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NOVEMBER 2025 |
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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 in July, 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. |
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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.
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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).
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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).
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Members that want to update or select a new PCMP can contact Health First Colorado Enrollment.
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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.
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Members with questions or concerns about this transition can contact Health First Colorado Enrollment or their RAE.
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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.
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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.
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Behavioral and Physical Health |
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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. |
MUE (Medically Unlikely Edits) Claim Processing Issue
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. |
Colorado Receives Federal Approval to Better Support Health First
Colorado Members
On October 1, 2025, HCPF expanded coverage for inpatient mental health services from under 15 days to up to 60 days (for individuals with a serious mental illness (SMI) or serious emotional disturbance (SED)). This policy change will help ensure that Medicaid members are not discharged before they are full stabilized and will help improve outcomes and lower the need for readmissions for psychiatric care. More information will be released here and here when available, and in an upcoming engagement forum. |
Federal Shutdown: No Impact to Medicaid and CHP+, November
SNAP Benefits Delayed
Medicaid and CHP+ were not impacted by the government shutdown. Members were advised to continue applying for and using their Medicaid and CHP+ benefits as normal.
Funding for the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC) was affected by the government shutdown, although WIC benefits continued without disruptions. November SNAP payments were delayed substantially, and most Colorado recipients have not yet received their benefits. Counties continued to process applications, but new benefits were not issued in November. We expect November SNAP payments to go out soon now that the government has reopened.
We will share new information as it becomes available.
Food resource help for SNAP and WIC recipients:
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Clarifying Behavioral Health Secure Transport (BHST)
BHST is an unscheduled, specialized Medicaid benefit designed exclusively for the safe and secure transport of people experiencing a behavioral health crisis to an allowable facility. BHST providers must be enrolled with Health First Colorado, have appropriate licenses and permits, and be contracted with a RAE. Learn more here and here. |
Managed Care Claims Processing Changes
To continue getting reimbursed for providing covered services to Health First Colorado and CHP+ members, make sure you are enrolled, and that you submit claims with information that matches your enrollment record, otherwise your claims may be denied by your RAE or MCO. Any claims that are denied for this reason can be resubmitted once the appropriate information has been updated in the Provider Web Portal and claims are revised to include the appropriate NPI or Taxonomy Codes in the correct fields. RAEs and MCOs will implement this change on the following rolling basis:
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November 3, 2025: Northeast Health Partners and Rocky Mountain Health Plans will flag incorrectly submitted claims, but they will not be denied.
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Anticipated December 1, 2025: Colorado Access will begin denying incorrectly submitted claims.
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Anticipated January 5, 2025: Colorado Community Health Alliance, Denver Health, Kaiser Permanente, Northeast Health Partners and Rocky Mountain Health Plans will begin denying incorrectly submitted claims.
RAEs and MCOs have identified providers in their networks who will be impacted by these changes and will contact you directly if this applies to you.
These changes are being implemented to ensure that all claims are submitted and adjudicated in alignment with provider enrollment requirements to achieve the following goals:
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Compliance with federal and state policy: Only properly enrolled providers may bill for services under Health First Colorado and CHP+.
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Consistency across RAEs and MCOs: Establishing a uniform standard for claim processing.
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Program integrity: Ensuring claims are paid only to properly enrolled providers strengthens accountability and reduces administrative burden caused by incorrect submissions.
If you have any questions, contact your RAE or MCO:
Learn more here. |
Reminder: Enhanced Standard Assessment (ESA)
As of November 15, 2025:
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All children and adults being considered for residential treatment (Qualified Residential Treatment Program (QRTP), Psychiatric Residential Treatment Facility (PRTF), or Out-of-State High Intensity Residential Treatment (OHIRT)) will be required to undergo an ESA for initial Health First Colorado coverage authorization. This applies when residential services are to be directly reimbursed by HCPF. Continuing stay approval will also be required for periods of treatment longer than 30 days.
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Any child already in an episode of care in a QRTP or a PRTF will receive an initial 30-day approval. OHIRT reviews will continue their regular 30-day review cadence.
Continued stay reviews will begin December 15, 2025, and occur every 30 days after.
Click here and here to learn more or email christina.winship@state.co.us if you have policy or enrollment questions. |
Peer Support Professional Certification Requirements
In June 2025, the Medicaid Sustainability Memo outlining changes to peer support was published. The State Medicaid Director letter (SMDL) #07-011 indicates that states must determine the minimum training and certification criteria for peer support providers, which led to a policy change:
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Effective January 1, 2026, all peer support professionals delivering Medicaid behavioral health services must either be certified or will be certified by July 1, 2026, to be eligible for reimbursement for delivering peer support services.
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Agencies must sign and submit an attestation to their RAEs by January 1, 2026, indicating that all peer support professionals are either certified or are in the process and will be certified by July 1, 2026.
