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Colorado RAC

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Colorado RAC

The Recovery Audit Contract Project is a federally mandated audit and recovery program, pursuant to Section 6411 of the Patient Protection and Affordability Care Act of 2010. The Colorado Department of Health Care Policy and Financing (the Department) has contracted with Health Management Systems, Inc. (HMS) as the Health First Colorado Recovery Audit Contractor (RAC), who is authorized to conduct post-payment reviews of claims submitted for fee-for-service and managed care services on behalf of the state.

As the Health First Colorado RAC, HMS® works to identify under and over payments and assist the Department in recovering any overpayments made to the provider through Health First Colorado.

This website provides information relevant to the work to be completed by HMS on behalf of the Department for the RAC Project. It is intended to support the Department in achieving its mission to reduce improper Health First Colorado payments and to support providers with education and resources.

For state and federal statutes and regulations, refer to the following links and citations which further outline the Department’s authority and the provider’s responsibilities with regards to the Health First Colorado RAC program:

Code of Colorado Regulations:
10 CCR 2505-10 8.015.8.B;
10 CCR 2505-10 8.076.2.A-D;
10 CCR 2505-10 8.076.3A;
10 CCR 2505-10 8.130.2A

Colorado Revised Statutes:
CRS 25.5-4-301

Code of Federal Regulations:
42 CFR Part 455, Subpart F
42 CFR 433.316

Provider Billing Manual

Colorado RAC Scope:

The RAC lookback period is 7 years (84 months) from the Medicaid Paid Date of the claim.  All claim and provider types are included. State Plan Amendment CO-16-003

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Resources 

Colorado RAC Informational Documentation:


Upcoming Training

CO RAC Rebilling/Scorecard Training

CO RAC Mailing Limits Training

CO RAC Making the Most of Informal Reconsiderations Training

CO RAC 101 Complex Training


CO RAC 101 Automated Training

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Inpatient Clinical Claim Review Medical Record Request Limits

*Effective April 2023

  • Claim limits are based on the Providers Total Health First Colorado Payments received in the prior State Fiscal Year, ensuring like providers are treated equitably.
  • All Post Payment Claims selected for inpatient claims review will be grouped into a single Medical Records Request letter. However, a provider may receive an additional letter for a separate review type in the same month.
  • These letters are mailed monthly, during the 4th week of the month.
  • State Fiscal Years run July 1-June 30th each year.
  • Provider Size is re-evaluated and updated every year between July and August.
  • Limits are applied at a Medicaid Billing Provider ID level.

Hospital Reimbursement SFY

Monthly Claim Limit
$250 Million+ 600
$69 Million - $250 Million 400
$39 Million - $69 Million 200
$19 Million - $39 Million 100
$9 Million - $19 Million 50
$1 Million - $9 Million 25
< $1 Million 20
Out of State Facilities 10

 

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Hospice Clinical Claim Review Medical Record Request Limits

*Effective April 2023

  • The same limit applies to All Health First Colorado Providers.
  • Hospice Reviews are completed by reviewing the total of a patient encounter not single claims.
  • Each Case represents ONE Health First Colorado member/patient
  • The number of claims included in each case will be based on the claim submitted for a patient's episode of care billed by the provider.
  • Each case will have its own letter with a list of claims selected for that case.
  • A provider may receive up to 10 letters a month.
  • All letters will be mailed once a month during the 4th week of the month. 

Provider Type

Monthly CASE Limit
All Hospice Providers 10

 

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Physician Administered Drugs Clinical Claim Review Medical Records Request Limits

*Effective April 2023

  • The same limit applies to All Health First Colorado Providers.
  • All letters will be mailed once a month during the 4th week of the month. A provider may receive a PAD review and Inpatient claim review in the same month.

Provider Type

Monthly Claim Limit
All Providers 50

 

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Automated Scenario Mailing Limits

Post Payment Review

  • Claim limits are based on the Providers Total Health First Colorado Payments received in the prior State Fiscal Year, ensuring like providers are treated equitably.
  • Limits are applied at Colorado Medicaid Provider ID level. Providers may receive more than one Automated Finding letter a month. The below limit is applied across all Automated Finding Letters for that month. 
  • All Automated Findings will be mailed within the 3rd or 4th week of every month.

