We have included resources below to help you and your practice navigate this unprecedented time. We are currently in the process of enhancing this forms library. 1570 Grant Street Visit "Where can I get vaccinated" or call 1-877-COVAXCO (1-877-268-2926) for vaccine information. Federal and state laws allow Medicaid applicants and clients who have their benefits denied, terminated, or reduced to appeal the decision. INCLUDE THE FOLLOWING: 1. Unless another address is specified on the form, mail the completed form and the completed PAR to: Additional information and ongoing updates can be found on ColoradoPAR.com or the Department's website. This issue brief provides an overview of the Medicaid appeals process in Colorado… Published. Provider Forms & Guides. If you appeal an action verbally, you must also send in a written appeal (unless you have requested an expedited appeal) Fill out the Complaint and Appeal form and fax to 303-602-2078 or mail to: DHMC Grievances and Appeals 938 Bannock St. Denver, CO 80204. Provider resources: Quick guides, known issues, EDI, training, and more. Care and Case Management. Department of Health & Human Services. Once the updates are submitted, providers must call the Provider Services Call Center at 1-844-235-2387 to request the change from IWG to BI. Provider Number: _____ __ Nursing ... We Request Medical Authorization for Medicaid Nursing Facility Care for the Above Patient: Request for Reconsideration form may be processed using routine claims processing procedures. OMB Exempt . COLORADO ACCESS CLAIM APPEAL FORM All fields are required. Federal and state laws allow Medicaid applicants and clients who have their benefits denied, terminated, or reduced to appeal the decision. COMPLETE A SEPARATE REQUEST FOR EACH RECIPIENT AND/OR CLAIM. Together, eQHealth and HCPF will serve Medicaid members by focusing on and implementing HCPF’s mission to improve health care access and outcomes for the people we … Colorado Medicaid Change of Provider Form. All pharmacy-related documents and forms are now found on the Pharmacy Resources page. Practitioner and Provider Complaint and Appeal Request NOTE: Completion of this form is mandatory. This form must accompany the new Prior Authorization Request (PAR) Form when a member has a current and active PAR with another provider. Retain a copy in your files for reference. Credentialing Packet. The Department of Health Care Policy & Financing works in partnership with the State of Colorado Division of Housing to administer housing vouchers for individuals transitioning from a long-term care facility. Department of Health Care Policy & Financing Download the Member Handbook Transportation to an appointment for a Medicaid covered medical service with verification from a physician or facility that the member must be seen or picked up from a discharged appointment when there is less than 48 hours’ notice. If an enrollee would like to appoint a person to file a grievance, request a coverage determination, or request an appeal on his or her behalf, the enrollee and the person accepting the appointment must fill out this form … What you need to apply. See the reverse side of the form for additional information. Revalidation. Please contact RMHP Customer Service Monday - Friday, 8:00 a.m. to 5:00 p.m. at 970-248-5036 or 800-854-4558 (TTY: 711) for questions about the prior authorization process or to receive benefit quotations. Medical PARs are submitted via the eQSuite® PAR Portal. The following forms are for HCBS Service Providers who experience a critical incident involving a client enrolled under the following waiver programs, Brain Injury, Children's HCBS, Children with Autism, Consumer Directed Care, Elderly, Blind and Disabled, and Community Mental Health Supports,and need to report the critical incident to the SEP Agency Case Manager. For any questions regarding this review, please email: DMEPOS.BMReview@state.co.us. A copy of the EOP showing the recent payment 3. Client Information Client Name: Medicaid ID#: Date of Birth: Current PAR Number (if known): Previous Provider Information. All fields are required. Revised October 2018 . Change of Provider Form- Complete this form when a member has a current and active PAR with another provider. Name: Last Day of Services: New Provider Information Currently, providers can submit claim payment disputes