children's health insurance program...

Children's Health Insurance Program Update

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September 20, 2017

Susan E. Birch, Executive Director & Gretchen Hammer, Medicaid Director

Our Mission

Improving health care access and outcomes for the people we serve

while demonstrating sound stewardship of financial resources

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Presentation Agenda

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• Overview of Children’s Health Insurance Program Title XXI Funding in Colorado CHP+ only, some Medicaid kids

Potential Congressional Actions Federal Update Resources for Partners

• Update on the Colorado interChange

Children’s Health Insurance Program (CHIP)

• Enacted in 1997, CHIP is public health insurance for low-income children and pregnant women

• CHIP is jointly funded by federal and state governments

• CHIP funding pays for: Child Health Plan Plus (CHP+), Colorado’s CHIP Medicaid expansion children and pregnant women (MCHIP)

• CHIP federal financing is only authorized through September 30, 2017

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CHIP Funding Pays for Two Populations

Medicaid CHP (MCHIP) Child Health Plan Plus (CHP+)

# of Kids and Pregnant Women Covered

66,433 children 2,276 pregnant women

75,287 children 788 pregnant women

Family Income Limits ($ Estimate is for a Family of 4)

MCHIP Kids: Up to $2,911/month

MCHIP Pregnant: Up to $3,998/month

Up to $5,330/month

Current Federal Match Rate 88% 88%

State Match Fund Sources General Fund

CHP+ Trust Fund Healthcare Affordability &

Sustainability Fee Appropriated Total

Funds $142.4 million $184.8 million

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Source: FY 2017-18 Appropriated Funding for Title XXI Programs.

CHP+ Program Overview

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Data Note: Data is based on 2016 annual caseload. The latest monthly County by County Caseloads are available at Colorado.gov/hcpf

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Data Note: Chart is annual caseload, the latest monthly County by County Caseloads are available at Colorado.gov/hcpf

Congressional Action Impacts If... Then... Congress passes Senate Finance Committee Plan

• 5-year extension

• FMAP at 88% for FFY 2018 & 2019

• FMAP at 76.5% in FFY 2020

• FMAP at 65% in FFY 2021

No immediate impact on coverage or financing structure for two years Federal financing would be reduced starting in FFY 2020

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Congressional Action Impacts If... Then... Congress does not act to continue funding CHIP

Federal funding for CHP+ would run out in early 2018 for Colorado. Coverage for 76,075 kids and pregnant women currently enrolled in CHP+ would end Enhanced federal funding for 68,709 CHIP financed-Medicaid enrolled kids and pregnant women would end

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Congressional Action Impacts If... Then... Congress acts to continue funding but at a lower match rate

No impact on coverage but federal funding levels could move from 88% to 65%

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Department Contingency Planning • Current law allows states to continue to spend unspent

federal fund allotments collected before October 1, 2017 We estimate funds will run out in calendar year Q1 2018

• No immediate changes to CHP+ eligibility, enrollment, renewals, or benefits on October 1, 2017 CHP+ applications and redeterminations will continue to be

processed CHP+ members will be able to use their benefits and access

care • If program ends, system will automatically check to see if

CHP+ members qualify for other Medical Assistance or a subsidy to purchase private insurance through Connect for Health Colorado

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Resources for Partners

• Stay up-to-date at the Future of CHP+ website: https://www.colorado.gov/pacific/hcpf/future-child-

health-plan-plus-chp

• Resource for Call Center Agents • CHP+ Member Frequently Asked Questions (FAQs) • *Future Resources - Upcoming webinars, samples of

member letters and other resources for partners/stakeholders (*could change based Congressional action)

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https://www.colorado.gov/pacific/hcpf/future-child-health-plan-plus-chp


https://www.colorado.gov/pacific/sites/default/files/Future%20of%20CHP%20-%20Call%20Center%20Resource%208-16-2017.pdf