Learn more here, and you can ask questions/give feedback in the quarterly peer support forums and peer support office hours, and by emailing hcpf_peerservices@state.co.us. |
New Drug Unit Limitations and Documentation Requirements
As of October 10, 2025, these limits are effective for substance-specific confirmatory laboratory tests:
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Healthcare Common Procedure Coding System (HCPCS) codes G0480-G0483 have a combined unit limit of 16 per state fiscal year (July 1 through June 30).
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Members ages 0 to 20 have access to additional testing as clinically appropriate with a prior authorization.
All documentation, including the order for the drug test, the clinical indication/medical necessity and the lab results must be maintained in the member’s medical record. Review the video explaining the proposed changes and project timeline and submit feedback in the Definitive Drug Testing Limit Rule Change Feedback Form until December 12, 2025.
If you have any questions, email sarah.kaslow@state.co.us. |
340B Rebate Model Pilot Program
Starting January 1, 2026, the Health Resources and Services Administration (HRSA) is implementing a 340B Rebate Model Pilot Program, where certain drug manufacturers will sell selected 340B drugs to covered entities at Wholesale Acquisition Cost (WAC). Covered entities will later get manufacturer rebates that reduce the final net price to the statutory 340B ceiling price. When billing Health First Colorado for prescription drugs purchased through the 340B Rebate Model Pilot Program:
Learn more here, and email korri.conilogue@state.co.us if you have any questions. |
Immunization Updates and Reminders
All recommended seasonal and routine immunizations are a benefit for all Health First Colorado members without cost sharing. Members under age 19 are also eligible to receive all immunizations available from the federal Vaccines for Children (VFC) Program at VFC-enrolled provider offices and pharmacies.
All vaccines that are part of the VFC Program are only reimbursable when administered to members under age 19 and when administered by a VFC-enrolled provider using VFC vaccine products. Health First Colorado will not reimburse for the cost of vaccines that are available through the VFC Program or for the cost of vaccines that you get at no cost.
You must enroll with VFC and Health First Colorado and use VFC vaccines to get reimbursed for administering vaccines to members under age 19. Product and administration codes must always be included on any claims for vaccination.
Health First Colorado covers and reimburses vaccine counseling visits where you talk to families about the importance of vaccination. Do not bill for the vaccine counseling code and the vaccine administration code on the same date of service when vaccine administration codes are inclusive of counseling. Learn more here and here, and email christina.winship@state.co.us if you have any questions. |
Member Eligibility and Non-Emergent Medical Transportation (NEMT)
Members who have the benefit plan “EMS – Emergency Medicaid and Reproductive Health Program” are not eligible for the NEMT benefit. Please verify member eligibility before you schedule a trip. The trip request should be denied if the member has this benefit plan. Learn more here and here, and email courtney.sedon@state.co.us if you have any questions. |
News From HCPF |
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Health First Colorado Behavioral Health Updates
Read more here. |
Colorado System of Care (CO-SOC) National Wraparound Implementation Center (NWIC) Potential Provider Forums
We are working with HCPF to implement CO-SOC Intensive Behavioral Health Services (including intensive in-home and community-based mental health services and intensive care coordination) for Health First Colorado members under age 21 who have been diagnosed with a mental health or behavioral disorder and for whom these services are medically necessary. The RAEs are responsible for developing a network of services. Learn more here.
HCPF is hosting national experts from NWIC to talk about the model. HCPF will present on the CO-SOC philosophy, the partnership with the 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:
If you are interested in providing any CO-SOC services in the future, please email amanda.berger@coaccess.com and providerrecruitment@coaccess.com. |
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:
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The rates will be reduced for dates of service on or after October 1, 2025. Some fee schedules have been updated to reflect this.
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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. |
Federal Changes to Medicaid Survey
On July 4, 2025, the House Reconciliation bill (H.R.1) was signed into law with several changes to Medicaid that take effect over the next few years. HCPF has a survey to better understand your concerns about H.R.1, where you go for trusted information, and how they can best share information with you. The survey is open in English and Spanish through November 21, 2025.
The survey does not cover personal case or enrollment issues. If you need help with either of those, click here or call 800-221-3943 (toll-free). |
News from Colorado Access |
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Colorado Access Address Change
As of January 5, 2026, we will have a new address:
Colorado Access
Access Management Services
4643 South Ulster Street
Suite 700
Denver, CO 80237
The address for mailing claims will not change, but it is always better to submit claims electronically on the portal. |
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. |
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. Learn more in English and Spanish. |
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:
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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.
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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.
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Credentialing and Recredentialing Process Change
During this process, you have the right to:
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Review information submitted to support your credentialing application
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Correct erroneous information
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Get the status of your credentialing or recredentialing application, upon request
If you have any questions, please email credentialing@coaccess.com.
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