through our Claim Action Request form (for a reconsideration), or through the Provider Dispute Resolution form (for an appeal). INCLUDE THE FOLLOWING: 1. There are copies of your form… If not, please call the Provider Services Call Center at 1 (844) 235-2387 (toll-free) to see if the check has been cashed. Legislative Council Staff. Apply Now. COMPLETE A SEPARATE REQUEST FOR EACH RECIPIENT AND/OR CLAIM. Provider Identification - Required Important: Do not use this form to rebill claims or request routine adjustments. Once the signed affidavit is returned, the accounting team will cancel the lost check and reissue in the Colorado interChange system. Ways to File an Appeal. Provider services (forms, rates, & billing manuals) What's new (bulletins and updates) CBMS: CO Benefits Management System. ��yQ�U�����˖sqy��
̪��LUw �k7����8�U�q��^�qzGGϏ�{,�?��I:�ݙ��X(�ڜ�t���d�;�F(>�ԲB@=)�z8,�?p��G�o����N��w�*Ko�������(���\��ܣ����V���E��W[̆��-��>�� �e������Q�;�F�,�L7uQ���H��8�P�`D�h�������/����p#�"\Aٮ[�^v�U�V}�!م��lj�Z��"K^���`��.Vƿ+)�����^��v�~~={P�A� T�a��*�;0O/.��}�=���O)��Ԣ�����ޭ�z�/��}���EV�*)�eq�W�f���Ϟⴹ8J�W��G��J�����8��$͗�s��*��'iY��+Un���P{��|R�ܒ�M2� l�͋�&K�UuM��L~ܿ������� Conduent Provider First-Level Appeal Request Instructions Submission Requirements: This Conduent First-Level Appeal Request must be completed to appeal the denial or reduction of a claim or service. Easily find and download forms, guides, and other related documentation that you need to do business with Anthem all in one convenient location! COLORADO ACCESS CLAIM APPEAL FORM All fields are required. Claim Appeal Form Provider Payment Options. In 2016, from September through December, the Department posted recommendations made by the Colorado Association for Medical Equipment Services (CAMES). Health First Colorado Change of Provider Form . ... Alcohol and Substance Use Screening, Brief Intervention, and Referral to Treatment, SBIRT (Centers for Medicare and Medicaid) Bipolar Disorder – Adult (American Psychiatric Association) Intensive Outpatient ... Synagis is covered for eligible patients through the Colorado Access pharmacy benefit. Box 30 Denver, CO 80201 . As of June 1, 2013, this is the only Adult LTHH PAR form accepted by Health First Colorado (Colorado's Medicaid program). You can file an appeal in any of the following ways: 1. This updated handbook explains member benefits and provides resources to help members manage their health care. Be sure to choose a payment option for how you want to receive your payment. ColoradoPAR Provider Portal: eQSuite. Title: COLORADO DEPARTMENT OF HEALTH CARE POLICY AND FINANCING Author: Lawrence E. Lowe Created Date: 8/3/2011 5:20:14 PM Colorado Access Appeals Department PO Box 17950 Denver, CO 80217-0950 • You or your DCR can request a “rush” or expedited appeal if you are in the hospital, or feel that waiting for a regular appeal would threaten your life or health. Transportation providers with questions should contact the transportation provider line at (833) 643-3010. • This form must be submitted with a corrected CMS-1500, UB-04 or Dental claim form and must include red-drop out ink and legal claim notice on the back. Health First Colorado and Child Health Plan Plus members, providers, and stakeholders: Get updated information about COVID-19.. HCPF Website Relaunch. Call: Call (855) 489-4999to schedule single or recurring trips on behalf of patients, Monday – Friday from 8 AM to 5 PM MST. Section 1135 Waiver Flexibilities - Colorado Coronavirus Disease 2019. The section called “Expedited (“Rush”) Appeals” tells you more about this type of appeal. A copy of the claim in question 2. Medical providers and facility staff can schedule patient trips at least two days before the appointment date using any of the following methods: 1. For more information including application forms, guidance, and training, please visit the Division of Housing website or contact Kimberley Dickey at 303-864-7831 or Kimberley.Dickey@state.co.us, Visit Transition Services Website for more information, Member Contact Center1-800-221-3943 / State Relay: 711. Use this Provider Reconsideration and Appeal Form to request a review of a decision made by Sunflower Health Plan. 1-877-644-4623 www.SunflowerHealthPlan.com KDHE-Approved 04-04-18 8325 Lenexa Drive Lenexa, KS 66214 . Please print the relevant questionnaire from the list below