COMMIT Update to the

Joint Budget Committee

Chris Underwood, Health Information Office Director

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September 20, 2017

Multiple Modernizations

New Systems Launch

New Policies/Checks

Re-Enrolled all Providers

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• Three Components • Colorado interChange • Pharmacy Benefits

Management System • Business Intelligence

Data Management

• Example: EAPG Policy • Budget savings

expected in Year 1 • Transparency

• Where services are provided & what we pay for

• 50,000+ enrolled • 8,000 added from

October - March • 7,800+ added since

Go Live in March 2017

• Adding more each day

Meeting Federal and State Requirements, Responding to Audit Findings

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Implementation Phases

Go Live

Implementation

Normal Operations

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Mostly Reactive Initial training on system and policy, identifying bugs, fixing one-off issues as reported, adjusting to new business processes

Some Reactive, Some Proactive Additional training, monitoring known issues and escalated system fixes, implementing system changes and improvements Mostly Proactive

System maintenance, claims processing and review, ongoing training, system changes that are strategic

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$60,000,000.00

$70,000,000.00

$80,000,000.00

$90,000,000.00

$100,000,000.00

$110,000,000.00

$120,000,000.00

$130,000,000.00

$140,000,000.00

$150,000,000.00

$160,000,000.00

Weekly Provider Payments (Excludes Capitation Payments)

Old MMIS New MMIS

Old MMIS Average (7/15/2016 - 1/27/2017) New MMIS Average (3/10/2017 - 9/15/2017)

Old MMIS Average Payments = $117.0 Million New MMIS Average Payments = $120.9 Million Difference is +$3.9 Million

New MMIS Go Live: 3/1

Common Reasons for Claim Denials

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Error Code- Explanation of Benefits (EOB)

What does it mean? Provider action

EOB 1473 - Multiple provider locations for billing provider specialty.

In general, EOB 1473 is an indication that the system cannot determine which location to look at. If a National Provider Identifier (NPI) is associated with more than one (1) provider type or location address, additional steps are needed to ensure proper claims adjudication. A unique nine (9) digit zip code or taxonomy code is required to identify the correct billing provider ID.

Confirm the address, NPI and taxonomy on the claim match the information reported on provider maintenance tab on the provider web portal.

EOB 3261 - The procedure code currently is not a benefit for date of service billed.

This is not a covered procedure. The code may be covered, but there may be further restrictions on the procedure codes. Please see the billing manual for further directions.

Confirm the correct procedure code was submitted on the claim. Refer to billing manual for information on covered procedures and any restrictions on the code.

EOB 2590 - The client has Medicare. Charges must billed to Medicare before billing Medicaid.

This member has other coverage with Medicare. Medicare would be the primary insurance and should be submitted.

Rebill the claim after billing Medicare first.

Payment by Provider Type • Hospitals: 8.6% Lower Inpatient: Paid $381.5 Million, 2.4% Higher Outpatient: Paid $278 Million, 20.4% Lower

• Nursing Facilities Paid $332.8 Million, 4% Higher

• Federally Qualified Health Centers Paid $81.6 Million, 3% Higher

• Rural Health Centers Paid $8.9 Million, 3% Lower

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Payment by Provider Type • Community Centered Boards (CCBs) Paid $83.8 Million, 16.1% Lower

• DIDD Providers Paid $139.8 Million, 4.8% Lower DD Waiver

• Paid $113.7 Million, 6.7% Lower

SLS Waiver • Paid $17.2 Million, 10.0% Higher

CES Waiver • Paid $8.2 Million, 2.4% Lower

• Alternative Care Facilities Paid $23.6 Million, 14.3% Lower

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Provider Support Services

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Field Agents

Call Center

Provider Resources Web Page

Email & Provider Bulletins

DXC Regional Field Representatives DXC Agent Hired DXC Hiring in Progress

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Since the March 1 Go Live…

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28 Million claims processed in the Colorado interChange

We have paid $4.3 Billion to providers

Approximately 66% of submitted claims are paid

Questions?

