Known interChange Eligibility Issues Fact Sheet June 2017 On March 1, 2017, the Department of Health Care Policy and Financing (the Department) launched its new Medicaid Management Information System (MMIS) claims processing system – the Colorado interChange. As expected with any system change of this magnitude and size, the Department has identified issues and defects within the system. The Department continues to work daily with its new fiscal agent, DXC Technologies (DXC) to ensure all issues and defects are addressed and system fixes are identified and implemented on a regular basis. The Department has identified a system issue which prevents the Colorado interChange from processing some retroactive changes to a Health First Colorado (Colorado’s Medicaid Program) and Child Health Plan Plus (CHP+) member’s eligibility span. Colorado allows a member’s eligibility spans to be retroactively updated for several circumstances. The implementation of this policy historically caused numerous audit problems as the member’s previous eligibility information was completely deleted in the old MMIS when a retroactively update was made. In the new Colorado interChange, the solution to eliminate these audit problems has caused some members eligibility information to show incorrectly when a retroactive change has been authorized in CBMS. The possible issues are: • Member is eligible in the Colorado Benefits Management System (CBMS) but showing as ineligible in the Colorado interChange (e.g., the member’s eligibility was terminated, but then was retroactively authorized for Medicaid or CHP+ in CBMS) • The member has changed programs or benefit plans but the previous program or benefit plan is still showing active in the Colorado interChange (e.g., the member was CHP+ but eligibility in CBMS was changed to Medicaid such that the CHP+ eligibility span needed to be deleted or changed in CBMS) • The member’s benefit plan needs to be retroactively updated in CBMS to process claims but the previous benefit plan is still showing active in the Colorado interChange which prevents claims payment (e.g., an eligibility technician updates CBMS to retroactively authorize Nursing Facilities services for a client covered under a HCBS Waiver benefit plan) This issue does not affect newly eligible members or members who have not had retroactive changes applied to their eligibility file. The Department is working to proactively identify and manually correct affected eligibility files through staff who review the impacted records daily. As a long-term solution, the Department has planned a system update to retain all client eligibility spans when retroactive changes occur. This system update will be completed before the end of the calendar year. 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

Known interChange Eligibility Issues

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In the case a member’s eligibility file or benefit plan has not been updated yet, the Department has provided the below guidance for members, providers and pharmacists. Guidance for Members Members who believe the eligibility information found by their provider in the Colorado interChange is incorrect should follow the same process that would have been followed with the old MMIS. The member should contact the Health First Colorado Member Contact Center at 1-800-2213943; State Relay: 711 (for members with speech or hearing disabilities) to speak with an agent who can research to confirm their eligibility information and then initiate a correction as appropriate. If the agent is able to confirm the member’s eligibility information is incorrect in the Colorado interChange, the agent will begin the process to update the eligibility information. The agent can issue a Proof of Insurance which certifies eligibility which should be accepted by providers. Once the correction request is initiated it can take 2-3 business days to complete the manual override process. In addition, some eligibility information may need to be fixed by an eligibility technician to correct the information in CBMS. Guidance for Providers Providers are responsible for checking and confirming member eligibility before providing services—this is not an expectation for members unless they believe their eligibility information is incorrect. If a member believes a fix to their eligibility information is necessary, the process is the same as it would have been with the old MMIS; the member must call the Health First Colorado Member Contact Center to initiate the correction. If the member has already contacted the Member Contact Center and obtained the Proof of Insurance, the provider should accept this as eligibility verification and render services. The eligibility update will take 2-3 business days to appear in the Colorado interChange. Once the fix is made, the provider will be able to submit or resubmit claims for services to the member. Providers can check eligibility on the new Provider Portal (see here for instructions) or by calling Provider Services at 1-844-235-2387 (Press 1 for the automated voice response system, then Press 1 again to verify eligibility). Guidance for Pharmacists Some members were incorrectly showing as "incarcerated" in the interChange system. This issue was fixed on May 1, 2017, but in some very limited cases, members may still be listed incorrectly as incarcerated in the system. Pharmacists should call Magellan at 1-800-424-5725 to confirm whether the system is incorrectly showing someone as incarcerated.

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