and enter all requested information. THE COLORADO MEDICAL ASSISTANCE PROGRAM P.O. We've recently relaunched the HCPF website with a redesigned look and an even greater focus on our members, providers, and stakeholders. PEAK is the fastest way to obtain a copy of the 1095-B Form.Go to the Mail Center in your Colorado.gov/PEAK account. Member Information Member Name: Health First Colorado ID#: Date of Birth: Current PAR Number (if known): Previous Provider Information . �r$!s|!I*dHR'jϖ�(�C�[�`���U��-Az� ��*�|��"�-O�,Oɋ�����=guº���_�S�;��cH��%�� �6"t���d�����LIH�$��Q�I��l"���`%���8�. For a list of the codes reviewed, please reference the DMEPOS Billing Manual. Online:Login to the online facility portal to schedule, revise or cancel one or more trips for patients. Colorado has a state-supervised and county-administered human services system. To obtain a review submit this form as well as information that will support your appeal, which may include medical records, office notes, discharge summaries, lab records and/or member Date the service or item was received (mm/dd/yyyy) Item or service you wish to appeal . If it has been 30 days since the date of the payment, verify with your bank to ensure the check was not cashed. 7500 Security Boulevard, Mail Stop S2-26-12. The Department will now review both CAMES's recommendations and the received Stakeholder feedback. Providers must phone or fax clinical information supporting the medical necessity of the continued stay within one working day of the request for information from Colorado Access. 10/24/2016. You can learn about the process in the DAL SSN verification form and in the SSN verification form. Click here to read more about that process. Ask the customer service representative for the warrant number for your reference. Colorado Medicaid Change of Provider Form. Web portal. Client Information Client Name: Medicaid ID#: Date of Birth: Current PAR Number (if known): Previous Provider Information. In order to demonstrate sound stewardship of state resources and ensure that Medicaid members have access to and receive appropriate care, the Department sets reasonable limits on the type and amount of durable medical equipment and supplies that may be obtained without a prior authorization (PA). Mail your completed appeals request form to: Office of Appeals 4600 South Ulster Street Suite 300 Denver, CO 80237 ��v?��и���V� ��c1�.�q�kN����t�~{���~,_t��9���S���,���Jҝ- X�J0a�V7F`�3��%���ji4x�Ouv�/�D��h For more provider enrollment instructions and information, please go to the Provider Enrollment web page. Accounting Department Send the original completed reconsideration request form to the fiscal agent at: Request for Reconsideration, P.O. During this time, you can still find all forms and guides on our legacy site. EXCEPTION TO COVERAGE REQUEST FORM Requesting provider contact information: Name: Address: Phone: Fax: Colorado Medicaid Provider ID#: 1. Box 30 Denver, CO 80201-0030. Therefore, Health First Colorado (Colorado’s Medicaid program) will not be mailing out 1095-B forms this year. eQHealth Solutions is pleased to be selected by the Colorado Department of Health Care Policy and Financing (HCPF) to provide services for the ColoradoPAR (prior authorization request) program, effective September 1, 2015. All required information below must be completed. If a PAR status shows as "pending state review," providers are advised to contact the Provider Services Call Center (1-844-235-2387) to ensure the PAR was submitted via the correct method. 2. Fax Cover Sheet - for submitting records. Colorado has a state-supervised and county-administered human services system. They were primarily in regards to unit limits and the need or lack thereof for PA. During the posted time span, Stakeholder feedback was requested and responses were received. COVID-19 News. PROVIDER RECONSIDERATION &APPEAL FORM . 2. Baltimore, Maryland 21244-1850. Beginning in early November we will start a limited launch with designated providers. All questions must be answered in order to make a Prior Authorization Request (PAR) determination. Provider contacts: Who to call for help Provider resources: Quick guides, known issues, EDI, & training SAVE System Report Fraud Provider Enrollment Provider Bulletins Billing FAQs For further information, visit the ColoradoPAR Program website or call 1-888-801-9355. h��X�o�8�W���nE�)�`�Nc�y��lo�#ѶYr�H���oHʊ�u�m�M`Q���9�Q$������ �@B+