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Stu Bailey

Vice President State and Local Government Healthcare

7910 Sawgrass Court Pleasanton, CA 94588

www.dxc.technology

September 18, 2017

Susan Birch, Executive Director

Department of Health Care Policy and Financing

1570 Grant Street

Denver, CO 80203

Dear Sue,

Thank you for your leadership as we work through the stabilization of the Medicaid operations following the Go Live of the new Colorado interChange. DXC Technology (DXC) is committed to being a valued partner to the Colorado Department of HealthCare Policy and Financing (Department). The role we serve as the Department’sFiscal Agent and system administrator for the Colorado interChange is an essentialpartnership as Colorado’s Medicaid program continues to make significant advancesin payment modernization and to add transparency for services provided and inpayments to providers.

DXC currently supports Medicaid programs and systems in 23 states, 16 of which use CMS-certified system versions of the Colorado interChange. We are leaning in with our large national team and experience to make system and operational changes and add necessary resources during this implementation period.

DXC understands the impact a change of this magnitude can have on the provider

community. We are committed to helping the Department and providers. DXC

continues to have daily meetings with Department staff, as well as weekly meetings

with you and your senior leadership to review the implementation and create paths

to resolution to system and operational issues.

We are staffed at a level substantially above the levels originally planned for normal

operations. By maintaining these increased staffing levels, we are working to

minimize provider and/or citizen impacts. DXC is maintaining 71 non-technical staff

and 24-man months of technical staff above normal operations staffing levels. These

resources have been brought on at no additional cost to the Department to address

areas that need attention regardless of what may have caused the situation. Our

operational focus areas:

Call Center Operations

Claims Inventory

Provider Enrollment Processing

Provider Portal Effectiveness

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Call Center Operations

The Colorado interChange went live with more than two times the staffing of the

previous vendor. Within 30 days of go-live we had increased our call center staff by

75%. By mid-April we had doubled our staff. We continued to add staff and are now

maintaining a staff of 60. DXC is funding 36 of these 60 staff without any additional

state or federal funds being add to the contract. This additional staff has had a

positive impact on our average speed to answer (ASA) rates. With the exception of

the claims inquiry queue, calls now have an average speed to answer of less than 10

seconds. We are continuing to shift staff to the claims queue to reduce those ASA

rates which are currently averaging 2.5 minutes.

In addition, we have expanded our quality reviews of calls to more quickly identify

opportunities to provide one-on-one training to call center agents such that they

best handle the conversation. This enhanced training addresses not only the

accuracy of the responses being provided but also the softer skills to provide a

positive provider experience.

Suspended Claims Inventory

Claims pay rates reached over 60% in May and continue to improve weekly to about

65% currently. By week 15 we exceeded the paid rate experienced by two recently

implemented states, at their week 15. Our claims team currently has 40 staff

members supporting claims processing, more than three times our proposed staffing

for normal operations. DXC is funding 33 of these 40 staff without any additional

state or federal funds being added to the contract.

The volume of suspended claims has been reduced by half. By addressing policy

issues, multiple surgery, rates, defects and reprocessing we are on track to reduce

claims suspended to half of what it is today over the next couple of weeks.

Provider Enrollment

Due to the volume of new provider enrollments, the Colorado interChange and re-

enrollment activity at Go Live and through the implementation period required

additional personnel to be added. Focus on Provider Enrollment is also having a

positive impact on addressing issues as quickly as possible.

Our Provider Enrollment team was increased to 26. DXC is funding 19 of these 26

staff without any additional state or federal funds being added to the contract. This

staffing level is more than three times our original proposed staffing levels for

normal operations. We have enrolled over 50,000 providers and have fewer than

1,000 applications in review. The provider enrollment email box has dropped from

2,800 messages last week to approximately 500.

