback from our providers. We know that there have been some challenges with initial member attribution. As the RAE for regions 3 and 5, we are working closely with the Colorado Department of Health Care Policy and Financing (HCPF) and the enrollment broker, Health First Colorado Enrollment, to address these challenges. We are sharing issues as soon as we’re alerted and working to find solutions. We have a few tips and reminders to help you navigate these early challenges. You can find additional information from HCPF here.

Attribution vs. Fee-for-Service Payments

Even if a member is not attributed to your practice, you can bill HCPF for fee-for-service (FFS) payments if the member is enrolled in Health First Colorado FFS Medicaid. If you have a patient that needs care, you can see the patient and bill FFS while encouraging the member to call Health First Colorado Enrollment to change their primary care provider (PCP). The member’s attribution determines your per-member per-month (PMPM) payment from the RAE and your key performance indicator (KPI) calculations. It is not tied to your FFS payments.

How to determine if a Health First Colorado Member is enrolled in Denver Health Medicaid Choice (Managed Care Organization) vs. Denver Health PCMP

When verifying Health First Colorado (Colorado’s Medicaid Program) member eligibility in HCPF’s Provider Web Portal, a practice/provider may see that a member has a managed care assignment with Denver Health and Hospital Authority. This does not always mean that a member is enrolled in Denver Health’s Medicaid Choice Managed Care Organization. Denver Health and Hospital Authority currently participates with Health First Colorado in two benefit plans:

  • 1. Denver Health Medicaid Choice (PIHP)--a closed-network managed care organization; and
  • 2. Primary Care Medical Provider--A fee-for-service provider within the open network of Health First Colorado

To determine whether the member is enrolled with Denver Health and Hospital Authority’s Managed Care Organization, a provider/practice needs to look specifically at the benefit plan column on the managed care assignment table of the HCPF Provider Web Portal. For step-by-step instructions see the Verifying Member Eligibility and Co-Pay Quick Guide which can be found here. Assignment to a Denver Health and Hospital Authority Primary Care Medical Provider Benefit Plan does not impact your fee-for-service payments. Health First Colorado members can continue to see any Health First Colorado provider, including specialists.

The screenshots below show the two types of member benefit plan enrollments in Denver Health and Hospital Authority.

examples.png

Enrollment Caps/Panel Limit

As part of the RAE contracting process, we asked each provider how many additional Health First Colorado members they were willing to accept as part of the new process for attributing unattributed members. Due to some attribution challenges, providers are currently experiencing with enrollment caps/panel limits, HCPF would like regional organizations to distribute the following messaging:

  • Background: Primary care medical providers (PCMPs) are not required to have a limit on the number of Health First Colorado (Colorado’s Medicaid Program) members that can be attributed to them and have the ability to set their own panel limit/cap. RAEs are responsible for working with PCMPs to identify and set in the interChange a PCMPs panel limit/cap.
  • Key information for PCMPs:
    Primary care medical providers (PCMPs) are not required to have a limit on the number of Health First Colorado (Colorado’s Medicaid Program) members that can be attributed to them
    • PCMPs have the ability to set their own panel limit/cap
    • PCMPs can maintain an open panel with no limit
    • PCMPs should contact their Regional Accountable Entity to establish their panel limit/cap
  • If a PCMP chooses to have a panel limit/cap and reaches this limit, the PCMP will not receive any additional attributions, including claims history, geographic attributions or member choice
  • PCMPs must contact their RAE for their panel limit/cap, if one has been established; PCMPs cannot view their panel limit/cap through the Provider Web Portal

If you would like to change your panel limit for Health First Colorado members attributed to your practice, you can do so by contacting your provider relations representative by phone or email at ProviderRelations@coaccess.com

Updated Website for the Health First Colorado Data Analytics Portal

HCPF has contracted with IBM Watson Health (formerly Truven) to host the new Data Analytics Portal (DAP), which replaces the former SDAC. The Data Analytics Portal is a tool for primary care medical providers and RAE that includes population and performance information for the Accountable Care Collaborative. HCPF has updated the DAP website to include background information, job aids, trainings and contact information. To visit the website, click here.

If you are a primary care provider contracted with us, you can gain access to the portal by contacting Sandy Rangel at sandy.rangel@coaccess.com.