(�!bA��!�(fļ��J�%�q|���%��"QơG��dH���$bF�8b�K �B�����"�[Q�80��#.�E����(D��j�#A����L��~��DM�p���7�2�%������s태�O�_"Y����k^ v��!cH�G"�H��
��eח��y�(�5����S�߹�y^�GG�x�'�A'x���XO?�����-TV� 2. Referral to case-disease Management Form. • Reconsideration requests cannot be completed via the web portal. • For reconsideration request exceeding 5 claims or more, please contact New Mexico Medicaid Provider Your provider will submit the prior authorization request for you. If you are directing a Member to a non-contracted provider, please submit a request for authorization prior to any service being performed. Provider contacts: Who to call for help. Home and Community Based Services (HCBS) waiver PARs are submitted by Case Managers via the Bridge. Under this system, county departments are the main provider of direct services to Colorado’s families, children and adults. CENTERS FOR MEDICARE & MEDICAID SERVICES . A copy of the claim in question 2. This issue brief provides an overview of the Medicaid appeals process in Colorado. Public Health. Client information (name of adults and/or children): NAME: Last, First MI BIRTH DATE CLIENT MEDICAID ID / ELIGIBILITY TYPE 2. Injury Information Form. Appointment of Representative Form CMS-1696. Under this system, county departments are the main provider of direct services to Colorado’s families, children and adults. Our This updated handbook explains member benefits and provides resources to help members manage their health care. You should submit all Medicaid physical health claims directly to the state through the Health First Colorado (Colorado’s Medicaid Program) Provider Web Portal. Medicaid Director. Denver, CO 80203-1714. Online- log into your online Connect for Health Colorado account (under “Documents and Notices”) and upload the appeal request form. Apply in person: Apply in person at your county of residence’s local county office or at a local application assistance site. Once the review is complete, any alterations to the current policy will be published with a future effective date. This includes PARs for supply, surgery, out of state, therapy, audiology, home health and pediatric behavioral therapy. Agency. After your prior authorization request is reviewed you and your provider will find out Health First Colorado 's decision. If information is missing, the appeal will not be processed and will be returned to the address listed on the form below. If information is missing, the appeal will not be processed and will be returned to the address listed on the form below. March 26, 2020. Appeals and Grievances Contact Information & Resources For Providers Agency. Provider Information Update/Change Form. 3. Member Handbook. Providers must complete and submit the Request for eQSuite Access form. UB-04 Claim Form. I want a copy of my 1095-B form. Filing an expedited (quick) appeal eQSuite is eQHealth Solutions' proprietary, web-based, HIPAA-compliant prior authorization request system, which offers providers 24/7 accessibility to the information and functions providers need. The Colorado Department of Human Services connects people with assistance, resources and support for living independently in our state. The Affidavit of Lawful Presence form is available on the Provider Forms web page under the Provider Enrollment and Update Forms drop-down section. Medical PARs are not submitted through the Provider Web Portal. Apply by phone: Call 1-800-221-3943 / State Relay: 711. COLORADO DEPARTMENT OF HEALTH CARE POLICY AND FINANCING STATUS OF NURSING FACILITY CARE I . Your provider will submit the prior authorization request for you. This form must accompany the new Prior Authorization Request (PAR) Form when a client has a current and active PAR with another provider. Box 30, Denver, CO 80201-0090. A copy of the EOP showing the recent payment 3. 