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Provider Portal Effectiveness

As part of post Go Live and implementation activities, we closely monitor utilization

of the provider portal to identify opportunities to tune system performance and

address any defects. Because of this ongoing activity, portal performance has

improved and is currently experiencing an average claim submission time of slightly

more than 5 seconds. Portal claims submission timeouts are also being monitored.

These are instances where the portal “hangs” during claims submission. Since the

last week of June this has happened an average of 30 times a day. While this

equates to only 0.12% of the daily average of the 26,000 Portal claims submitted,

providers are impacted so we are aggressively working to fix this as soon as possible.

We are currently testing a database version upgrade and will release it to production

when testing is completed. We anticipate this will occur by the first week of October

and that will address the timeouts.

Finally, we will continue to address dynamic programmatic needs. While we work

through the settling in period including accommodating and refining policy

implications of the configuration decisions made in implementation, we have made

over 550 state-requested adjustments to configurations in how the Colorado

interChange processes claims. These adjustments align the results of the system to

the desired policy as your team employs the broad capabilities of this new system.

In closing, thank you for your continued support and collaboration. We are

committed to Colorado, this industry, this platform and further evolving our

solutions and personnel to provide Colorado with a modern, flexible system to meet

the Colorado Medicaid program goals. Thank you for your partnership.

Sincerely,

Stuart L. Bailey

Vice President, State and Local Government Healthcare

CC: Parrish Steinbrecher, Health Information Deputy Office Director

Chris Underwood, Health Information Office Director

Carol Pangborn, DXC Account Executive, Colorado Healthcare

Susan Arthur, DXC Vice President & General Manager, Americas Health, Public Sector &

Regulated Industries

Our mission is to improve health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources.

www.colorado.gov/hcpf

Colorado interChange Update September 2017

Colorado interChange Updated Statistics Colorado launched the Colorado interChange, a new claims payment system and fiscal agent service on March 1, 2017. Since Go Live, the Colorado interChange has processed 28 million claims and paid $4.3 billion to providers.

There are currently 50,470 providers enrolled as Colorado Medicaid providers. Of those, 8,027 have enrolled since our March 1, 2017 Go Live. Providers continue to enroll every day.

Recent Impactful System Updates & Enhancements The Colorado interChange has more flexibility to quickly and effectively implement system updates and improvements. Below are some recent examples of widely impactful improvements.

Provider Web Portal Improvement for PAR Status Inquiry In response to provider feedback, the Department and DXC Technology (DXC) have implemented a system update to the Colorado interChange which will allow Home and Community-Based Services (HCBS) Waiver providers to view a member’s Prior Authorization Request (PAR) status in the Provider Web Portal. This enhancement was implemented on September 14, 2017. To assist providers with billing, the Department and DXC are working on an additional improvement to allow these providers to easily obtain modifiers on a PAR through the web portal, rather than requesting that information from the case manager.

2016 and 2017 Healthcare Common Procedure Coding System The Department and DXC updated the 2016 and 2017 Healthcare Common Procedure Coding System (HCPCS), which resulted in $12 million in payments to providers.

• The 2016 HCPCS codes were updated on July 12, 2017. All associated denied and suspended claims were reprocessed by DXC on July 14, 2017.

• The 2017 HCPCS codes were updated on August 10, 2017. All associated denied and suspended claims were reprocessed by DXC on August 11, 2017.

Evaluation and Management codes In early July, an issue with Evaluation and Management (E/M) codes was identified and resolved within three weeks. This system update meant claims that had been delayed or suspended were reprocessed and paid to providers.

Colorado interChange Update Page 2 of 12



DXC Technology (DXC) interChange System • The DXC interChange was first installed in Oklahoma in 2002. • The DXC interChange has been certified in 13 states and is in process in three

states. • There are 16 states (AL, CO, CT, DE, FL, GA, IN, KS, KY, MA, OH, OK, OR, PA,

TN, WI) currently using the DXC interChange system and three more are in the process of being implemented (AR, NV, PR).