Provider Reimbursement (Previous SFY)

Monthly Maximum Claims Limit
$50 Million+ 3.33%
$10 Million - $50 Million 2.92%
$4 Million - $10 Million 2.50%
$1 Million - $4 Million 2.08%
< $1 Million 1.67%

 

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Previous Limits

Post Payment Review

Prior Mailing Limits
Complex

Complex February 2018 to September 2020

Complex September 2020-March 2023
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Exit Conference Process


Exit Conferences are optional and must be requested by the provider and occur prior to finding letters being mailed, per State Statute C.R.S. 25.5-4-301.

How to request an Exit Conference:

  • If an Exit Conference is desired, providers must call HMS Provider Services within ten (10) days of the Medical Records Request Letter to request an Exit Conference.
    • HMS cannot guarantee the processing of late or misrouted requests for an Exit Conference.
  • After review of the submitted medical records, or the expired time allowed to submit medical records, HMS will contact the provider to schedule the Exit Conference. Please note that Exit Conferences are scheduled to occur after the completion of the medical record reviews and prior to finding letters being mailed.

Prior to the Exit Conference:

  • Provider submits medical record withing 45 days of medical record request.
  • HMS will complete a review of the medical records.
  • HMS will supply preliminary findings and agenda to the provider five (5) days prior to the Exit Conference.
  • Provider reviews preliminary findings and determines if there are additional medical records to be sent to HMS.
    • This could include missing medical records, missing inpatient orders, incomplete medical records or additional records that would justify inpatient admission, based on the preliminary findings.

During Exit Conference:

  • Exit Conferences will be recorded by HMS.
  • Review summary and trends from preliminary findings.
  • Discuss and answer questions on criteria or standards of care that may impact findings.
    • If the provider disagrees with the finding/criteria or standard of care applied to justify the finding, it can be disputed in the Informal Reconsideration process. It is not deliberated within the Exit Conference. Exit Conference are intended to give providers the opportunity to seek clarity and provide transparency regarding how HMS determines its findings.
  • Review the number of claims listed with No Findings.

Following Exit Conference:

  • Per State Rules, upon completion of the Exit Conference, the provider has five (5) business days to upload to portal or mail in additional records or supporting documentation.
  • HMS reviews any additional documentation within 20 calendar days of receipt.
  • Formal findings letters are mailed to providers after Department approval.
  • After receiving findings letter provider can request an Informal Reconsideration or Appeal.

For any additional questions please attend CO RAC Complex 101 Training or utilize CO RAC Complex Audit Process under Resources & Informational Documentation. 

References

  • Please see State Statute C.R.S. 25.5-4-301
  • Please see State Rules 10 CCR 2505-10 8.076.2.H PROGRAM INTEGRITY
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Electronic Submission

  • HMS prefers medical records be submitted electronically through the Provider Portal.

Mailing in Medical Records

  • Providers may mail in hard copies of medical files, or fax copies to: 1-855-278-3479.
  • HMS prefers medical records be submitted electronically through the Provider Portal.
  • Please mail records or CDs or DVDs to the address below:

HMS – Colorado Recovery Audit Services
5615 High Point Drive
Mail Stop 200-CO
Irving, TX 75038

  • For password, protected DVD or CDs to ensure proper processing email the password to CORAC@hms.com. Please include the following in the email:
    • Letter Reference number (example: ) and/or Internal Control Number (ICN) from the Medical Records Request Letter
    • The password
    • Any CD label information
    • Tracking information to include the carrier and tracking ID
  • HMS recommends that preferred provider point(s) of contact are loaded into the HMS Provider Portal. In the event of a damaged CD or incomplete record, HMS will attempt to contact the provider.  Please see the Provider Portal training for information on how to add/update provider contacts.  

