JULY 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 (ACC) Phase III Updates

Accountable Care Collaborative (ACC) Phase III began this 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.

• The State Behavioral Health Services billing manual has been updated

• Important updates from the Department of Health Care Policy and Financing (HPCF)

• Coding changes for specific provider types: Some changes effective July 1, 2025, are relevant to specific provider types: Peer services, substance use disorder (SUD), comprehensive safety net providers (CSNP), and recovery support services organization (RSSO).

  • As of July 1, 2025, you must be a SUD, CSNP, or RSSO provider type to bill H0038 and H0023. If you are not one of those provider types, you can no longer have a peer render the service and bill these codes. Your claims will be denied.

  • Peers cannot bill the rendering provider for H2014 for any billing provider type.

  • Learn more about what provider types can bill for specific services in the billing manual

• SUD/CSNP/RSSO updates: As of July 1, 2025, Colorado will be utilizing National Correct Coding Initiative (NCCI) edits.

  • H0023 will have a maximum medically unlikely edits (MUE) of eight units per day when medically necessary

  • H0038 will have a MUE of 12 units per day when medically necessary

  • Service billed in excess of the Colorado MUE will have a denial message regarding the MUE limit being exceeded. You have a right to appeal and submit any necessary clinical documentation to determine if more units should be allotted.

  • Learn more here.

Physical and Behavioral Health

Clarification for Substance Use Disorder (SUD) Continuum Providers

On July 1, 2024, new Specialty Types were added under Provider Type (PT) 64 (Substance Use Continuum) to align with Behavioral Health Administration (BHA) Endorsements for each American Society of Addiction Medicine (ASAM) level of care. This allows HCPF and Regional Accountable Entities (RAEs) to accurately track network adequacy for all SUD levels of care.

Make sure that PT 64 enrollments include a Specialty Type for each ASAM level of care endorsement on BHA licenses by June 15, 2025. Add a Specialty Type to the PT 64 enrollment with a maintenance request through the Provider Web Portal. Read more about how to submit a maintenance request here. Please note that you cannot remove a Specialty Type with a maintenance request.

View the list of ASAM level of care Specialty Types here under “SUD Continuum.” Specialty Type 477 is not associated with an ASAM level of care and is being discontinued. When all SUD continuum providers have added the necessary ASAM level of care Specialty Type(s), the 477 Specialty Type will be end-dated in the system.

If you have any questions, please email hcpf_sudbenefits@state.co.us.

Provider Services Call Center Virtual Hold

The Provider Services Call Center is currently experiencing higher-than-average wait times. To reduce wait times, select the new "virtual hold" option to hang up the phone while keeping your place in line and get a call back when an agent is available. The system is unable to call back numbers with extensions. With this new self-service option, you can verify payment history, claims status and associated explanation of benefit (EOB) codes, and member eligibility.

Pediatric Behavioral Therapy Providers Provider Type Transition

Pediatric behavioral therapy providers who are still enrolled in PT 25, please note that the billing codes associated with pediatric behavioral therapies will be closed for PT 25 as of June 30, 2025. If you need help enrolling in an approval provider type to ensure payments continue to be received for services, email Martina Schmidt at martina.schmidt@state.co.us with the subject line “Provider Type Transition” as soon as possible to ensure a smooth transition and minimize disruption to your practice. Learn more in the pediatric behavioral therapies billing manual or email Gina Robinson at gina.robinson@state.co.us.

Choosing Wisely Initiative: Sparking Conversations Between Providers and Partners

Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) Foundation that promotes conversations between clinicians and patients to avoid unnecessary medical tests, treatments, and procedures. It encourages shared decision-making, enhances trust and transparency with patients, and reduces overuse and potential patient harm.

Matching Individuals with Addiction to Treatment Based on Their Needs

The American Society of Addiction Medicine (ASAM) created a questionnaire to recommend a treatment setting to the individual needs of people with addiction. A study funded by the Patient-Centered Outcomes Research Institute (PCORI) found that counties using the questionnaire had more individuals stay in residential treatment over the first year of implementation. These individuals also reported a better understanding of their mental and physical health, and greater satisfaction with their treatment setting.