• DXC is the fiscal agent for 17 states (AL, AR, CA (Denti-Cal), CO, CT, DE, FL, GA, IN, KS, KY, NV, OK, PA, RI, VT, WI, MA, OH, OR, TN).

• Nationally in 2016, DXC processed 643.5 million Medicaid claims and paid $88.2 billion in provider payments. In addition, DXC processed 616.2 million in managed care encounters and paid $82.2 billion in caption payments for Medicaid programs last year.

Colorado interChange System Go Live and Implementation Currently, the Colorado interChange and fiscal agent operations are in an implementation phase. Although we can be proactive with systems updates, we are still in a space where we have to be reactive to issues brought to our attention by providers. We have made significant improvements between the March 1st Go Live and today. This progress will continue as time goes on until we get to normal operations.




System Testing Overall, the Department estimates that more than 200,000 hours were spent on testing the Colorado interChange, the new pharmacy system managed by Magellan, and our data analytics system managed by Truven, prior to our March 1, 2017 Go Live date.

• Testing of the new Colorado interChange began in October 2014. o The Department began the new ACA Provider Revalidation and Screening

requirements through the Colorado interChange in September 2015. The vendor and Department began testing a year before providers began the new enrollment and screening process.

o Development, Construction, and Unit Testing began in October and concluded in June 2015.

o System Testing and System Integration Testing began in July 2014 and concluded in August 2015.

o User Acceptance Testing began in July 2015 and concluded in September 2015 with the launch of the new enrollment and screening process.

• Testing of the remaining components of the Colorado interChange began in December of 2014.

o Development, Construction, and Unit Testing began in December 2014 and concluded in August 2016.

o System Testing and System Integration Testing began May 2015 and concluded in December 2016.

o Parallel Testing, Performance Testing, Penetration Testing, and End-to-End Testing began in June 2016 and concluded in February 2017

o User Acceptance Testing began in May 2016 and concluded in January 2017.

• Throughout Implementation and Normal Operations of the Colorado interChange, DXC performs continuous testing of new system enhancements and functionality. In addition, the Department performs User Acceptance Testing of each weekly release.




Metrics on Paid Claims Percentage The Weekly Paid Claims Percentage the Go Live and Implementation go the Colorado interChange is in line with other DXC recent implementations.

Based on systems that have been in production for several years, the Department expects that the Paid Claims Percentage should average around 75% in Normal Operations. Below is data for five states that have been in Normal Operations for several years:

State Claims Paid

Percentage

Claims Denied

Percentage

Claims Suspended Percentage

State A 71 – 73% 22 – 24% 5 – 6% State B 72% 27% 1% State C 74 - 77% 22 - 24% 2% State D 76% 24% 0.2% State E 77 – 80% 20 – 23% No data

0%

10%

20%

30%

40%

50%

60%

70%

80%

Weekly Paid Claims Percentage Follow Go Live

CO State A State B




In Normal Operations, the Department expects to have an average of 30,000 claims in a Claims Suspense Inventory and then to manually review claims within 10 business days. These are claims that have neither paid or denied. Instead, these claims need to be reviewed or priced manually. The goal is to reduce the current suspended claim volume of 98,000 to 50,000 by the end of this month.

Currently, the majority of the suspended claims (approximately 56,000 claims) are multiple-surgery claims that need to be manually priced. The Department and DXC are working on a long-term solution that will automate this pricing logic.

Metrics on Weekly Payments Average The current average weekly payments exceed the weekly payments in the old MMIS by $3.9 Million. The weekly financial payment cycle to providers for Friday, September 15th was $131.1 Million compared to only $68.3 Million in the first payment cycle after the system was launched. The Department estimates that there will be a higher than normal weekly payments during the Implementation phase as provider payments make up for lower than normal payments during the Go Live launch.