SFTP

Providers may also request a Secure File Transfer Protocol (SFTP) be set up for delivering electronic medical records. Please contact HMS Provider Services with any SFTP requests.
  • Providers may request an extension of the Medical Records due date. Requests must be made in writing and received by HMS within fifteen (15) days of the date of the Medical Records Request Letter.  The written request for extension must include the reason for the request and the length of the requested extension.   Extension requests must be mailed to:

HMS – Colorado Recovery Audit Services
Medical Records Extension Request
5615 High Point Drive
Stop 200-CO
Irving, TX 75038

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Scenario Name  Description 
Automated review of inappropriate use of modifier 57 An audit of a facility’s medical claims containing Evaluation and Management (E&M) services rendered to clients during a global surgical period for a minor procedure. Under the Health First Colorado fee schedules and the National Correct Coding Initiative (NCCI), surgical procedures are considered minor if no preoperative period is required, and the postoperative period is no more than 10 days. In addition, E&M services that are related to the minor surgical procedure are already included in the surgical package and should not be separately billed to the Health First Colorado program.
Automated review of incorrect billing of patient demographic information An audit of Health First Colorado claims that were billed for services rendered to patients and contained American Medical Association (AMA) Current Procedural Terminology (CPT) codes that are specific to a patient’s age and/or gender. Per AMA CPT guidelines, providers are required to use codes that assign an age range and/or gender when using specific medical service codes. HMS found that facilities incorrectly billed CPT codes that did not match the patient’s age and/or gender based on data maintained by the Health First Colorado program, and therefore, was paid for services that were not accurately reported. 
Automated review of durable medical equipment (DME) rentals in excess of purchase price An audit of Professional DME Provider claims to determine whether durable medical equipment (DME) rented to Health First Colorado clients were billed properly and did not exceed the purchase price of the DME. Health First Colorado rules limit DME rental claims from exceeding the purchase price of certain DME equipment.
Automated review of Evaluation and Management code billed within the global post-operative days (0, 10, or 90) of a surgical code without a modifier 24, 25 or 57 being appended to the E&M code. An audit of a facility’s medical claims containing Current Procedural Terminology (CPT) Evaluation and Management (E&M) services rendered to Health First Colorado clients during a global post-operative (post op) period for a medical or surgical procedure. Post op periods are indicators of how long the recovery for surgeries will be—either a 0-10-day post op period for a minor procedure or a 90-day post op period for a major procedure.
Post Payment Review of Incorrectly Coded Carrier Screen Panels and Genetic Tests Not in Accordance with Professional Standards A review of claims that identifies improper coding of genetic testing panels due to 1) the most specific code available not being utilized and 2) the comprehensive panel code being combined with individual codes.
Automated review of intensity-modulated radiation therapy (IMRT) planning services An audit of claims where a facility inappropriately billed one of IMRT planning service codes (77280,77285,77290, or 77295) in addition to 77301 for the same client. 
Automated review of outpatient Evaluation & Management (E&M) services inappropriately billed with a modifier 59 An audit of facilities outpatient claims billed for Evaluation and Management (E&M) services. HMS reviewed claims data for Current Procedural Terminology Codes (CPT) 99201-99499 specifically, that were billed incorrectly by appending modifier 59 to the E&M code.
Automated review of incorrectly billed new patient Evaluation & Management (E&M) services An audit of Health First Colorado claims that contain American Medical Association (AMA) Current Procedural Terminology (CPT) codes within the Office or Other Outpatient Evaluation and Management (E&M) code set. These include the New Patient E&M CPT Codes.  In this audit, HMS found facilities submitted claims and were reimbursed for New Patient E&M code(s) when the patient had been seen by the same rendering provider (Colorado Medicaid provider ID) within 3 years of the date of service (DOS) and therefore was not a new patient. HMS calculated the difference between the new patient code and repriced the claim at the appropriate established patient pricing for the claims to determine the overpayment amount. 
Post Payment Review of Incorrectly Coded Hereditary Cancer
Panels, GSP, and PLA Claims		 A review of claims that identifies genetic testing that is incorrectly coded.  Including hereditary cancer genetic testing claims that were not billed with the most specific code available and or genetic testing claims that include both a specific panel code (GSP and/or PLA) and individual CPT codes that are components of the more specific code.
Automated review of professional claims that paid more than once for the same service A post-payment compliance and utilization review of professional claims to verify if they were paid appropriately. This audit reviewed professional claims where the claims paid to a provider were exact duplicates of each other. A duplicate claim is defined as any claim paid across more than one claim number for exact matches of the following claim elements: Health First Colorado client, Healthcare Common Procedural Coding System (HCPCS) Level I/II, Modifiers, service date, provider(s). 
