SEPTEMBER 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).

  • 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.

Physical and Behavioral Health

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.

Beginning October 1, 2025, HCPF is instituting Colorado-specific MUEs and PTPs.

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.

Learn more on the CMS NCCI for Medicaid webpage.

Benefits Added to the Colorado Access Provider Manual

Behavioral Health Secure Transportation (BHST) is a Health First Colorado (Colorado’s Medicaid program) benefit for members experiencing a behavioral health crisis and need urgent transportation for stabilization and treatment. You must be enrolled with Health First Colorado to deliver BHST services. BHST services are billed to the member’s RAE as of July 1, 2025. More information:

• Covered services include voluntary and involuntary transportation from the crisis site to the closest, most appropriate facility, or between approved facilities such as hospitals, psychiatric hospitals, behavioral health entities, and walk-in crisis centers.

• Prior authorization is not required.

• Balance billing is prohibited.

• Members cannot request BHST directly; the need must be established by a qualified professional, such as a behavioral health provider, peace officer, or emergency medical services (EMS) provider.

• Providers must maintain complete records in accordance with state and county requirements.

Learn more in the updated Colorado Access provider manual.

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.

Colorado System of Care (CO-SOC) Potential Provider Forums

CO-SOC is looking to expand the provider network through an initiative focused on enhanced high fidelity wraparound (EHFW) using the National Wraparound Implementation Center (NWIC) model, enhanced multisystemic therapy (EMST), and enhanced functional family therapy (EFFT). This collaboration will strengthen the workforce and ensure program fidelity to enhance service to our most vulnerable children and youth, and will empower them to lead healthier, more fulfilling lives. These forums are open to anyone and no registration is needed. Learn more on the Intensive Behavioral Health Services for Medicaid (IBHS) website.

Peer Support Professionals Certification Update

In June 2025, The Department of Health Care Policy and Financing (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:

• Join HCPF’s next peer support forum on Thursday, September 25, from 11:30 a.m. to 12:30 p.m. Register through Zoom.

• 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.

Health-Related Social Needs (HRSN) – Nutrition Benefit Stakeholder Webinars

HCPF is hosting webinars to share feedback and ask questions about the development and implementation of the nutrition benefits under the HRSN initiative.

• Other benefit details: Wednesday, October 15, 12:00 p.m. to 1:30 p.m.

Register for the meetings and learn more here.

Resources for Behavioral Health Providers

The Behavioral Health Initiatives and Coverage (BHIC) office at HCPF offers regular forums, meetings, and office hours for behavioral health providers. Learn more on their calendar or sign up for their newsletter to stay informed. If you have any questions, please email hcpf_bhbenefits@state.co.us.

Breast Pump Equipment Bundle

As of July 1, 2025, you may supply a bundle of breast pump equipment that includes: one manual pump, one single-user electric pump, and one set of replacement shields/flanges (when all three items are provided on the same day of service). This bundle is billed using Healthcare Common Procedure Coding System (HCPCS) E0603 and modifier U1. All components of this bundle must be supplied when submitting a claim. If you have any questions, please email alaina.kelley@state.co.us.

Colorado Medicaid eConsult Update

The eConsult free, secure, statewide platform allows PCMPs to consult electronically with experts, often reducing the need for in-person referrals for members. As of July 1, 2025, eConsult has expanded to support specialty-to-specialty consultations. The existing PCMP user role is now a general “submitter” role, which allows specialists, including medical doctors (MDs), doctors of osteopathic medicine (DOs), nurse practitioners (NPs), and physician assistants (PAs) to initiate eConsults as treating practitioners.

The billing manual will be updated to reflect these changes, enabling third-party platforms to implement and submit claims for specialty-to-specialty reimbursement. Learn more here, and if you have any questions, please email:

• hcpf_econsult@state.co.us for more information about this feature

• coloradosupport@safetynetconnect.com for help with platform access and more technical support

New Integrated Care Policy Published

This new policy is now available here. There are also new rates for the Collaborative Care Model (CoCM) and Health Behavior Assessment and Intervention (HBAI) here. Additional updates were made to the guidelines for billing the HBAI and CoCM codes compared to the HCPF billing system on July 18, 2025. If you have any questions, please email hcpf_integratedcare@state.co.us.

