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Colorado Access is a nonprofit health plan that provides access to behavioral and physical health services for Coloradans. Established in late 1994, the.

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Presentation on theme: "Colorado Access is a nonprofit health plan that provides access to behavioral and physical health services for Coloradans. Established in late 1994, the."— Presentation transcript:

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2 Colorado Access is a nonprofit health plan that provides access to behavioral and physical health services for Coloradans. Established in late 1994, the company is sponsored by Children's Hospital Colorado, Colorado Community Managed Care Network and University of Colorado Hospital/University Physicians, Inc.

3 Access Long Term Support Solutions Access Behavioral Care Child Health Plan Plus offered by Colorado Access Child Health Plan Plus offered by Colorado Access Colorado Access Advantage (Medicare) Regional Care Collaborative Organization (RCCO) Regional Care Collaborative Organization (RCCO) Colorado Access also provides administrative services for the CHP+ State Managed Care Network and CHP+ Prenatal Care Program.CHP+ State Managed Care Network and CHP+ Prenatal Care Program

4 Child Health Plan Plus (CHP+) is low-cost health insurance for Colorado's uninsured children and pregnant women. CHP+ is public health insurance for children and pregnant women who earn too much to qualify for Medicaid, but cannot afford private health insurance. CHP+ is not Medicaid. They are two completely separate programs.

5 Link to the SMCN CHP Provider and Member Website: What you can find here:  Provider Manual  Member Benefit Booklet  Updated Rate information  Claims and billing processes  Provider materials…. and much more…..

6 plan-plus What you can find here:  Information about Colorado Access  Check member eligibility for Co Acc CHP+ members and SMCN members.  Co Acc CHP updates What you can find here:  Who is eligible for CHP  How families can apply for CHP

7 Children up to age 19 whose families fall within the Federal Poverty Levels of 133% to 250% Members can CHURN between CHP+ and Medicaid There is a State rule that requires members on Medicaid and CHP to have their income reviewed quarterly to determine if they are on the right program. If there is a change in the families income then members can move between the CHP and Medicaid plans.

8 How can a provider know if a member is on CHP+ or Medicaid?? Providers can apply to have access to the State Web Portal (SWP). This link explains how to get access, logging in, changing password, etc. https://sp0.hcpf.state.co.us/Mercury/Training/player.html This link has information on how to look for eligibility in the SWP. https://sp0.hcpf.state.co.us/Mercury/Training/player.html You can also check the on the Colorado Access Website at: (contact to get a login ID and

9 Colorado Access Provider Network Services and Contracting Department

10 How to contract (who to contact/web link/where to send): Go to the Colorado Access Website under the section “For Our Providers” Send an to and include the following  Provider/Practice Name  Contact name, and phone number  Address  Provider specialty  Provider Tax ID Number (TIN)  Provider NPI Number

11  What is required to contract? To start the contracting process a current W-9 is needed.

12  How long does the contracting process take? -Two to five business days for staff to prepare the contract for the provider. -Once the complete contract is returned it will go through credentialing. -The entire process can take up to 60 days

13  Delays in getting the contract back from the provider  Contracts sent back with incomplete information  Missing or expired documentation **To expedite the contracting process follow the instructions included with the contract

14 SCA – Single Case Agreement – Colorado Access will utilize network providers in favor of non-participating providers. SCA’s are for limited periods of authorized services, only when network providers are unable or unavailable to provide services to members, or under specific circumstances, such as continuity of care and/or network adequacy. The SCA process must be followed for each member the non-contracted provider sees. Contracted – providers can treat, bill and be paid for services when seeing our members by simply requesting an authorization for services.

15  What is RBRVS? Resource-based Relative Value Scale is a plan used to determine how much money medical providers should be paid. It is partially used by Medicare in the US and by nearly all Health Maintenance organizations (HMOs).

16  Overview of RBRVS  In 1992, Medicare significantly changed the way it pays for physicians' services. Instead of basing payments on charges, the federal government established a standardized physician payment schedule based on RBRVS.  Link to the American Medical Association website with additional info on RBRVS.  resources/solutions-managing-your-practice/coding- billing-insurance/medicare/the-resource-based- relative-value-scale/overview-of-rbrvs.pagee resources/solutions-managing-your-practice/coding- billing-insurance/medicare/the-resource-based- relative-value-scale/overview-of-rbrvs.pagee

17  What is the reimbursement for Child Health Plan plus (CHP+) for PT/OT/ST providers? For Co Acc CHP+ HMO: 70% of the Colorado Adjusted Medicare RBRVS Professional Fee Schedule.  Colorado Access will update the Medicare Fee Schedule in accordance with CMS’ published updates and compensate Provider based on the Medicare Fee Schedule that is current on the date services are rendered.  SMCN fee scheduled are posted on line at:

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19  All Early Intervention claims should be billed on a HCFA 1500 form.  HCFA 1500 claim forms can be purchased at the office supply stores such as Office Depot and Staples.  CHP HMO Timely filing is 120 days from the date of service or 60 days from the last timely EOP date to appeal or send a corrected claim  SMCN Timely filing is 180 days from the date of service or 60 days from the last timely EOP date to appeal or send a corrected claim.