Automated review of unbundled DME oxygen accessories and supplies included in the purchase or rental of an oxygen system A post-payment review of Durable Medical Equipment (DME) claims to verify if they were paid appropriately. This audit reviewed DME supply claims (HCPCS code sets E0424-E0440 & K0738) providers were paid for, where the Oxygen system and the oxygen equipment accessories were unbundled and billed separately. Health First Colorado follows Federal National Correct Coding Initiatives (NCCI) procedure to procedure (PTP) and HIPAA coding rules for all claims submitted for reimbursement. Unbundling of the Oxygen system accessories from the equipment is a violation of both NCCI and HCPCs rules.
Multiple Ambulatory Surgery Center (ASC) Surgical Procedures Incorrectly Billed A post-payment review of Ambulatory Surgical Center (ASC) claims to verify if they were paid appropriately. This audit reviewed ASC claims that included more than one surgical procedure code for the same Health First Colorado client during the same date of service for the same provider. This audit includes Current Procedural Terminology (CPT) codes in the range 10000-69999 billed for Surgical procedures. This audit did not include any claims with CPT codes billed with appended modifiers 80, 81, AS, 76, 77, 78, or 79 as these modifiers would justify the billing of multiple surgical procedures for the same patient on the same date of service by the same provider. 
Durable Medical Equipment billed While a Health First Colorado Client was Formally Admitted as Inpatient. A post-payment review of your professional Durable Medical Equipment (DME) supplier claims with the Current Procedural Terminology (CPT) code range(s) B9002—B9006, E0110—E8002 and K0001—K0861 to verify that they were paid appropriately. This audit reviewed claims with these CPT codes for DME supplier(s) that were unbundled from the inpatient services for the same client, on the same date of service that they were formally admitted as an inpatient. Per Health First Colorado program rules, all DME supplier services with the above CPT codes, are reimbursed to the inpatient facility in a bundled payment and are payable to the inpatient facility.
Outpatient Services that should be included in Inpatient Payment (DRG) A post-payment review of outpatient claims to verify if they were paid appropriately. This audit reviewed outpatient claims that were paid to a provider when the Health First Colorado client was admitted as inpatient. Health First Colorado (Medicaid) Program rules stipulate that all medical services rendered for a client who is formally admitted as an inpatient are to be bundled in the inpatient claim (DRG). This includes the timeframe when the client was admitted/discharged as inpatient, either 24 hours before, during and/or 24 hours after the inpatient stay.
Incorrectly Billed Inpatient Claims for Hospital Transfers  A post-payment review of inpatient claims to verify if they were paid appropriately. This audit reviewed inpatient claims where a discharge status was incorrect. Inpatient transfers discharge statuses on claims were reviewed and had overlapping inpatient admittance at a separate facility which caused an overpayment to the transferring/originating facility. The claims identified as overpayments were paid at the APR-DRG rate instead of the transfer per-diem rate.
Automated review of outpatient claims that paid more than once for the same service  A post-payment compliance and utilization review of outpatient claims to verify if they were paid appropriately. This audit reviewed outpatient claims where the claims paid to a provider were exact duplicates of each other. A duplicate claim is defined as any claim paid across more than one claim number for exact matches of the following claim elements: Health First Colorado client, Healthcare Common Procedural Coding System (HCPCS) Level I/II, Modifiers, service date, provider(s). 
Unbundled EAPG Outpatient Services Billed on Multiple Claim Lines A post-payment review of your Outpatient Enhanced Ambulatory Patient Grouping (EAPG) claims to verify if they were paid appropriately. This audit reviewed the outpatient EAPG claims paid for where Healthcare Common Procedural Coding System (HCPCS) codes were paid incorrectly resulting in duplicate payments on multiple claim lines for the same Health First Colorado client on the same date of service for the same medical service(s) provided.  As a result of this audit, HMS has found that there were outpatient EAPG claims that were billed/paid inappropriately. The overpayments found fall into one of two categories; (1) Claims were unbundled and billed in duplicate on multiple lines resulting in an overpayment. (2) Claim lines with drug codes were incorrectly calculated resulting in an overpayment.  These drug codes required billing of the drug for each separate line in accordance with NDC reporting. The amount paid to each line was incorrectly calculated.  Each line separately paid the total amount for all the lines of the same drug instead of paying the correct amount for each line.
HCBS Services Billed While Client was Admitted as an Inpatient. A post-payment review of your Home & Community Based Services (HCBS) claims to verify if they were paid appropriately. This audit reviewed HCBS services that were rendered while a Health First Colorado Client was formally admitted as an inpatient in a hospital or Nursing Facility. This directly violates Health First Colorado rules and as such is an overpayment as the inpatient facility has been paid for all services during the time period that the client was admitted as an inpatient to their facility. 
Automated review of Home Health claims paid for a date(s) of service while a member was admitted to an  inpatient stay A post-payment review of outpatient Home Health claims to verify if they were paid appropriately. This audit reviewed the Home Health claims paid where the Health First Colorado client had overlapping dates of service when they were formally admitted in an inpatient setting at another facility. Home Health services are reimbursable when Health First Colorado client(s) are provided these services in their place of residence, however, when a client is formally admitted as an inpatient, the inpatient facility is paid for all services for this client.
