OCTOBER 2025

At Colorado Access, caring for you and your success is our top priority as you serve our members. This monthly Provider Update serves as a highlight of important information and resources to help you as a contracted provider with us. 

Accountable Care Collaborative Phase III Updates

Accountable Care Collaborative (ACC) Phase III began last month, and we want to keep you informed on what you need to know. Please make sure to check this section each month for updates that may affect you. Stay updated about previously shared information from Colorado Access here.

• Primary care medical providers (PCMPs): HCPF released a new fact sheet to help you plan for your primary care practice in ACC Phase III. Learn more about changes for Phase III in the Attribution fact sheet and the PCMP Payment Structure fact sheet.

  • If you experience issues due to the transition or you have questions around contracting, payment, attribution or member care coordination and support, contact your RAE first.

• Members and organizations supporting members: Resources are available on the Member Messaging Resource Center.

  With program changes for ACC Phase III, including new RAE regions, some members may have a new PCMP or RAE or may be newly enrolled in one of the two managed care organizations (MCOs).

  • With program changes for ACC Phase III, including new RAE regions, some members may have a new PCMP or RAE or may be newly enrolled in one of the two managed care organizations (MCOs). 

  • Members that want to update or select a new PCMP can contact Health First Colorado Enrollment.

  • Members enrolled in an MCO that want to opt out will receive instructions in a letter from Health First Colorado (Colorado's Medicaid Program) contact Health First Colorado Enrollment if you have any questions.

  • Members with questions or concerns about this transition can contact Health First Colorado Enrollment or their RAE.

  • Members who are on Home and Community-Based Services (HCBS) waivers and were newly enrolled into Elevate (Denver Health) Medicaid Choice as of July 1 can get more information in the System-Wide Issues and Resolutions Log.

• For all ACC Phase III: Complete this form if you have been notified of or are experiencing a critical issue due to the transition that could not be resolved through the above steps. Identified issues that may impact a larger number of stakeholders will be documented on this System-Wide Issues and Resolutions Log.
  

Behavioral Health

Peer Support Professionals Certification Update

In June 2025, HCPF published the Medicaid Sustainability Memo outlining changes to peer support professional’s certification requirements that would require additional documentation of peer credentialing by January 1. 2026.

After considering feedback, HCPF has changed reimbursement guidelines to require all peer support professionals delivering Medicaid behavioral health services to either be credentialed, or will be credentialed, by a nationally recognized organization by July 1, 2026. Agencies must sign and submit an attestation to their Regional Accountable Entity (RAE) by January 1, 2026, to confirm the peer support professional is either credentialed or in the process and will be credentialed by July 1, 2026.

If you would like to provide feedback on these changes:

• Attend HCPF’s next peer support office hours on Thursday, October 23, from 11:30 a.m. to 12:30 p.m. There is no structured presentation, so they request that you only register if you have a question and list your question on the Zoom registration form.
  

Discontinuation of Provider Specialty Type 64/477

On July 1, 2025, new specialty types (ST) were added under provider type (PT) 64 (substance use continuum) to align with BHA endorsements. Providers should no longer be enrolled with ST 477. All substance use disorder (SUD) providers who currently have an ST 477 enrollment must submit a maintenance request through Gainwell to modify your ST to align with your BHA endorsement for level of care. Claims with dates of service after December 31, 2025, will be denied when billed by provider specialty type 64/477. If you have any questions about this, please email hcpf_sudbenefits@state.co.us.

Behavioral Health Secure Transport (BHST) Billing

As of July 1, 2025, BHST is included in the capitation and paid by the RAEs. This change will require providers to contract with the RAEs to bill for payment.

BHST is a benefit for all Health First Colorado members who are experiencing a behavioral health crisis and require urgent transportation for behavioral health stabilization and treatment.

The required codes/modifiers to be billed for these services are:

* When submitting a claim, providers must use modifier ET to get reimbursed.

The National Correct Coding Initiative (NCCI)

As of July 1, 2025, HCPF is requiring RAEs to implement all NCCI edits. The NCCI was created by the Centers for Medicare & Medicaid Services (CMS) to reduce improper payments stemming from incorrect coding and billing practices, including reimbursement for inappropriate combinations of Current Procedural Terminology (CPT) codes. There are three types of NCCI edits:

• Add-on code (AOC): Ensures add-on codes aren’t billed without a primary procedure code.