Metrics on Provider Call Center DXC is currently staffed at levels substantially higher than planned for Normal Operations. DXC is working to minimize provider impacts by maintaining these increased staffing levels. DXC is maintaining 71 non-technical staff and 24-man months of technical folks above normal operations staffing levels. These resources have been brought on at no additional cost to the Department to address areas that need attention.

The Colorado interChange went live with more than two times the staffing of the of old MMIS and previous Fiscal Agent. Within 30 days of Go Live DXC had increased call center staff by 75%. By mid-April DXC had doubled the call center staff. Through Implementation, DXC continued to add staff and are now maintaining a call center staff of 60. This additional staff has had a positive impact on our average speed to answer (ASA) rates. Except for the claims inquiry queue, calls now have an average speed to answer of less than 10 seconds. DXC are continuing to shift staff to the claims queue to reduce those ASA rates which averaged 2.5 minutes in September.

Provider Call Center Statistics for Friday, September 15th

Call Center Queues Average Speed to Answer

Number of Calls

Answered

Percent Abandoned

Average. Talk Time

Max Delay for a

Provider Call Claims 1:56 428 5.73% 10:46 11:25 EDI 0:01 24 0.00% 5:40 0:01 Eligibility 0:01 115 0.00% 5:24 0:42 Prior Authorization 0:01 36 0.00% 5:54 0:01 Provider Enrollment 0:01 137 0.72% 8:57 0:15 Provider Services 0:09 102 1.92% 6:29 2:27 Total 1:00 842 3.33% 8:52 11:25

Operational & Policy Related Changes Impacting Providers While the Department understands the frustration and challenges facing some providers, it helps to take a step back and understand where these challenges are coming from. The implementation of the Colorado interChange and transition to a new fiscal agent, DXC, certainly accounts for some of these challenges, but not all.

With the implementation of the Colorado interChange, the Department was enabled to enforce Federal and State regulations and policies which were not technologically possible with the outdated Xerox system.




The Colorado interChange has or will address the follow audit findings:

• OSA - 2015 Medicaid Prescription Drug Performance Audit, Recommendation Numbers: 1a, 1b, 1c, 2a, 3a, 3b, and 4

• OSA - 2015 Single Statewide Financial Audit (1501F), Recommendation Numbers: 37a. 37b, 37c, 38a, 39a, 39b, 40b, and 41

• OIG - Colorado Did Not Always Identify or Prevent Excluded Providers From Participating in the Medicaid Program, Recommendation Number: 2

• OIG - Colorado Paid Over 800 Thousand Medicaid Claims with Missing or Invalid NPIs During 2011

• 2014 Single Statewide Audit - Health and Safety Certifications, Recommendation Number: 35

• 2014 Single Statewide Audit - Medical Claims Processing, Recommendation Number: 36

• 2014 Single Statewide Audit - Provider Eligibility Determination, Recommendation Numbers: 38b, and 38c

• 2014 Single Statewide Audit - Controls Over Provider Eligibility Determination, Recommendation Number: 39

Some examples of policy changes include the implementation of EAPG rates, provider enrollment requirements by the ACA, and multiple changes to billing manuals including to changes to several Type of Bills that were no longer compliant.




Payment Information by Provider Type Hospitals: 8.6% Lower than expected Inpatient: Paid $381.5 Million, 2.4% Higher than expected Outpatient: Paid $278 Million, 20.4% Lower than expected

Nursing Facilities Paid $332.8 Million, 4% Higher than expected

Federally Qualified Health Centers Paid $81.6 Million, 3% Higher than expected

Rural Health Centers Paid $8.9 Million, 3% Lower than expected

Community Centered Boards (CCBs) Paid $83.8 Million, 16.1% Lower than expected

Division for Intellectual and Developmental Disabilities (DIDD) Providers Paid $139.8 Million, 4.8% Lower than expected Persons with Developmental Disabilities (DD) Wavier

• Paid $113.7 Million, 6.7% Lower than expected Supportive Living Services (SLS) Waiver

• Paid $17.2 Million, 10.0% Higher than expected Children's Extensive Support (CES) Waiver

• Paid $8.2 Million, 2.4% Lower than expected Alternative Care Facilities (ACFs)

• Paid $23.6 Million, 14.3% Lower than expected

Assistance Available to Providers The Department is aware some providers continue to face frustrations related to the Colorado interChange and is working with DXC to address those struggles.