Automated review of Professional Evaluation & Management (E&M) services inappropriately billed with a modifier 59 A post-payment review of Professional claims to verify if they were paid appropriately. This audit reviewed professional claims where an Evaluation and Management (E/M) code(s) (range 99201-99499) that were billed inappropriately with modifier 59 appended to the E/M code. The American Medical Association (AMA) Current Procedural Terminology (CPT) coding guidelines state that modifier 59 is used to identify procedures and/or services other than E/M services. By appending modifier 59 to the CPT code(s) the Medicaid Management Information System edits were bypassed resulting in an overpayment. 
Excessively billed Evaluation and Management Initial Hospital Care Codes. A post-payment review of professional claims to verify if they were paid appropriately. This audit reviewed claims with an American Medical Association (AMA) Current Procedural Terminology (CPT) code(s) in the range of 99221—99223 that were billed in excess of the specific CPT code description(s) and rule(s). Under AMA rules for the initial hospital care code(s), the description states that the initial hospital care visit is the first encounter with a client by the admitting physician or qualified clinician when the client is in an inpatient hospital setting. All other providers with the same or different specialties and/or visits on subsequent days by the admitting physician should report CPT codes 99231—99233, for subsequent inpatient care. 
NCCI Edit-Outpatient NCCI Edits A post-payment review of outpatient claims to verify if they were paid appropriately. This audit reviewed National Correct Coding Initiative (NCCI) paid medical code combinations that were performed on the same client, by the same provider, on the same date of service (DOS).  This includes review of NCCI Procedure-to-Procedure (PTP) edits.  NCCI rules are enforced by the Centers for Medicare and Medicaid Services (CMS) and are required medical coding rules which were fully implemented in Colorado in 2014. The NCCI manual states that “NCCI PTP edits prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code, called a "pair." If a provider reports the 2 codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is permitted and reported.” Overpayments occur when the coding pairs are billed together which indicate a billing error, such as unbundling, up coding, or incorrect use of medical codes or modifiers. 
NCCI Edit-Professional Claims NCCI Edits A post-payment review of professional claims to verify if they were paid appropriately. This audit reviewed National Correct Coding Initiative (NCCI) paid medical code combinations that were performed on the same client, by the same provider, on the same date of service (DOS).  This includes review of NCCI Procedure-to-Procedure (PTP) edits.  NCCI rules are enforced by the Centers for Medicare and Medicaid Services (CMS) and are required medical coding rules which were fully implemented in Colorado in 2014. The NCCI manual states that "NCCI PTP edits prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code, called a "pair." If a provider reports the 2 codes of an edit pair for the same beneficiary on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is permitted and reported." Overpayments occur when the coding pairs are billed together which indicate a billing error, such as unbundling, up coding, or incorrect use of medical codes or modifiers.
Inpatient Transfer to a specialty unit within the same hospital. A post-payment review of your general acute inpatient transfer claims to verify if they were paid appropriately. This audit reviewed the inpatient claims which were paid where a Health First Colorado client was transferred between different Distinct Part Units (DPUs) within the same facility/hospital. Health First Colorado does not recognize DPUs as separate from the general acute hospital under which they are licensed. Hospitals may not submit two claims for a client who are admitted to a general acute hospital and then transferred within a hospital’s DPU. A single claim should be submitted covering the dates of service from admission to the general acute facility through the discharge from the DPU.
Automated review of duplicate inpatient claims that paid more than once for the same service for the same member on the same dates of service  A post-payment compliance and utilization review of inpatient claims to verify if they were paid appropriately. This audit reviewed inpatient claims where the claims paid to a provider were exact duplicates of each other. A duplicate claim is defined as any claim paid across more than one claim number for exact matches of the following claim elements: Health First Colorado client, Healthcare Common Procedural Coding System (HCPCS) Level I/II, Modifiers, service date, provider(s). 
Post Payment Review of outpatient Rural Health Clinic (RHC) and/or Federally Qualified Health Center (FQHC) duplicate encounter claims A post-payment review of outpatient RHC and/or FQHC provider’s claims that were paid by Health First Colorado (Colorado Medicaid) for services rendered to Clients where there was a duplicate encounter payment made for the same client, for the same service category, occurring on the same day and at the same location.
Incorrect use of Bilateral Modifiers A post-payment review of professional claims billed as a bilateral procedure with modifier(s) -50 or RT (right) and LT (left) that were paid, where the Medicare Physician Fee Schedule Data Base (MPFSDB) bilateral indicator has a ‘0’ or ‘2’, which identified the procedures as inappropriately reimbursed as a bilateral procedure.
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Scenario Name  Description 
Post Payment Review of Inpatient Hospital Services A review of the medical record is conducted to verify the claim was billed appropriately.  This review could include one or all of the following:

