DECEMBER 2024

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 (ACC) Phase III Updates

ACC Phase III will begin in July 2025, 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:

• September 11, 2024: The Department of Health Care Policy and Financing (HCPF) has issued the intent to award for the four Regional Accountable Entity (RAE) contracts in ACC Phase III. Read HCPF’s announcement and find additional information here.

Stay updated about previously shared information from Colorado Access here.

Behavioral Health and Substance Use Disorders (SUD)

State Plan or B3 Modifiers on Behavioral Health Claim

All first position modifiers that indicated a State Plan (SP) service or a “B3” service (i.e. HE, HF, TT, HK, etc.) were deleted from the State Behavioral Health Services (SBHS) Billing Manual on January 1, 2024.

Effective for dates of service on or after January 1, 2025 Regional Accountable Entities (RAEs) are instructed to reject or deny claims that included the SP or B3 modifiers on claims in the first position.

If you receive a claim rejection, please resubmit a new claim without the SP or B3 modifier. If you receive a claim denial, please resubmit either a new claim or a corrected claim without the SP or B3 modifier.

Physical Health

For Clinic Practitioners – Provider Type 16 – Claims with Certain Procedure Codes Paying Incorrect Rates

Claims billed with procedure codes 51725, 51736, 51741, 51785, 51792, 54240, 54250, 59020, and 62252 have modifier-specific rates on the Fee Schedule for modifiers TC and 26. These claims are paying incorrect global rates even when these modifiers for the professional or technical component are present. Affected claims will be reprocessed.

News From HCPF

Cover All Coloradans – Expanding Health Coverage for Children and Pregnant People

Beginning January 1, 2025, under Cover All Coloradans initiative, Health First Colorado and CHP+ will offer health coverage to children under 18 and pregnant people, regardless of their immigration status. This new initiative aims to improve health access and equity by providing free health insurance for eligible individuals who may have previously lacked coverage. These members will have access to full Health First Colorado and CHP+ benefits and may seek services from providers with no action required from you.

Cover All Coloradans was established through House Bill HB22-1289 and recognizes the importance of accessible health care for all Coloradans, supporting healthier communities by offering affordable coverage to those who might otherwise be excluded. These members will have access to full Health First Colorado and CHP+ benefits and may seek services from providers without additional action needed by those providers.

Program Details

• Groups who may qualify and should apply, no matter their immigration status:
  
  

  • Children age 18 and younger

  • Pregnant people

  • People whose pregnancy ends on or after January 1, 2025

• Coverage begins January 1, 2025

• Enrollment is open year-round with no cap on enrollment

• Income requirements are based on family size, standard eligibility criteria apply

Frequently Asked Questions

What does this mean for providers?

There will be no change to processes for eligibility checks or submitting claims, but there may be a potential increase in patients seeking services who do not speak English well or at all. Section 1557 of the Affordable Care Act (ACA) requires health care providers who receive federal funding to provide limited English proficiency (LEP) patients with a qualified interpreter.

Is billing for members with Cover All Coloradans eligibility different than billing for other members?

No, you do not need to do anything different when seeing these members.

Do providers have to see members eligible under Cover All Coloradans?

Yes, the Provider Participation Agreement, nondiscrimination section 3.4, represents this newly eligible population.

How will this expansion of eligibility affect providers?

You may see an increase in members seeking services and an increase in members who speak English as a second language or do not speak English at all.

We can assist with interpretation services. Please call us at 800-511-5010.

How can I help?

As a trusted provider, you play a critical role in informing eligible patients about this coverage expansion. By raising awareness and helping patients navigate enrollment, you contribute to improving health outcomes and reducing barriers to care within your community.

Learn more here.

New From Colorado Access

Checking Credentialing Status

You can now check the status of those approved for credentialing at your clinic. Log into the provider portal and click “Reports” to get a list of credentialed providers under the clinic tax ID number and the approval/effective date. If you have any questions about credentialing, please email credentialing@coaccess.com.

Clinical Practice Guidelines

To ensure adequate informational support for network providers and members, we adopt clinical practice guidelines that are known to be effective in improving health outcomes, including topics related to well-child care, perinatal, prenatal, and postpartum care, and conditions related to persons with a disability or special health care needs. These guidelines were revised and updated during a recent review by a cohort of our medical directors.

We also updated resources on immunizations, chronic obstructive pulmonary disease (COPD), diabetes, alcohol and substance use screening, brief intervention, referral to treatment (SBIRT), and other topics applicable to our members. Learn more about these clinical practice guidelines and other resources on our website. If you have any questions, or have a suggestion for a clinical practice guideline or resource, please email us at qualityimprovement@coaccess.com.  

Quality of Care Concern (QOC) and Critical Incident Reporting

A QOC is a concern that care provided did not meet a professionally recognized standard of health care. A general quality of care review or a beneficiary complaint review may cover a single concern or multiple concerns (See 42 CFR §476.1). A QOC is a complaint made about a provider’s competence, conduct, and/or care provided that could adversely affect the health or welfare of a member. A critical incident is defined as a patient safety event not primarily related to the natural course of the patient’s illness or condition that results in death, permanent harm, or severe temporary harm. Critical incidents are subject to mandatory reporting under Colorado law, as well as your provider agreement.

Any potential QOCs and critical incidents identified during a course of treatment for a member must be reported in addition to any mandatory reporting you may be responsible for. When a potential QOC or critical incident has occurred, please fill out the Quality of Care Concern and Critical Incident reporting form in its entirety and email it to qoc@coaccess.com. The identity of the person or entity reporting will remain confidential. If your facility is contacted with a medical records request pertaining to a QOC investigation, records should be returned to us promptly and no later than 10 business days of receipt of the request. If you have any questions about QOCs, critical incidents, or reporting requirements, please email qoc@coaccess.com.

Help Us Hear from Your Patients

As of mid-December, some of your patients may be randomly selected to participate in the 2025 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. This anonymous survey, available in both English and Spanish, helps us improve the care experience for our members and providers like you.

The survey runs from mid-December 2024 to mid-May 2025. Members can respond online, by phone, or by mail. A key priority statewide is to increase response rates. If members ask about the survey, encourage them to complete it and explain how their feedback makes a difference in improving care. Thank you for helping us drive positive change! Read past Health First Colorado and CHP+ CAHPS reports here. Learn more about the CAHPS survey here.