Online The Department’s Provider Resources web page (colorado.gov/hcpf/provider-resources) has many resources for providers and their billing staff. The page links to:

• The Known Issues & Updates web page (colorado.gov/hcpf/known-issues) is frequently updated with system issues and, when applicable, workarounds and estimated resolution dates. Please note, this web page is not an all-inclusive list of issues.

https://www.colorado.gov/hcpf/provider-resources




• The Fiscal Agent and Colorado interChange web page (colorado.gov/hcpf/interchange-resources) houses resources for getting better acquainted with the new provider web portal including Quick Guides, trainings, FAQs and some big changes in the new system.

• The Provider Enrollment and Revalidation web page (colorado.gov/hcpf/provider-enrollment) offers instructions and cheat sheets to assist providers through the enrollment process.

The Department and DXC work to send email communications regarding system updates, FAQs, newly identified system issues and applicable work arounds directly to providers. Some of our regularly scheduled publications include:

• Bi-weekly (previously weekly) Provider Association and Regional Care Collaborative Organizations (RCCO) leader newsletter

• Weekly email to providers with updates to Known Issues web page and new resources

• Monthly Provider Bulletin

Providers can sign up to receive email communications by following the link to the Provider Resources web page or by updating their contact information in the Provider Web Portal. The Provider Resources page has an archive of emails sent to providers (although it does not post a complete archive, the Department does have a copy of every email it has sent to providers).

Call Center The Provider Services Center (1-844-235-2387) remains the first line of assistance for providers. The Department and DXC are aware of continued frustration by many providers and are working diligently to address the issues. A corporate DXC call center lead has come to Colorado to make needed improvements to processes and training for the agents. We anticipate marked improvements in the customer service providers will receive.

DXC Regional Field Representatives DXC is preparing to launch regional provider training sessions through their regional field representatives. These representatives will be assigned to a regional area and provide additional support to providers in those areas. Six of the eight agents have been hired and are assisting escalated providers work through claims issues as a form of training. We expect the training sessions and general support to be launched later this fall.

Financial Assistance The Department is aware some providers are experiencing billing difficulties. If you are an enrolled provider experiencing financial distress, you can call the Provider Services Call Center at 1-844-235-2387 and select option 2 to "speak with an agent" and then option 4 to learn about interim payment options. Interim payments are paid at 80 percent of a provider's historic weekly payment over a three-month period prior to




March 1st.

Interim payments are meant to provide temporary relief to providers until their claims are processed correctly. These payments are not intended to pay outstanding claims billed or charges on a claim. Once claims are processing correctly, an accounts receivable will be set up and these payments will be recouped from future payments. We cannot issue interim payments to providers who are not enrolled or who have not yet completed the revalidation process.

Top Reasons for Claim Denials Claims can deny for a variety of reasons. While some systems issues are causing some claims to deny improperly, some claim denials are appropriate for reasons such as billing for non-covered services, duplicate claims or other errors in the claim submission process. If a provider has a question about why they are receiving a denial, they can call the DXC Provider Services Call Center.

The Department and DXC understand that new denial reasons can be confusing for providers. Some of the denial reasons are not clear or do not offer clear instructions for correcting the issue. The Department and DXC are working to publish these denial reasons (the EOB a provider sees) in clear language for easier resolution.

The next table provides the top reasons for claims denials, in no particular order.

EOB What Does It Mean? Provider Action

EOB 1473 - Multiple Provider Locations for Billing Provider Specialty.