• Medically unlikely edits (MUEs): Prevent inappropriate payments when services are reported with an unusually high number of units of service.

• Procedure to procedure (PTP) edits: Prevent code pairs that should not be reported together on the same date of service.

Understanding Medically Unlikely Edits (MUEs)

MUEs define the maximum number of units of service a provider would typically report for a single patient on a single date of service under most circumstances. They are designed to:

• Ensure billing accuracy and medical necessity

• Detect potential coding errors

• Reduce overutilization of services

• Streamline claims adjudication

For example, if a provider submits 20 units of a single-injection vaccine for one patient on one date, and the MUE for that vaccine is set at 1, the claim will be flagged for denial.

When MUEs are exceeded, claims may be automatically denied. However, providers can appeal or resubmit with supporting clinical documentation if services were medically necessary. Ultimately, MUEs help safeguard program integrity while supporting the sustainability of Medicare and Medicaid.

Specific guidance for H0005 (group counseling by a clinician) and H0006 (substance use disorder (SUD) targeted case management):

• H0005: HCPF is enforcing the NCCI limit of one unit per day (one unit = one hour/day).

• H0006: HCPF will retire this code as of December 31, 2025. Claims for H0006 with dates of service on or after January 1, 2026, will deny. All behavioral health targeted case management services must be billed under T1017 (Behavioral Health Targeted Case Management) instead.

  • Providers contracted with a RAE to deliver T1017 may transition immediately.

  • Before December 31, 2025, HCPF will not enforce the NCCI edit for H0006 and will align it with the Colorado MUE limit of four units per day (one unit = 15 minutes/day) for T1017.

Beginning October 1, 2025, HCPF is instituting Colorado-specific MUEs and PTPs. Colorado MUE and PTP limits are available below:

Learn more on the CMS NCCI for Medicaid webpage.

Appropriate HCPF Provider/Specialty Type billing  

Please ensure that you are validated with the correct provider and specialty type, and that you bill with the correct provider/specialty type referenced in the State Behavioral Health Services (SBHS) Billing Manual. We have enabled new configuration that will check the provider/specialty types billed against what is allowed in the SBHS Billing Manual. Anything that is not appropriate will be denied. A backdated provider type enrollment will need to be obtained and corrected claims submitted.

Each practice location that delivers behavioral health services must obtain their own NPI, and that NPI must be enrolled/validated with HCPF. The NPI must be registered as a billing NPI during the validation process with HCPF. We will have configuration edits turned on to validate this information.

News From HCPF

Health First Colorado Behavioral Health Updates

Read more here.

Lactation Support Services/Doula Billing Update

As of August 1, 2025, the Colorado interChange automatically bypasses third party liability (TPL) edits for both commercial insurance and Medicare when claims are submitted by these specific provider types:

• PT 70: Lactation consultant

• Pt 72: Lactation/doula professional group

• Pt 79: Doula

Learn more in the lactation support services billing manual or doula billing manual.

If a claim was denied between January 1, 2025, and July 31, 2025, due to TPL, resubmit the claim electronically as a new submission. If you have any questions, please email hcpf_maternalchildhealth@state.co.us.

Colorado System of Care (CO-SOC) National Wraparound Implementation Center (NWIC) Potential Provider Forums

HCPF is hosting national experts from NWIC to talk about the model. HCPF will present on the CO-SOC philosophy, the partnership with the Regional Accountability Entities (RAEs) and the opportunities for funds to support expansion through the Workforce Capacity Center (WCC). There will also be an opportunity for questions and answers. Sign up for an upcoming forum with the below links, and learn more here:

• October 30, 12:00 p.m. - 1:30 p.m. Join Forum
  
• November 17, 8:00 a.m. - 9:30 a.m. Join Forum
  
• December 9, 12:00 p.m. - 1:30 p.m. Join Forum
  
• January 27, 2026, 11:00 a.m. - 12:30 p.m. Join Forum
  

Rate Reductions for Services Billed on Professional Claims and Institutional Hospital Claim

On August 28, 2025, Governor Polis issued Executive Order D 2025 014 declaring insufficient revenues available for expenditures and ordering the suspension, in whole or in part, of certain State programs or services in order to meet a revenue shortfall for Fiscal Year (FY) 2025-26 and balance the state budget. HCPF will reduce all fee-for- service (FFS) rates previously increased by 1.6% as a result of legislative appropriations for FY 2025-26. This is pursuant to the Executive Order and consistent with the Governor’s Office presentation to the Joint Budget Committee. More information:

• The rates will be reduced for dates of service on or after October 1, 2025. Some fee schedules have been updated to reflect this.