Known Issue: Comprehensive Safety Net Provider Fee-For-Service (FFS) Claims Denial

Comprehensive Safety Net Provider (CSNP) (Provider Type 78) FFS claims are currently being denied due to system implementation delays. CSNPs may continue to submit FFS claims; they will be reprocessed once system updates are complete this fall. All RAEs are aware of the issue and have been advised of the process for reprocessing claims. All CSNP claims will bypass timely filing. If you have any questions, please email hcpf_bhbenefits@state.co.us.

Colorado Health Foundation Pulse Poll

The Colorado Health Foundation works to ensure Coloradans’ voices are heard on issues like affordable housing, health care and economic concerns. Their Pulse Poll offers valuable insights to help shape policies that will improve the long-term health and well-being of Colorado’s communities. Learn more about the survey here and read frequently asked questions here. If you have any other questions, email info@copulsepoll.org.   

Verbal Order Requirement Reminders

When a verbal order is issued, it must be properly documented, contain all necessary components, and be signed by the ordering physician or approved practitioner before submitting a prior authorization request (PAR). Providing services without a valid order violated Medicaid and Medicare regulations and PAR submission requirements. Read more about the federal and Health First Colorado (Colorado’s Medicaid program) regulations (10 CCR 2505-10, Section 8.520) for this here. Failure to follow these guidelines may result in holds for additional information or delays in PAR processing.

Colorado Health Foundation Public Briefings

There are three upcoming public briefings to go over the Colorado Health Foundation’s recent survey. Register for any or all sessions and learn more here:

• Economic strain and political discontent: Tuesday, July 15, 10:00 a.m. (Presented in English, live interpretation in Spanish)

• Beyond the numbers: Wednesday, August 13, 10:00 a.m. (Presented in English, live interpretation in Spanish)

• Insights from Hispanic and Latino Coloradans: Wednesday, September 10, 5:30 p.m. (Presented in Spanish and English with simultaneous interpretation)

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

The Department of Health Care Policy and Financing (HCPF) is hosting three webinars to share feedback and ask questions about the development and implementation of the nutrition benefits under the HRSN initiative.

• Nutrition counseling/education and pantry-stocking, or home-delivered meals: Wednesday, August 13, 12:00 p.m. to 1:30 p.m.

• Medically-tailored meals: Wednesday, September 10, 12:00 p.m. to 1:30 p.m.

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

Register for the meetings and learn more here.

NCCI Notification of Quarterly Updates

Monitor the Centers for Medicare & Medicaid Services (CMS) website for updates to NCCI rules and guidelines. Updates to the procedure-to-procedure (PTP) and medically unlikely edit (MUE) files are completed quarterly. The next file update is this month. Learn more here.

News From HCPF

Explanation of Benefits (EOB) 3110

There have been questions about denials related to EOB code 3110 “The rendering provider is not a group member.” Notations that affiliations are missing do not cause claims to deny and are informational only. HCPF is giving an extended grace period to make all necessary updates to affiliations to avoid future claims denials. If EOB code 3110 appears on a claim, make sure your affiliations are up-to-date and check other EOB codes to see why the claim was denied. Updated affiliations are currently taking five days for final approval. Do not submit duplicate update requests.

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, July 17, 2025, 12:00 to 1:30 p.m.
• Thursday, October 16, 2025, 12:00 to 1:30 p.m.

Updated Supervision Policy for Unlicensed Professionals and Pre-Licensed Clinicians

Medicaid services provided by individual service providers not enrolled in Medicaid must be supervised by and billed under a Medicaid-enrolled provider who is documented as overseeing the member’s course of treatment. Supervision for the purposes of Medicaid billing and rendering of services is distinct from clinical supervision standards for professional licensure under the Department of Regulatory Agencies (DORA).

As of July 1, 2025:

• There is an updated version of the Colorado Medicaid Standards for Supervision of Unlicensed Professionals policy document. An annual attestation form must be submitted to each RAE the provider is contracted with to affirm they follow this policy.