HCPF Track One PCP APM update

January 1, 2018 kicked off the baseline year for the Track One Primary Care Provider (PCP) Alternative Payment Methodology (APM). All PCPs are required to participate or face declining Medicaid reimbursement rates over the coming years. The model reduces the reimbursement rate for select codes by 4%, and a practice’s achievement on a combination of self-selected structural and performance measures will allow them to earn back that 4%.

Practices were able to select their measures in January, and the Department of Health Care Policy and Financing (HCPF) will reopen the measure selection process again in November. All practice sites will be able to add or change their measures at that time.

HCPF indicates that 100 practice sites in Colorado have not yet completed the measure selection process. It is imperative that you select measures in November.

Prior to November, HCPF aims to provide PCPs with their claims baseline data via the provider portal so they have a gauge as to how they are doing and what measures they may want to select when the process reopens.

In the first year, HCPF is paying for simply reporting on those measures that do not yet have performance goals attached to them.

As a reminder, the timeline for the APM is as follows:

Calendar Year 2018 = Baseline year for selected measures

  • July 1, 2018 = Reimbursement rate reduced by 4% (HCPF will continue to reimburse at 100% until July 2020; possible 4% reduction will occur retroactively at that time, for the following fiscal year).

Calendar Year 2019 = Performance year for selected measures

  • Early 2020 = RAEs to assess PCP site achievement on structural measures; HCPF to calculate achievement on performance measures
  • July 1, 2020 = Reimbursement rate on identified codes adjusted for following year based on measure achievement in 2019 over 2018

More information: HCPF will be doing more webinars in the coming months, as well as reaching out to those practice sites that have not yet selected measures in order to help them do so. You can also contact Dan Obarski at daniel.obarski@coaccess.com for more information. Your assigned provider representative can help you contact him.

The most current and critical information related to the APM and measure selection can be found here.

Additionally we have prepared this document to help you select measures that most align with other programming, so that you might maximize your focus and resource allocation. However, the measures you select are entirely your choice.

Behavioral Health (RAE)

Important Member Eligibility Changes for Behavioral Health Providers

On July 1, ACC 2.0 went live. ACC 2.0 combines the administrative duties of the previous Behavioral Health Organizations (BHO) and Regional Care Collaborative Organizations (RCCO) into a single regional entity, known as a Regional Accountable Entity, or RAE. Claims that were previously paid by the BHOs will now be paid by the RAEs.

As with the previous BHO system, RAEs are contracted with HCPF to administer and support Medicaid operations in a particular region of the state. However, one major change will impact the way you bill for services. In the BHO system, members were assigned to—and their behavioral health claims paid by—a BHO based on their county of residence. That is no longer the case. Under the new RAE system, members are assigned to—and their claims paid by—a RAE based on the location of their primary care provider. This means that a member might live in one RAE region and be assigned to a different RAE region, simply because their primary care provider is in that other region. When you bill for behavioral health services, you must submit you claims to the RAE to which the member is assigned, regardless of where the member lives. This information will be available on the member’s eligibility record.

Members can see the behavioral health provider of their choice, regardless of location. It will be up to the provider to have a contract with and bill the proper RAE for services rendered. Therefore, we encourage behavioral health providers to contract with all RAEs so that you can bill the appropriate entity for your claims. Remember, it does not matter if a member is assigned to the RAE for your region, as you can see members from any region—just be clear (by reviewing eligibility) which RAE will need to receive your claims for any given member.

Behavioral Health Modifier Requirements:

As a reminder per the USCS Coding Manual effective 1/1/18 and forward, all covered CPT/HCPCS codes billed on a 1500 will require the applicable modifier to be billed on the claim. Please reference the coding manual for applicable modifiers for each code as well as the applicable modifier position. If you have questions about these requirements, please contact your provider relations representative.

CHP+ HMO & SMCN


New Inbound Claim Rules

We are implementing a new EDI front end validation process to ensure that inbound claims are meeting the standard HIPAA validation rules and to increase auto-adjudication rates. With this change, we will be applying stricter front-end transaction validation, which may result in an increase in rejections on your 277CA reports. Your clearinghouse may contact you with items that have been rejected that need to be corrected. Please work with your clearinghouse in this effort. If you have questions about these changes, please contact your provider relations representative.

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