2/28/17
Providers – What you need to know or do in preparation for March 1, 2017 It’s very important that you read this entire guide. Please share it widely across your organization.
Contents Are you ready? .............................................................................................................................2 Section 1 - Have you completed revalidation and/or enrollment into the Colorado interChange? ........2 Section 2 - Are you aware of the upcoming deadlines to submit claims and PARs? ............................3 Section 3 - Are you planning for a delay in payment? $$ .................................................................3 Section 4 - If you transmit batch (x12) files, have you enrolled as a Trading Partner for the Colorado interChange? ................................................................................................................................4 Section 5 - Do you know when training will begin on the new systems? ...........................................4 Section 6 – General claims & billing changes you need to be aware of .............................................5 “NEW” Provider IDs ................................................................................................................5 Claims Reporting.....................................................................................................................5 Timely Filing Reminder and Changes to Late Bill Override Dates in the New System....................6 NPI Required on Paper Claims .................................................................................................7 Co-Payment Policy Changes .....................................................................................................7 Section 7 –NUBC Guidelines – Now strictly enforced ........................................................................7 Skilled Nursing and Intermediate Care Facilities - TOB Change ..................................................7 Supply (DME) Claims - GY Modifier ..........................................................................................8 NEMT Transportation (ONLY) – Procedure Code changes ..........................................................8 Home Health – TOB Change ....................................................................................................8 Mental Health Hospital – TOB Change ......................................................................................9 Institutional Claims – Line item DOS ........................................................................................9 Section 8 –NCCI Edits – Now strictly enforced.................................................................................9 HCBS Waiver Claims - NCCI Edits – Now Strictly Enforced .........................................................9 Section 9 – General operational changes you need to be aware of ...................................................9 Claims Submission ..................................................................................................................9 Eligibility Verification ............................................................................................................. 10 Reports ................................................................................................................................ 10 Page 1 of 12
2/28/17 Provider Information Updates ................................................................................................ 10 Prior Authorization Requests (PARs) ....................................................................................... 10 Electronic Funds Transfer ...................................................................................................... 10 Support Numbers .................................................................................................................. 11 New Provider Web Portal URL (Web Address) ......................................................................... 11 Section 10 – Specific changes you need to be aware of ................................................................. 11 Section 11 – These items are NOT changing with Go Live .............................................................. 11 PARs Submitted via the eQHealth PAR portal .......................................................................... 11 Claims submitted to Delta Dental or DentaQuest ..................................................................... 11 Claims submitted to a Managed Care Organization (MCO) or Behavioral Health Organization (BHO). ................................................................................................................................. 12 Billing Procedures for Medical CHP+ Providers ........................................................................ 12 Fiscal Agent’s P.O. Box 30 ..................................................................................................... 12 Section 12 – Provider Web Portal Frequently Asked Questions (FAQs) ............................................ 12 Provider Web Portal FAQs...................................................................................................... 12 Provider Web Portal Cheat Sheets .......................................................................................... 12
Are you ready? On March 1, 2017, the Department of Health Care Policy and Financing (Department) will launch a new Claims Payment System, the Colorado interChange, for processing payments for services rendered on behalf of Health First Colorado (Colorado’s Medicaid program) and Child Health Plan Plus (CHP+) members. In addition, the new Provider Web Portal will launch February 6, 2017, and a new Pharmacy Benefits Management System (Pharmacy Point of Sale system) will launch February 25, 2017. This will not only be a transition to new systems, but to new vendors and new processes, as well. The Department has created this guide to help inform and prepare providers for these changes. This document contains general guidelines for our providers and is not intended to provide comprehensive guidance for every situation.
Section 1 - Have you completed revalidation and/or enrollment into the Colorado interChange? No? Please visit our Provider Enrollment web page to get started or to complete your application. Enrollment into the Colorado interChange is the most basic requirement when preparing for March 1, 2017. The provider information in the interChange feeds into the rest of our systems. If you are not enrolled in the Colorado interChange, you will not be able to Page 2 of 12
2/28/17 perform basic tasks such as verifying member eligibility and submitting PARs. Most importantly – you will not be able to submit claims or receive payments. If you need help with revalidation or enrollment, please call the Health First Colorado Enrollment and Revalidation Information Center at 1-844-235-2387. Providers please note: The Health First Colorado Enrollment and Revalidation Information Center is experiencing extended wait times. You should anticipate longer than usual wait times between now and in the days following Go Live on March 1st as providers have questions about the Provider Portal or revalidation and enrollment. We apologize for this inconvenience.