• This will affect providers who bill using the Professional claim form (CMS 1500) and hospital providers who will on the Institutional (UB-04) claim.

Learn more here.

2025 Annual 1115 Waiver Substance Use Disorder (SUD) Stakeholder Forum

The annual SUD Continuum of Care (1115 SUD Waiver) stakeholder forum will be hosted virtually on Tuesday, October 28, 2025, from 9:00 a.m. to 10:30 a.m. The most recent annual report outlining the substance use disorder (SUD) component of Demonstration Year 4 of the 1115 SUD Waiver and update the community about ongoing efforts and anticipated changes will be reviewed during the forum by HCPF. Register here and learn more here. If you have any questions or comments, email hcpf_1115waiver@state.co.us. 

Error During Eligibility Verification

You may have seen an error message when performing member eligibility verification in the provider web portal if the search contained a date range. This occurs for members with multiple, non-overlapping aid code records within the date range searched. You may search by a single date instead of a date range to avoid this error message. A resolution is in progress for this.

You may have also seen an “Unknown Error” message when attempting to add or update information in the service address information panel of the provider web portal. This issue has been resolved.

Submit Paid Claims as Adjustment

An update to a previously-paid claim can be submitted as an adjustment. You should not void the claim and rebill unless the claim was billed in error or for an incorrect member. All adjusted claims should be sent electronically, not by paper. Adjustments can be sent in the provider web portal or in batches through your clearinghouse

Pharmacy and All Medication Prescribers: Prescriber Tool Update

The Prescriber Tool is a powerful resource available directly within many Electronic Health Record (EHR) system workflows, giving providers seamless access to vital member pharmacy benefit information. This tool has integrated features such as e-prescribing, Real-Time Benefits Inquiry (RTBI) and electronic prior authorizations to deliver transparency and efficiency at the point of care. You can make faster, more informed decisions with instant access to medication coverage details and lower-cost therapeutic alternatives, improving care while managing rising pharmaceutical costs.

Key benefits include: 

• EHR integration: The Prescriber Tool is accessible in most EHRs within the provider workflow, making it easily accessible during patient visits.

• Real-time pharmacy benefit information: Gain immediate access to member-specific benefits, including cost-effective therapeutic alternatives and coverage details.

• Faster prior authorizations: Submit and manage prior authorizations electronically and efficiently.

• System upgrade coming: Beginning in February 2026, the new Pharmacy Benefit Management System will expand access to the tool by integrating with more EHR systems. 

Click here to learn more.

News from Colorado Access

MUE claim processing issue

As indicated above and in multiple newsletters, MUE edits went into effect 7/1/2025. Colorado Access has identified a configuration issue with several codes that has allowed for more units to pay than allowed by the MUE. We have corrected this issue and will be reprocessing all effected claims back to July 1, 2025. The affected codes will deny in their entirety and providers will need to send a new or corrected claim with the corrected units per the MUE.

Online Directory

Is your information correct in our online directory where members search for care? Please go to our online directory, search for yourself, and check that your data is accurate. Use the form at the top of the page to report any discrepancies or email updates to providerdatamaintenance@coaccess.com.

Colorado System of Care (CO-SOC) Recruitment

The state entered a settlement agreement to develop a system of care for Colorado youth. In ACC Phase III, RAEs are required to build capacity for specific services including Enhanced MST/FFT, Enhanced High-Fidelity Wraparound (HFW) and Enhanced Standardized Assessments (ESA) to support Colorado youth with complex behavioral health needs.