20  Colorado Access strongly recommends that you enroll in the Electronic Funds Transfer (EFT) program through Emdeon. This will make your payments faster and more secure.  To enroll please call Emdeon toll free at with questions or to enroll. Additional information can also be found at Coaccess.com/provider-claims-FAQ  There are 3 methods of payment to choose from: ◦ 1. EFT through Emdeon ◦ 2. Virtual Credit Card (VCC): A merchant fee will apply ◦ 3. Paper Check: The first payment will be via VCC than you will need to opt out of the VCC in order to receive a conventional check

21  Providers have the right to appeal any claim when they disagree with the outcome of a claim  Claim appeals must include: ◦ A copy of the claim ◦ A Claim appeal form (available on our website) or cover letter ◦ Detailed information supporting the reason for the appeal ◦ All other supporting documentation  If additional information is requested by Colorado Access, the provider has 30 days to submit the requested information  Claim appeals will be processed within 45 days

22 Explanation of Process Codes

23  Initial or Corrected claims: ◦ Colorado Access Claims ◦ P.O. Box ◦ Denver, CO  Claim appeals: ◦ Colorado Access Claim Appeals ◦ P.O. Box ◦ Denver, CO

24  ClaimRemedi: (Payer ID: coacc)  CPSI: (Payer ID: coacc)  Emdeon: (Payer ID: 84129)  ENS: (Payer ID: coacc)  MedAssets/ Xactimed: (Payer ID: coacc)  Office Ally: (Payer ID: coacc)  Practice Insight: (Payer ID COA)  Relay Health: (Payer ID: coacc)  SSI Group: (Payer ID: coacc)  S&S Datalink: (Payer ID: coacc) Note: There is also a list of secondary vendors on the website and in the provider manuals

25 Colorado Access Clinical Support Services

26  To request an authorization for EI services please submit your request forms to: FAX#  Our Clinical team will process the request within two business days for contracted providers.  Authorized EI services will be for one year at a time or until the child’s third birthday.  An authorization letter will be provided that will include all necessary information pertaining to the authorization request

27 1. If the requesting provider is not contracted The process for non-contracted providers:  The Clinical Staff will contact the provider to notify them that we will need to do a SCA and gather preliminary information  The Clinical Staff will notify Provider Contracting who will begin the SCA process which includes contacting the provider to discuss SCA requirements and rates.

28  SCA must be signed and returned by the provider  SCA is then returned to the Clinical staff to complete the authorization process  The SCA MUST be billed with the claim in order for the claim to pay correctly.  This process can take up to 3 days if all parties respond quickly with needed information.

29 2. Missing information on the request:  Authorization requests from providers that are missing phone and fax numbers slow our ability to contact you if additional information is needed. 3. Eligibility issues.  We can work with the State and research these issues and have corrections made when appropriate but this may take time depending on the situation.

30 Colorado Access Provider Network Services

31  Jennifer Rogers-Manager, Credentialing Program,  Erin Webber-Credentialing Program Coordinator,  Stacey Matthews-Credentialing Program Coordinator,  Shanna Salazar-Credentialing Program Coordinator How can you get a hold of us? us at

32  Colorado Access is committed to providing a QUALITY network of providers.  The Credentialing Team completes a “quality check” on all the providers that fall under the credentialing scope in the network using National Committee for Quality Assurance (NCQA) and URAC standards.  Credentialing is a requirement under NCQA and URAC. Managed Care Organizations are required to credential their providers prior to executing the provider contract.  Credentialing is performed for individual providers that fall within the scope of credentialing.  Re-credentialing occurs every 3 years.

33  Allopathic Physician (MD)  Osteopathic Physician (DO)  Doctor of Dental Science (DDS)*  Doctor of Dental Medicine (DMD)*  Podiatrist (DPM)  Certified Nurse Midwife (CNM)  Nurse Practitioner (NP)  Physician Assistant (PA)  Optometry (OD)  Physical Therapy (PT)  Occupational Therapy (OT)  Chiropractor (DC)  Speech Pathology (SLP) *Dentist who provide care under the medical benefit program only

34  Psychiatrist (MD, DO)  Psychologist (PsyD, PhD, EdD)  Licensed Clinical Social Worker (LCSW)  Licensed Professional Counselor (LPC)  Licensed Marriage Family Therapist (LMFT)  Clinical Nurse Specialist (CNS)

35  Colorado Health Care Professional Credentials Application (26 pages)  Current DEA Certificate (if applicable)  Current Professional Liability Insurance (must include the providers name who are covered under the policy)  You can get a copy of the Colorado Health Care Professional Credentials Application at

36  The Universal Provider Datasource (UPD) is a part of CAQH’s credentialing application database that seeks to make the provider credentialing process more efficient for providers as well as healthcare organizations.  CAQH has created an online database that collects all provider information necessary for credentialing, CAQH helps eliminate the paperwork and hassle that many providers face during the credentialing process.  CAQH will help avoid the hassles of completing the same paperwork for multiple healthcare organizations.  Colorado Access participates with CAQH.  There is no cost for the providers to participate with CAQH.  To have an account with CAQH, an healthcare organization will need to submit a request. To create an account with CAQH, we will need the provider’s full name, degree, date of birth, office address, and phone number. Once in the system, the provider creates a user name and password, and can complete the application online.  To learn more about CAQH please visit the website at https://upd.caqh.org/OAS/https://upd.caqh.org/OAS/

37  The credentialing process can take up to 60 days after the request has been received from the Provider Network Services.  If the application is incomplete or if there is additional information needed to complete the credentialing process, a Credentialing Program Coordinator will contact you.  After the credentialing process has been completed, you will receive a letter from the credentialing department.  When you receive this letter, this does not mean your contact is effective with Colorado Access. You will need to contact your Provider Contract Coordinator to obtain the effective date of your contract.

38 Questions??


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