Section 2 - Are you aware of the upcoming deadlines to submit claims and PARs? No? Please download this list of important dates. Pharmacies – Please download this important pharmacy notice for dates and deadlines. DentaQuest Dental providers – Please download this list of important dates for DentaQuest Dental providers. A lot of work goes into building a new system, with a lot of moving parts. We are doing everything possible to minimize any negative impacts of this transition on our provider community and the Coloradans we cover. Even so, we are approaching a point where we need to stop incoming data so the new systems can pick up where the old ones left off. Unfortunately, this means there will be times when we cannot accept incoming claims, PARs, or even updates to provider information. We have outlined these dates and times for you in the ‘important dates’ and ‘calendar’ documents referenced above. To help us help you, please make sure these documents make their way to your billing department, your front desk, the people who submit your PARs and your accounting team.
Section 3 - Are you planning for a delay in payment? $$ No? Please read this 30-Day Transition Notice, or watch this video, for more information. As noted above, we will need to stop incoming data so the new systems can pick up where the old ones left off. Without incoming data, we are not able to process claims or send outgoing payments. The length of delay you should expect will depend on the type and methodology of the claims you are submitting. Paper claims take longer to process, so we will stop accepting them earlier than claims submitted electronically. Specific dates are provided in the 60-Day Transition Notice. Just like the documents in Section 2, please share them with your billing department and your accounting team so they can plan accordingly.
Page 3 of 12
2/28/17
Section 4 - If you transmit batch (x12) files, have you enrolled as a Trading Partner for the Colorado interChange? No? Please visit our EDI Support web page to get started. Colorado.gov/HCPF/EDI-Support If you submit batch files (such as the 837I, 837P, or 837D), you will need a HPE Trading Partner ID (TPID) to do so after March 1, 2017. If you receive batch files (such as the 834, 820, or 835), you will need a HPE TPID to do so after March 1, 2017. The Trading Partner ID (TPID) you currently use to transmit your batch files will not work in the interChange. The process to enroll as a Trading Partner is fairly simple, but you will need to submit test transactions before being approved to submit production transactions in the new system. Be sure you enroll, test, and receive authorization before March 1, 2017 (the first date you’ll be able to submit or receive batch files with your new TPID). The providers for whom you submit batch files will need to authorize you as their submitter, even if you were authorized in the old system. If you are not enrolled as a Trading Partner for the interChange, you will NOT be able to transmit files on March 1, 2017. All the information you need to enroll and test can be found on our EDI Support web page. We also recommend that you download the list of important dates and claims calendars referenced in Section 2 above. Important Note: Providers do not need to enroll as a Trading Partner if they plan to submit claims (one at a time) or verify eligibility (one at a time) through the new Provider Web Portal. Providers will be able to download their Remittance Advice (RAs), formerly called Provider Claim Reports (PCRs), though the new Provider Web Portal without needing to have a TPID. However, if a provider wants to be able to download an x12 file (such as the 835), they need to have a TPID to do so. If you accidently enrolled as a Trading Partner, but do not need a TPID, all you need to do is call HPE’s EDI Helpdesk and ask them to disenroll you as a Trading Partner. You can reach the EDI Helpdesk at: 1 (844) 801-8482.