News From HCPF

Special Session and Executive Order

On August 28, 2025, Governor Polis signed Executive Order D25 014 that reduces General Fund expenditures to bring Colorado’s budget into balance for the current fiscal year (state fiscal year (SFY) 2025-26). Reductions include impacts to programs administered by HCPF, such as Medicaid. In alignment with HCPF’s Medicaid Sustainability Framework, Governor Polis directed HCPF to enact budget reduction measures that target Medicaid trend drivers, reduce Medicaid spending, and help balance the state budget. These initial measures will result in $79.1 million in reductions to the General Fund. Unfortunately, further reductions may be implemented in the coming months. Read more here.

Health First Colorado Behavioral Health Updates

Read more here.

Provide Feedback on Member Correspondence Improvements

HCPF is holding quarterly virtual stakeholder meetings about ongoing improvements to member correspondence. Meeting agendas will include:

• Updates on improvements

• Timelines for changes

• Plans for future letter improvements

• An opportunity for attendees to give feedback in smaller workgroups (materials will be sent to registered attendees at least one week before the meeting)

The meetings will be in both English and Spanish, and American Sign Language interpretation will be provided.

Please register or request a recording from hcpf_stakeholders@state.co.us for one or all of the meetings:

• Thursday, October 16, 2025, 12:00 to 1:30 p.m.

Certified Community Behavioral Health Clinic (CCBHC) Monthly 

Stakeholder Forum

HCPF and the Behavioral Health Administration (BHA) are hosting a monthly public meeting for members, providers, individuals with lived experience and their families, advocates, state agencies, managed care entities, and anyone interested in learning more about the CCBHC model in Colorado. Register for one or more upcoming sessions here:

• CCBHC forum: Monthly on the last Wednesday from 1:00 p.m. to 2:00 p.m.

  • Register in advance. 

• CCBHC steering committee: Monthly on the last Monday from 3:00 p.m. to 4:00 p.m.

  • Register in advance.

• Prospective Payment System and Finance Subcommittee: Monthly on the third Wednesday at 2:00 p.m.

  • Register in advance. 

• Certification and provider readiness subcommittee: Monthly on the first Tuesday at 2:00 p.m.

  • Register in advance. 

• Quality Measure Data Management Subcommittee: Monthly on the third Tuesday of each month at 2:00 p.m.

  • Register in advance. 

Learn more here.

Behavioral Health Crisis Services Updates

The 988 Colorado Mental Health Line is now the primary way to connect to free emotional, mental health, or substance use support 24 hours a day, seven days a week, as a result of Senate Bill (SB) 25-236. As of July 1, 2025, if someone tries to call or text Colorado Crisis Services, they will be connected to 988 Colorado. Learn more here, or email 988colorado@state.co.us if you have any questions.

Prevent Inactivation of Provider Web Portal Accounts

If you are a delegate or trading partner, please make sure to log into the provider web portal regularly to prevent inactivation. This does not apply to administrators.

For new accounts, if the delegate or trading partner account has no login activity for a period of 60 days, the status automatically changes from “active” to “inactive.” For existing accounts, if the delegate or trading partner account has no login activity for a period of 90 days, the status automatically changes from “active” to “inactive.”

Learn more in the Delegates Quick Guide and the Link the Trading Partner Identification (TPID) Quick Guide on the Quick Guide webpage.

Refer to the Disenrollment Quick Guide webpage and the Provider Enrollment Manual if a TIN change is required. Refer to the Updating Legal Name and Tax Identification Number Quick Guide for more information.

Updating Legal Name and Tax Identification Number (TIN)

During enrollment, you’re asked to enter your TIN and legal name on the “request information” panel in the provider web portal. That information is compared against the Internal Revenue Service (IRS) record. If it doesn’t match, all subsequent claims submitted for processing are placed on a payment hold. If you need to update your legal name, you can submit a legal name change form in the provider web portal.

The TIN cannot be changed after enrollment. If the TIN is incorrect, you must disenroll and submit a new enrollment with the correct TIN. Compare the TIN on your profile in the provider web portal to the TIN on IRS form 147c to determine if disenrollment and reenrollment is required.