1500 Health Insurance Claim Form. Name: Last Day of Services: 9]�A����,Ŀ�c#? CCHA is committed to continuing to meet the needs of our Health First Colorado (Colorado’s Medicaid Program) members, providers, community partners, employees and vendors during the presence of COVID-19 in Colorado. Contact the Provider Services Call Center at 1-844-235-2387 for more information. Mail the completed form with all required and applicable documentation to the following address. Improve health care equity, access and outcomes for the people we serve while saving Coloradans money on health care and driving value for Colorado. To obtain a review submit this form as well as information that will support your appeal, which may include medical records, office notes, discharge summaries, lab records and/or member Claims Action Request CAR Form. Beneficiary’s name (First, Middle, Last) Medicare number . Appeals and Grievances Contact Information & Resources For Providers Centers for Medicare & Medicaid Services. Billing Provider NPI: _____ Reason for Reconsideration Request: Provider Signature: _____ DXC Technology P.O. N&����q'ܷ< ��i Request for Reconsideration . Member Handbook. Keystone Peer Review Organization (Kepro) will be the new utilization management (UM) partner for Health First Colorado (Colorado's Medicaid Program) as previously announced in the February 2021 Provider Bulletin (B2100459). Our member handbook for Health First Colorado (Colorado’s Medicaid program) members is now available. Tracy Johnson. After your prior authorization request is reviewed you and your provider will find out Health First Colorado 's decision. This form must accompany the new Prior Authorization Request (PAR) Form when a client has a current and active PAR with another provider. Our member handbook for Health First Colorado (Colorado’s Medicaid program) members is now available. 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In Colorado, we need a strong network of independent drivers and transportation providers as well as volunteers, local residents, facilities and community organizations with access to working vehicles to support the Health First program. The Colorado Department of Human Services connects people with assistance, resources and support for living independently in our state. Provider Dispute Resolution Form. If the criteria are not met, the doctor can re-submit with updated information, or appeal the decision to Health First Colorado 's Pharmacy Benefits section for further review. Questionnaire #2 - Pressure Relief Mattress, Questionnaire #11 - Adult Orthotics and Prosthetics, Questionnaire #12 - Wound Closure Therapy, Questionnaire #13 - Augmentative Communication Device, Questionnaire #14 - Mechanical High Frequency Chest Wall Oscillation, Questionnaire #15 - Wheelchair Tilt/Recline Device, Questionnaire # 16 - Oxygen Contents in Excess of 6 Liters Per Minute, Questionnaire #17 - Power Seat Lift Component Only, Questionnaire # 18 - Blood Pressure Unit/Monitor, Acknowledgment/Certification Statement for a Hysterectomy, Certification Statement Form for Non-Viable Pregnancies, DentaQuest Colorado Medicaid Dental Program Provider ORM, Health First Colorado Prior Authorization (PAR) Form, National Provider Identifier (NPI) Backdate Form, Provider Application Fee Refund Request Form, Consentimiento a la Esterilización - MED 178, Transition Coordination Participant Fact Sheet, Transition Services-Transition to Community Fact Sheet, Transition Coordination Process - Spanish, Transition Coordination Referral Form -Spanish, Options Counseling Authorization for Release of Information, Options Counseling Authorization for Release of Information - Spanish, Transition Coordination-Transition Options Form - Spanish, Team Roles and Responsibilities - Spanish, Transition Coordination Agency - Authorization of Release of Information - Spanish, Community Transition Participant Risk Agreement, Community Transition Risk Mitigation Plan-Participant Agreement - Spanish, Options Counseling Monthly Referral Report, Third Party User Access Forms (BUS & Bridge Access Form), Third Party User Modification/Revocation Form (BUS & Bridge Form). Practitioner and Provider Complaint and Appeal Request NOTE: Completion of this form is mandatory. Email:Complete and submit a Request for Transportation Services – Single Trip/Standing Order Subscription form via fax or secure e… %PDF-1.6
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�4� �����=L��L�9��rbQ?�8�������Tx���Ojz�|}�֏��er��!f[����c����I *nv�y ��͢�߷h��EC��E�O^� �������Z 80217-0470. Apply by mail: Download and print a paper application. Department staff have the ability to verify the social security number of clients who are submitting a HUD application, but do not have a social security card. MEDICARE RE DETERMINATION REQUEST FORM — 1st LEVEL OF APPEAL .