Section 5 - Do you know when training will begin on the new systems? In January 2017, Hewlett Packard Enterprises (HPE) hosted live Web-based instructorled training sessions for the new Provider Web Portal. Recordings of each session are available now. Pharmacies – your training schedule has been posted on our Pharmacy Transition web page. Registration information will be posted, as soon as it’s available. Training sessions cover a large variety of topics, including day-to-day tasks such as submitting claims via the Provider Web Portal, verifying member eligibility, updating your information online, pulling reports and verifying PARs. Page 4 of 12
2/28/17
Section 6 – General claims & billing changes you need to be aware of Beginning March 1, 2017, we will use the Colorado interChange to process claims and payments. While the general purpose of the interChange is the same as our current claims processing system, there are some substantial changes you need to be aware of. Please make sure your billing department gets this information, so they can submit/adjust claims accordingly. “NEW” Provider IDs Beginning March 1, 2017, “Non-Atypical” Provider ID’s will be a system generated number, which is unique to each Provider Type and Service Location. Providers will use this ID to register for the Provider Web Portal, and it will also appear on Remittance Advice (RA). If applicable, you can use this ID to verify member eligibility over the phone. For “Non-Atypical” providers, this Provider ID may NOT be used on claims. The only acceptable identifier on a claim, is your National Provider Identifier (NPI). This includes paper claims submitted after February 3, 2017 (if applicable). For most “Atypical” providers, their new Provider ID will be the same as their legacy Provider ID. Atypical providers will use this ID to both register for the Provider Web Portal, and on claims submitted March 1, 2017 or later. If applicable, you can also use this ID to verify member eligibility over the phone. Please note: if you are enrolled as more than one provider type, or are enrolled with more than one service location, you will have multiple Provider IDs. Each Provider ID requires separate Provider Web Portal registration, and then you can tie your accounts together using delegate access. An email was sent to all providers on February 6, 2017, with your new Provider ID, and instructions for registering on the new Provider Web Portal. Who got this email? This email was sent to an address you gave us during revalidation or enrollment. If you did not get your email on February 6, 2017, please check your junk and trash folders before calling the number above to retrieve that information. Note: if your email is the contact email address listed on 100 applications, you would have received 100 emails on February 6, 2017. Each email contains the registration instructions for a specific provider and, unfortunately, we were not able to combine all of your emails into one. Claims Reporting Batch claims processing through EDI will no longer include the 277CA and the proprietary Colorado Medicaid Accept Reject reports. The 835 will be the next report following the 999 in the life cycle of the file. Page 5 of 12
2/28/17 Timely Filing Reminder and Changes to Late Bill Override Dates in the New System This is not a change to policy, just a change in the way it’s administered. As of March 1, 2017, Hewlett Packard Enterprise (HPE) will no longer use the late bill override date. It is imperative that providers submit their claims within the 120 days and every 60 days thereafter, if necessary. The interChange system will then verify the previous claim was submitted within the timely filing guidelines. Timely filing for submitting Health First Colorado or Child Health Plan Plus claims is 120 days from the date of service. A claim is considered to be filed when the fiscal agent documents receipt of the claim. The provider is responsible for contacting the fiscal agent to determine the status of the claim and resubmitting the claim, if necessary, within the 120-day period. Holidays, weekends, and dates of business closure do not extend the timely filing period. Waiting for prior authorization or for correspondence from the department or the fiscal agent, is not an acceptable reason for late filing. Phone calls or other correspondence are not proof of timely filing. The claim must be submitted, even if the result is a denial or rejection. Agent or software failure to transmit accurate and acceptable claims or failure to identify transmission errors in a timely manner, needs to be resolved between the provider and the agent or software vendor. If the original timely filing period expires, the next submission must be received within 60 days of the last adverse action. Following are examples of adverse action:
A claim denial or payment on an RA or 835. o Payment is not an adverse action, but will suffice as proof of timely filing. Fiscal agent correspondence (including form letters) that identifies specific claims. Claims that have been date-stamped by the fiscal agent or the Department and returned to the provider. Provider enrollment letter for initial enrollment approval or a backdate approval (affiliations or updates are not acceptable reasons for late filing). Load letter for eligibility backdate. (retroactive eligibility) Affidavit of delayed notification of member eligibility.
Claims that are not able to be submitted within the 120 guideline, but have one (1) of the above documents attached to the submission, will be reviewed by the fiscal agent. Further information on timely filing can be found in the General Provider Information Billing Manual on the Department’s website.
Page 6 of 12
2/28/17 NPI Required on Paper Claims In the legacy MMIS, paper claims required the use of the 8-digit Legacy Provider ID. Any paper claims submitted after February 3, 2017, need to include to National Provider Identifier (NPI), unless the provider is “atypical” and does not have an NPI. Co-Payment Policy Changes Upon implementation of interChange, members shall not be liable for cost-sharing greater than 5% of their household’s monthly income per month. This means that all members will have a monthly copayment maximum which providers cannot exceed in co-payment charges. Providers will be able to view a member’s remaining co-payment liability through the new Provider Web Portal. When a member reaches his/her co-payment maximum for the month, the portal will display the member as co-payment exempt and the co-payment reimbursement reduction on claims will be automatically disabled for the remainder of that month. The co-payment maximum will be reset on the first day of each month. The following polices are still in place and have not changed. Please refer to Rule 8.754 for complete details:
Certain member groups are exempt from co-payments, such as children under the age of 19 and those receiving hospice care. Always check the member’s eligibility status in the provider portal prior to rendering services to see if they are liable for co-payments. Certain services are exempt from co-payments, such as emergency services, pregnancy related services, family planning services, preventive care, and behavioral health services. A provider may not deny services to a member when the member is unable to immediately pay the co-payment amount. However, the member remains liable for the co-payment at a later date.