Resources

• For a TIN update:

  • Disenrollment Quick Guide webpage

  • Provider Enrollment Manual

• Updating Legal Name and Tax Identification Number Quick Guide

Electronic Data Integration (EDI) Vendor Transition

EDI functionality, including batch processing and trading partner enrollment, will transition from Medicaid Management Information System (MMIS) operated by Gainwell Technologies to a new module operated by Cotiviti (formerly Edifecs). This will only affect trading partners who submit batch transactions for providers. Please ensure that the clearinghouse or billing agent is aware of these changes and in compliance before implementation.

What is staying the same?

• You may still use the Provider Web Portal to submit individual claims, maintain enrollment, verify individual eligibility and more.

• You may also still contact the Provider Services Call Center with any questions about claims, the provider web portal or EDI.

• Optum agents will still have access to the EDI systems and can answer your questions about EDI.

• Trading partners will retain the same trading partner IDs.

What is changing?

• Existing trading partners will need to test and sign a new agreement.

• New Secure File Transfer Protocol (SFTP) credentials will be issued.

The new EDI transition is scheduled to be implemented in the late summer of 2026, with phased implementation starting in 2025. Learn more on the Electronic Data Interchange (EDI) Support webpage and Colorado Medicaid Enterprise Solutions (CMES) Transition webpage. You can also sign up for targeted communications here.

Federal Policy Changes to the 1115 Waiver

On July 17, 2025, CMS sent state Medicaid programs a letter saying that CMS will no longer approve continuous eligibility for new or renewed 1115 waivers in Medicaid or Child Health Plan Plus (CHP+). Continuous eligibility allows certain children or adults to keep their coverage even if their income or household size changes temporarily. Colorado can no longer move forward with major components of Continuous Eligibility Medical Coverage (House Bill 23-1300), passed in 2023. Colorado was preparing to launch continuous eligibility on January 1, 2026, for:

• Children age zero until they turn three, and;

• Adults recently released from state prison for 12 months, regardless of income changes.

These changes were part of Colorado’s approved 1115 waiver for expanding substance use disorder (SUD) services, but the new CMS policy blocks implementation. This does not impact the current state policy of 12 months of continuous eligibility for members 19 years and under.

Learn more here. If you have any questions, please email hcpf_1115waiver@state.co.us with questions.

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.

Other Resources

Gun Violence Prevention Resources

The Office of Gun Violence at the Colorado Department of Public Health and Environment (CDPHE) has a bilingual statewide “Let’s Talk Guns, Colorado” campaign designed to reduce firearm injuries and deaths through education and open dialogue. The campaign websites, letstalkgunscolorado.com in English and coloradohablemosdearmas.com in Spanish, offer valuable tools, including safe firearm storage best practices, guidance on reporting lost or stolen firearms, information about Extreme Risk Protection Orders (ERPOs) and access to mental health and substance use treatment resources. For Health First Colorado providers and RAEs, these resources can support conversations with clients about firearm safety, particularly when addressing mental health concerns or substance use issues.

Colorado’s Extreme Risk Protection Hotline is available 24 hours a day, seven days a week at 855-999-3776 to provide information abot ERPOs when there are concerns about someone’s access to firearms. Email molly.siegel@state.co.us if you have questions or need more information.

Upcoming Trainings

Expand Your Impact in Youth Behavioral Health

If you currently deliver NWIC High-Fidelity Wraparound (HWF), Multisystemic Therapy (MST), or Functional Family Therapy (FFT) services, you may want to participate in an upcoming session related to the Colorado System of Care (CO-SOC). Learn more here.

PCMP Learning Community

The practice innovation program at University of Colorado (CU-PIP) is running learning community sessions for PCMPs to support success through the new ACC Phase III payment program. The sessions are planning for the second Thursday of the month at 12:00 p.m. Register here, and learn more here.

News from Colorado Access

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.

Claims Auditing Vendor – EXL

EXL is our external claims auditing vendor. EXL also reviews medical records for correct coding on our behalf. If you receive a request for information from EXL about a claim filed with us, please respond accordingly.

Smart Data Stream (SDS) Clearinghouse Service

We recently partnered with SDS to access their provider portal for direct claim entry, which eliminates the need to complete and mail a paper claim. This will result in faster turnaround time for claim processing and faster receipt of payment from the payor. This service is free for you to use. Read the user guide here and be sure to select the Colorado Access payer ID to establish the connection. If you have any questions, please email providernetworkservices@coaccess.com.

Please note: This is not intended to replace your current clearinghouse for electronic submissions; it is a more efficient avenue to submit paper claims.

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.