Place of Service or Level of Care  
Focused on the review of the inpatient hospital admission records to ensure that inpatient level of care was the most reasonable and appropriate setting. HMS will refer to McKesson InterQual® Guidelines for accepted clinical criteria regarding admission status and level of care determinations. These guidelines are nationally accepted standards. HMS does not perform quality of care reviews.
Clinical reviews result in individual claim determinations based on appropriate clinical knowledge and experience. Clinical review judgement involves two steps:
            (1) The synthesis of all submitted medical record information(e.g., progress notes, diagnostic findings, medications, nursing notes, etc.) to      create a longitudinal clinical picture of the patient and
            (2) The application of this clinical picture to the review criteria to make a reviewer determination on whether the clinical requirements in the relevant policy have been met.

DRG Validation
Inpatient hospital providers receive payment based on a diagnosis-related grouping (DRG) reimbursement methodology. Proper coding of all diagnoses and procedure codes, as well as accurate and complete recording of all data elements that affect the DRG assignment, is critical to ensuring that the hospital is properly reimbursed. HMS conducts reviews of targeted DRG claims to verify that all diagnoses and procedure codes were billed appropriately in accordance with official coding guidelines and were consistent with the documentation in the medical record resulting in accurate DRG assignment and reimbursement. This review validates all data elements that affect the DRG assignment, including accurate billing of present on admission indicators.

Clinical Validation
Inpatient hospital providers receive payment based on a diagnosis-related grouping (DRG) reimbursement methodology. Proper coding of all diagnoses and procedure codes, as well as accurate and complete recording of all data elements that affect the DRG assignment, is critical to ensuring that the hospital is properly reimbursed. HMS conducts reviews of targeted DRG claims from a clinical validation viewpoint to verify that not only were the diagnoses coded in accordance with applicable coding guidelines, but the diagnoses were also consistent with the clinical documentation in the medical record, and relevant diagnostic results. In addition, clinical staff may perform a review of conditions identified as hospital acquired conditions.
Post Payment Review of Hospice Claims HMS will conduct complex reviews of hospice service claims to ensure compliance with all applicable State and Federal regulations, including verification of terminal illness, inappropriate level of service setting issues, incomplete documentation, and any other billing issues. As stated in 10 CCR 2505-10 8.550.4.A.1 “Hospice Services must be reasonable and Medically Necessary for the palliation or management of the Terminal Illness as well as any related condition, but not for the prolongation of life.” Additionally, under 10 CCR 2505-10 8.550.8.D.10. it states that “Incomplete documentation in the Client Record shall be a basis for recovery of overpayment.”
Post Payment Review of Medical Drugs  A review of the medical record is conducted to verify the claim was billed appropriately.  This review could include one or both of the following:

Discarded Drugs
Claims will be reviewed for billing of discarded drugs/biologicals. According to Colorado HCPF CO Outpatient EAPG Policy Decisions published February 2017, “The Department will not reimburse for discarded portions of drugs.” Also, the Department’s Provider Bulletin in May 2018 (Reference: B1800415, page 10) states “Health First Colorado does not reimburse for any drug which is discarded or not administered to a Health First Colorado member. The amount of PAD administered to a Health First Colorado member must be documented in the member’s medical record and the provider must only bill for this amount.”

Unit
This complex audit review project targets claims for physician administered drugs (PAD) and biological medicines that are billed incorrectly based on discrepancies between the amount billed in the claims data from the Medicaid Information Management System (MMIS) and the amount administered to the beneficiary as documented by the provider in the medical records/documents. This audit is based on medical documentation or medical records requested from the provider that are reviewed by HMS pharmacists and HMS pharmacy technicians. 
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Informal Reconsideration Process

  • Under Health First Colorado's Medicaid Program providers who disagree with the Notice of Adverse Action/Overpayment Determination letter, have the right to file an informal Reconsideration.
  • The Informal Reconsideration must be received by HMS within 30 days of letter date on Notice of Adverse Action, Overpayment Determination letter.
    • Informal Reconsiderations can be uploaded in the Provider Portal. This is HMS preferred method.
    • Informal Reconsiderations can be mailed to:

HMS – Colorado Recovery Audit Services
Informal Reconsideration Request
5615 High Point Drive
Stop 200-CO
Irving, TX 75038

  • Providers should be specific about what they disagree with and include any documentation that may support their position.
  • Providers should receive a confirmation call from HMS Provider Services when an Informal Reconsideration request has been received for the claim(s).
  • Providers will receive a consolidated letter with the outcome of their informal Reconsideration request within 45 days after HMS receives the request. The letter will include claims that were overturned and/or upheld.
  • Informal Reconsiderations must comply with the Code of Colorado Regulations requirements:
  • Please see 10 C.C.R. 2505-10, Section 8.050.6, Informal Reconsiderations and Appeals of Overpayments Resulting from Review or Audit Findings, for Medicaid rules regarding a request for an Informal Reconsideration.
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Quarterly Reports

2024

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Contact Information

Inquiry Type Appropriate Contact Contact Information
Exit Conference Request HMS Provider Services 1-877-640-3419
Questions about HMS Provider Portal HMS Provider Services 1-877-640-3419
Rebilling Help Gainwell Provider Services 1-844-235-2387
Address updates in HMS Provider Portal HMS Provider Services 1-877-640-3419
Claim/Review Status Questions HMS Provider Services 1-877-640-3419
Providing a Password for a CD or DVD HMS Provider Services CORAC@hms.com
HMS Escalations HMS RAC Account Management CORAC@hms.com
Medical Records Address Mailed to HMS HMS – Colorado Recovery Audit Services
5615 High Point Drive
Mail Stop 200-CO
Irving, TX 75038
Informal Reconsideration Request Mailed to HMS HMS – Colorado Recovery Audit Services
Informal Reconsideration Request
5615 High Point Drive
Stop 200-CO
Irving, TX 75038
Medical Record Extension Requests Mailed to HMS HMS – Colorado Recovery Audit Services
Medical records Extension Request
5615 High Point Drive
Stop 200-CO
Irving, TX 75038
For questions about HMS letters regarding commercial or other coverage  TPL Provider Relations 1-877-262-7396