Section 7 –NUBC Guidelines – Now strictly enforced Some Type of Bills (TOBs), Procedure codes, Occurrence codes, and modifiers are currently being used outside of National Uniform Billing Committee (NUBC) guidelines in the legacy MMIS. However, NUBC guidelines will be strictly enforced in the interChange. We highly recommend you review NUBC guidelines, the new Billing Manuals, and this 2017 HCPCs Special Bulletin, then adjust your claims coding as necessary. Here are a few examples of what to except on March 1, 2017: Skilled Nursing and Intermediate Care Facilities - TOB Change In the legacy MMIS The Department processed claims with TOB 22x as inpatient claims when submitted with an accommodation revenue code (i.e., 0119 and 0129) and as outpatient claims when submitted without any room/board revenue code. However, NUBC designates TOB 22x only as OP. Page 7 of 12
2/28/17 Starting March 1, 2017 Claims submitted with an invalid TOB will be denied. Per NUBC rules, only the following TOBs are allowed for Skilled Nursing and Intermediate Care Facilities: 21x
Skilled Nursing – Inpatient (Including Medicare Part A)
IP
22x
Skilled Nursing – Inpatient (Medicare Part B only)
OP
23x
Skilled Nursing – Outpatient
OP
65x
Intermediate Care – Level I
IP
66x
Intermediate Care – Level II
IP
Supply (DME) Claims - GY Modifier In the legacy MMIS Providers could apply the GY modifier on a Supply (DME) claim, indicating a "Statutorily Excluded Service" on outpatient and supply claims, bypassing Medicare billing edits. Starting March 1, 2017 The GY modifier is applicable to Outpatient claims ONLY. Supply (DME) claims submitted with a GY modifier will be denied (unless on Outpatient claim). NEMT Transportation (ONLY) – Procedure Code changes In the legacy MMIS T2003 is an open code, commonly incorrectly billed as mileage. Starting March 1, 2017 T2003 is no longer a covered code for NEMT. NEMT claims submitted with T2003 will be denied. Note: This only applies to NEMT, providers of other services where T2003 is a procedure code can still continue billing as usual (e.g., HCBS NMT). Home Health – TOB Change In the legacy MMIS The Department processed institutional claims with TOB 033x. Starting March 1, 2017 Claims submitted with TOB 033x will be denied. The 032X Type of Bill has been redefined to mean "Home Health Services under a Plan of Treatment" and should be used to bill home health services. The National Uniform Billing Committee (NUBC) originally started using the 032X Type of Bill in 2013 and Health First Colorado must now enforce its use for home health claims submitted through the Colorado interChange.
Page 8 of 12
2/28/17 Mental Health Hospital – TOB Change In the legacy MMIS The Department processed Mental Health Hospital claims with various TOBs. Starting March 1, 2017 Fee-for-service claims and BHO encounters for Mental Health Hospital services, must be submitted with TOB 86x. Claims submitted with any other TOB will be denied. Note: This applies only to inpatient services only, as there are no outpatient services for Mental Health Hospitals. Institutional Claims – Line item DOS In the legacy MMIS The Department processed institutional claims, even if the Date of Service (DOS) was ONLY listed in the header. Starting March 1, 2017 Institutional claims without a line item DOS, will be denied.
Section 8 –NCCI Edits – Now strictly enforced HCBS Waiver Claims - NCCI Edits – Now Strictly Enforced In the legacy MMIS Not all National Correct Coding Initiative (NCCI) edits are currently active for HCBS waiver service claims. Starting March 1, 2017 CMS established the National Correct Coding Initiative (NCCI) program to ensure the correct coding of services. The NCCI program includes two types of edits: NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs). National Correct Coding Initiative (NCCI) edits will be active, and strictly enforced. As a provider it is your duty to learn about NCCI, understand proper billing procedures, and know the limits for the services you are providing. For further details about the NCCI program and how it applies to you, please visit the Department’s NCCI webpage.