In general, EOB 1473 is an indication that the system cannot determine which location to look at. If an National Provider Identifier (NPI) is associated with more than one (1) provider type or location address, additional steps are needed to ensure proper claims adjudication. A unique nine (9) digit zip code or taxonomy code is required to identify the correct billing provider ID.

Confirm the address, NPI and taxonomy on the claim match the information reported on Provider Maintenance tab on the Provider Web Portal.

EOB 4100 -Type of Bill Code Invalid.

Home Health Claim with an invalid Type of Bill (likely 33x).

Refer to the new Home Health Billing Manual for claims submission.





EOB 1454 - Procedure Code, Revenue Code, or Modifier is Invalid - Home Health.

Home Health Claim without the Procedure Code, Revenue Code or Modifier Code. While these are not required fields on the Provider Web Portal, they are required for the claim to process correctly.

Refer to the new Home Health Billing Manual for required fields. Don't forget to include all applicable procedure codes for PDN claims.

Example: Private Duty Nursing (PDN) claims will deny if submitted without the procedure code T1000, in addition to the revenue code for PDN.

The procedure code is not a required field in the Provider Web Portal, but page 11 of the Private Duty Nursing Billing Manuals does indicate this is required for the claim.

EOB 1786 - The date of service is out of timely filing. Refer to the new billing manual.

Claims must be submitted within timely filing limits. The Department has extended timely filing limits from 120 days from DOS to 240 days from DOS.

Submit the claims and reference the ICN of the last submission within 60 days.

EOB 1381 No billing rule for procedure.

The claim includes a procedure which is not a defined billing rule for the provider type. The rendering provider is not permitted to render the procedure to Medicaid members based on the provider type.

Ensure the correct procedure code was submitted on the claim. Refer to billing manual to confirm allowable procedures for the provider type.

If the procedure is allowable for the provider type, contact DXC.

EOB 1030 - The place of service code is invalid for procedure code. Correct the place of service.

The procedure and place of service cannot be billed together. This could be because the procedure can’t be performed at a specific POS (transplant in an office) or the combination is not allowed on the providers billing rule.

Ensure the correct place of service code and procedure code was submitted on the claim. Refer to billing manual to confirm allowable place of service code and procedures codes.

If the codes are allowable, contact DXC.





EOB 3261 - The procedure code currently is not a benefit for date of service billed.

This is not a covered procedure or the procedure has some restrictions for what it can be billed for.

Confirm the correct procedure code was submitted on the claim. Refer to billing manual for information on covered procedures.

EOB 2590 - The client has Medicare. Charges must billed to Medicare before billing Medicaid.

This member has other coverage with Medicare. Medicare would be the primary insurance and should be submitted

Rebill the claim after billing Medicare first.

EOB 2580 - The services must be billed to the HMO/BHO listed on the eligibility inquiry.

The client is a managed care member. Claims are therefore processed by the MCO.

The definition of Health Maintenance Organization (HMO) or Managed Care Organization (MCO) now includes Behavioral Health Organization (BHO). In the previous MMIS, there was an EOB code for HMO and a separate EOB code for the BHO. The new Colorado interChange combines these two EOB codes into one.

EOB 0966 - The rendering provider is not eligible at this location on date(s) of service.

The claim does not list a valid provider location.

Confirm the address on the claim matches the address reported on the Provider Web Portal.

EOB 1010 - This is a duplicate item that was previously processed and paid.

The denied claim was a duplicate of a claim that has already been processed and paid (or denied).

Providers who believe this error is returned incorrectly should contact DXC Provider Services (1-844-235-2387) with the interChange Control Number (ICN).

EOB 0678 - Billing Provider Type and Specialty is not allowable for the Rendering Provider.

The claim will deny if the Rendering provider type/specialty do not match or if the expected billing provider type/specialty do not match.

Providers who believe this error is returned incorrectly should contact DXC Provider Services (1-844-235-2387) with the interChange Control Number (ICN).

children's health insurance program...

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