• There is also an updated version of the Attestation for Supervision of Unlicensed Professionals and/or Pre-licensed Clinicians.

  • All providers with licensed clinicians intending to supervise unlicensed professionals and/or pre-licensed clinicians that fall under the guidelines of this policy must submit the updated attestation to each contracted RAE by September 1.

  • It must be submitted to each contracted RAE annually, no later than January 1 of each calendar year supervision may be rendered by the attesting organization.

Learn more Behavioral Health Policies webpage under Medicaid Supervision Policy, or email providernetworkservices@coaccess.com if you have any questions or need help getting accessing to our Learning Management System (LMS) to complete the attestation electronically.

News from Colorado Access

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.

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 II, 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.

Credentialing and Recredentialing Process

For our credentialing and recredentialing process, you have the right to:

1. Review information submitted to support your credentialing application.
2. Correct erroneous information.
3. Receive the status of your credentialing or recredentialing application, upon request.

If you have any questions surrounding credentialing or recredentialing, please email credentialing@coaccess.com.

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 payor 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.

Other News

Medicaid Cuts Would Hurt Coloradans – Dr. Laura Luzietti, Every Child Pediatrics

“As an experienced pediatrician at Every Child Pediatrics, I have grave concerns that the cuts to Medicaid currently being considered by Congress will be devastating for Colorado families. The well-being of our children depends on access to insurance coverage for them and their caregivers. This legislation directly strips coverage from more than 100,000 Colorado adults and children and increases administrative barriers, which will result in coverage losses for those who remain eligible.” Read more in Dr. Laura Lizietti’s guest column in the Douglas County News-Press here.

Bringing Shared Decision-Making to Weight Loss Surgery

A PCORI-funded patient-centered study followed more than 46,000 people with severe obesity for five years after they had weight loss surgery and found that outcomes, including differences in weight loss, varied by surgery type, in addition to differences in whether people’s diabetes improved or whether they had another surgery. Learn more about the study here.

Comparing Diabetes Medicines for People With Chronic Kidney Disease (CKD)

Many people with Type 2 diabetes also have CKD. Metformin is considered a safe medication for people with mild CKD, but less is known about its use by patients with diabetes and moderate to severe CKD. A PCORI-funded study used real-world data from the National Patient-Centered Clinical Research Network (PCORnet®) to compare patients starting four other types of diabetes medications, and results revealed differences in blood sugar levels. Learn more about the study here.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 

Training Update

Our biannual EPSDT training update is now available through our provider LMS. The EPSDT program is a vital component of preventive care in Medicaid. This training helps you stay current with guidelines and best practices related to:

• Regular screenings and well-child visits

• Vaccinations and developmental assessments

• Early identification and treatment of health conditions

We encourage all network providers to complete this training to remain aligned with program expectations and to continue delivering comprehensive, child-focused care.

EPSDT training will be refreshed each January and July. Program updates will be included in the training materials and highlighted in future Provider Updates.

Thank you for your continued partnership and commitment to whole-person, whole-community care. If you have questions or need support accessing the training, please contact providernetworkservices@coaccess.com.

Provider Manual Updates

We recently made updates to our provider manual. You can view the updated manual on our website and in the provider portal. Key updates include:

• New regional coverage: As of July 1, 2025, we are the RAE for Region 4 of Colorado (Adams, Arapahoe, Denver, and Douglas counties).

• ACC Phase III: Implementation updates emphasizing integrated care, member engagement, and value-based outcomes.

• Updated prior authorization requirements: Revisions to utilization management policies, including updated processes for prior authorizations for physical and behavioral health services.

• Value-based payment enhancements: Expanded support for alternative payment models (APMs) and clearer guidance on performance metrics and incentives.

• Claims and billing clarifications: New guidance on modifier usage and claims submission protocols aimed at reducing denials and improving payment accuracy.

• Provider orientation and training: Emphasis on mandatory orientation for new providers and ongoing training opportunities, including webinars and town halls.

• Revised contact and support information: Updated contact details for claims research, provider network services, and portal support to enhance provider communication.