Section 9 – General operational changes you need to be aware of Claims Submission Beginning March 1, 2017, claims must be submitted through the new Provider Web Portal or through the new FTPS portal. Exceptions include claims that are submitted by DentaQuest, Delta Dental, Veyo, etc. Providers who submit claims to one of these entities now should continue to do so. Page 9 of 12
2/28/17 Eligibility Verification Beginning February 27, 2017, providers will verify member eligibility through the new Provider Web Portal or via Telephone. Instructions for verifying eligibility via telephone are provided in the new General Provider Information Billing Manual, which is located at: Colorado.gov/HCPF/billing-manuals. Ways to verify eligibility:
Call the Health First Colorado Provider Information Center at: 1-844-235-2387 Check online in the Provider Web Portal (instructions here)
Reports Beginning March 1, 2017, providers will use the new Provider Web Portal to access and download reports. Six years of historical claims data will be migrated to the new system, but historical reports will not be migrated. The legacy Web Portal will be shut down on March 11, 2017. Please download any reports or PAR letters that you need copies of prior to that date. Reports and PAR letters from the legacy portal will NOT be available after March 11, 2017. Provider Information Updates Although claims submission and eligibility verification through the Provider Web Portal will not be available until March 1, 2017, updates to provider information can be made through the Provider Web Portal starting February 6, 2017. We will no longer require or accept paper requests to update information. All updates need to be made electronically though the Provider Web Portal. Prior Authorization Requests (PARs) While there are no changes to the “where” or “which” PARs you submit to EQHealth (the ColoradoPAR Program), there are changes to where you will submit the following PARs on or after March 1, 2017:
Nursing Facility PETI PARs - will now be submitted through the Care Management portion of the new Provider Web Portal. Nursing Facility PARs – no longer required. Targeted Case Management for Home and Community Based Services Waivers for children and adults with Intellectual and/or Developmental Disabilities – PARs no longer required. All HCBS Waiver PARs (including HCBS PETI PARs) – now submitted to the Bridge. Long Term Home Health PARs – will be submitted to
[email protected] (more information to come).
Note: you will receive a separate notice if you need to attend Bridge training. Electronic Funds Transfer Providers will see new ACH Company ID Numbers for EFT transactions: Page 10 of 12
2/28/17
Payments will come from 1811725341. Debits will come from 2811725341.
Support Numbers Beginning March 1, 2017, HPE will become the official, and only, fiscal agent for the Department. On or after March 1, 2017, Providers should call 1-844-235-2387 for revalidation/enrollment issues, as well as for issues with claims or PARs. Providers please note: The Health First Colorado Enrollment and Revalidation Information Center (Hewlett Packard Enterprise call center, 1-844-235-2387) is experiencing extended wait times. You should anticipate longer than usual wait times between now and in the days following Go Live on March 1st as providers have questions about the Provider Portal or revalidation and enrollment. We apologize for this inconvenience. New Provider Web Portal URL (Web Address) Link to the new Provider Web Portal: https://colorado-hcp-portal.xco.dcs-usps.com/hcp/provider
Section 10 – Specific changes you need to be aware of New Billing Manuals are available now. We highly recommend a thorough review of these manuals to familiarize yourself with billing rules for the Colorado interChange. The interChange will strictly enforce Department policies and billing rules, including those that the legacy system may not have. Failure to review and follow the instructions in the new Billing Manuals will likely result in claims denial. You can find the new billing manuals on the Department’s Billing Manual web page.
Section 11 – These items are NOT changing with Go Live PARs Submitted via the eQHealth PAR portal You will continue to submit the same types of PARs to the eQHealth PAR portal. PARs and PAR spans will be available in the new system. PAR spans and PAR numbers will remain the same. Claims submitted to Delta Dental or DentaQuest You will continue to submit your CHP+ Dental claims to Delta Dental or Health First Colorado dental claims to DentaQuest (as applicable).
DentaQuest Dental providers – Please download this list of important dates for DentaQuest Dental providers.
Page 11 of 12
2/28/17 Claims submitted to a Managed Care Organization (MCO) or Behavioral He alth Organization (BHO). You will continue to work with your network, as you always have, and operate business as usual (unless your network has specified otherwise). Billing Procedures for Medical CHP+ Providers You will continue to work with your network, as you always have, and operate business as usual (unless your network has specified otherwise). Fiscal Agent’s P.O. Box 30 P.O. boxes 90 and 1100 will no longer be used, but P.O. box 30 will transfer ownership to our new Fiscal Agent (HPE). That is P.O. Box 30 Denver, CO 80201.
Section 12 – Provider Web Portal Frequently Asked Questions (FAQs) Provider Web Portal FAQs A list of Provider Web Portal FAQs is available on our Provider Web Portal webpage. Provider Web Portal Cheat Sheets Delegates Provider Maintenance, including:
Updating contact information
Opt-out of Provider Directory
Managing Affiliations
Updating your EFT/ERA Information Validating a Trading Partner ID (TPID) Verifying Member Eligibility, including:
Managed Care Assignments
Primary Care Provider
Medicare Coverage
Member Co-pay amounts
Page 12 of 12