In ACC Phase 2.0, children and youth were able to access a standardized assessment (Independent Assessment) through the Administrative Services Organization (ASO). In ACC Phase III, it will be known as an Enhanced Standardized Assessment (ESA) – a comprehensive clinical assessment completed by a behavioral health provider to assist in determining appropriate treatment/service recommendations for children, youth, and families. It includes a modified template that has been used in the current Independent Assessment process, the use of the Child and Adolescent Needs and Strengths (CANS) and a new tool, the CANS Decision Support Matrix. ESAs will be completed by a provider in the RAE’s network, because it’s moving under the behavioral health capitated benefit for all youth without human service involvement. Learn more here.

If you are interested in joining our assessor network, please email providerrecruitment@coaccess.com.

Provider Self-Service From Now Available Online

The provider self-service form is now live on our website! This form is designed to streamline your communication with our provider teams. your questions will be routed directly to the appropriate department, saving you time and ensuring quicker responses. You can access the form anytime at coaccess.com/providers in the “Provider Self-Service Form” section at the top of the page.

Provider Bulletin Updates to Utilization Management Process for Colorado Access CHP+ Members 

As of August 18, 2025, we have updated our utilization management requirements:

Therapy Evaluations

• Prior authorization will no longer be required for outpatient physical therapy (PT), occupational therapy (OT), or speech therapy (ST) evaluations.

• When submitting claims, please ensure you are using one of the appropriate CPT codes:

  • CPT 97161-97163: Physical therapy evaluations

  • CPT 97165-97167: Occupational therapy evaluations

  • CPT 92521, 92522, 92523, and 92524: Speech therapy evaluations

Dental Services

• Prior authorization will no longer be required for dental code 41899.

• Dental anesthesia code 00170 already does not require prior authorization.

Hearing Aid Conformity Evaluation/Hearing Aid Exam

• Prior authorization will no longer be required for the following CPT codes:

  • CPT V5020

  • CPT 92590-92594

These updates are designed to streamline the utilization management process to allow providers to deliver care more efficiently and enhance member satisfaction through faster, uninterrupted access to necessary services.

Costco Added to CHP+ Network

As of September 1, 2025, Costco Pharmacy is now part of the CHP+ pharmacy network. CHP+ members do not need to have a Costco membership to use the Costco pharmacy; they just need to mention at the front of the store that they are using the pharmacy. Members can use Costco for all medications that do not have a mandatory specialty pharmacy designation on the formulary.

Trading Partner Agreement Required for Third-Party Billing Communications

As a reminder, we cannot release protected health information (PHI) – such as claims data, vouchers, or copies of contracts – to third-party billers or consultants without a valid Trading Partner Agreement on file. This agreement must be established between the provider and their third-party representative. We also require for you to email compliance@coaccess.com to authorize the third-party billing company to access member information on your behalf. This email should also include what information you’re allowing us to disclose.

You should be included in all communications involving third-party billers or consultants when PHI is involved. Our contracting and compliance teams are working tougher to ensure these agreements are requested, filed, and honored. We will share more detailed guidance in the provider manual and other future communications.

Caring Heart Award

Do you know a Health First Colorado or CHP+ member who is committed to serving their community? Nominate them for our 2025 Caring Heart Award!

Nominate someone you know through your practice or community work whose passion, volunteerism, service with community organizations, charitable work, and advocacy go above and beyond. Their actions create a lasting, meaningful difference in their community and earn the respect of peers and local leaders. Nominees must be at least 16 years old, live in Colorado, and be a Health First Colorado or CHP+ member. They do not need to be a Colorado Access member. Submit your nomination at coaccess.com/caringheartaward.

Evaluation and Management (E&M) Codes Billed to Denver Health Medicaid Choice (DHMC)

If you provide routine outpatient behavioral health services to DHMC members and need to bill E&M codes for those services:

• Effective July 1, 2025, Denver Health Medical Plan (DHMP) does NOT require these providers to contract. Their claim system has been configured to allow payment for these services without authorization. The services must be billed with a RAE covered behavioral health diagnosis. This only applies to E&M codes. All other CPT/HCPC codes need to be billed to Colorado Access.

• While we will not have record of your claim, if you receive denials from DHMP for E&M code billing, please contact Colorado Access and we will help with resolution. 

If you have any questions, please email providernetworkservices@coaccess.com.