Audiology
Providers must be enrolled as a Colorado Medical Assistance Program provider in order to:
Treat a Colorado Medical Assistance Program member Submit claims for payment to the Colorado Medical Assistance Program Providers should refer to the Code of Colorado Regulations, Program Rules (10 CCR 2505-10 8.2.3.D.2), for specific information when providing audiology care.
Billing Information
National Provider Identifier (NPI)
The Health Insurance Portability and Accountability Act (HIPAA) requires that covered entities (i.e., health plans, health care clearinghouses, and those health care providers who transmit any health information electronically in connection with a transaction for which the Secretary of Health and Human Services has adopted a standard) use NPIs in standard transactions.
Paper Claims
Electronic claims format shall be required unless hard copy claims submittals are specifically prior authorized by the Department of Health Care Policy and Financing (the Department). Requests for paper claim submission may be sent to the fiscal agent, Xerox State Healthcare (Xerox), P.O. Box 30, Denver, CO 80201-0090. The following claims can be submitted on paper and processed for payment:
Claims from providers who consistently submit 5 claims or fewer per month (requires prior approval)
Claims that, by policy, require attachments
Reconsideration claims Paper claims do not require an NPI, but do require the Colorado Medical Assistance Program provider number.
In addition, the UB-04 Certification document must be completed and attached to all claims submitted on the paper UB-04. Electronically mandated claims submitted on paper are processed, denied, and marked with the message “Electronic Filing Required”.
Electronic Claims Instructions for completing and submitting electronic claims are available through the following:
X12N Technical Report 3 (TR3) for the 837P, 837I, or 837D
Companion Guides for the 837P, 837I, or 837D in the Provider Services Specifications section of the Department’s website.
Web Portal User Guide
The Colorado Medical Assistance Program collects electronic claim information interactively through the Colorado Medical Assistance Program Secure Web Portal (Web Portal) or via batch submission through a host system.
Interactive Claim Submission and Processing
Interactive claim submission through the Web Portal is a real-time exchange of information between the provider and the Colorado Medical Assistance Program.
Colorado Medical Assistance Program providers may create and transmit HIPAA compliant 837P (Professional), 837I (Institutional), and 837D (Dental) claims electronically one at a time. These claims are transmitted through the Colorado Medical Assistance Program Online Transaction Processor (OLTP).
The Colorado Medical Assistance Program OLTP reviews the claim information for compliance with Colorado Medical Assistance Program billing policy and returns a response to the provider's personal computer about that single transaction.
If the claim is rejected, the OLTP sends a rejection response that identifies the rejection reason. If the claim is accepted, the provider receives an acceptance message and the OLTP passes accepted claim information to the Colorado Medical Assistance Program claim processing system for final adjudication and reporting on the Colorado Medical Assistance Program Provider Claim Report (PCR).
The Web Portal contains online training, user guides and help that describe claim completion requirements, a mechanism that allows the user to create and maintain a database of frequently used information, edits that verify the format and validity of the entered information, and edits that assure that required fields are completed.
Because a claim submitter connects to the Web Portal through the Internet, there is no delay for “dialing up” when submitting claims. The Web Portal provides immediate feedback directly to the submitter.
All claims are processed to provide a weekly Health Care Claim Payment/Advice (Accredited Standards Committee [ASC] X12N 835) transaction and/or Provider Claim Report to providers. The Web Portal also provides access to reports and transactions generated from claims submitted via paper and through electronic data submission methods other than the Web Portal.
The reports and transactions include:
Accept/Reject Report
Provider Claim Report
Health Care Claim Payment/Advice (ASC X12N 835)
Managed Care Reports such as Primary Care Physician Rosters
Eligibility Inquiry (interactive and batch)
Claim Status Inquiry
Claims may be adjusted, edited and resubmitted, and voided in real time through the Web Portal.For help with claim submission via the Web Portal, please choose the User Guide option available for each Web Portal transaction.
For additional electronic billing information, please refer to the appropriate Companion Guide located in the Provider Services Specifications section of the Department’s Web site.
Batch Electronic Claim Submission
Batch billing refers to the electronic creation and transmission of several claims in a group. Batch billing systems usually extract information from an automated accounting or patient billing system to create a group of claim transactions.
Claims may be transmitted from the provider's office or sent through a billing vendor or clearinghouse. All batch claim submission software must be tested and approved by the Colorado Medical Assistance Program fiscal agent.
Any entity sending electronic claims to Xerox Electronic Data Interchange (EDI) Gateway for processing where reports and responses will be delivered must complete an EDI enrollment package.
This provides Xerox EDI Gateway the information necessary to assign a Logon Name, Logon ID, and Trading Partner ID, which are required to submit electronic claims.
You may obtain an EDI enrollment package by contacting the Medical Assistance Program fiscal agent or by downloading it from the Provider Services EDI Support section of the Department’s Web site.
The X12N 837 Professional, Institutional, or Dental transaction data will be submitted to the EDI Gateway, which validates submission of American National Standards Institute (ANSI) X12N format(s).
The TA1 Interchange Acknowledgement reports the syntactical analysis of the interchange header and trailer. If the data is corrupt or the trading partner relationship does not exist within the Medicaid Management Information System (MMIS), the interchange will reject and a TA1 along with the data will be forwarded to the Xerox State Healthcare Clearinghouse (SHCH) Technical Support for review and follow-up with the sender.
An X12N 999 Functional Acknowledgement is generated when a file that has passed the header and trailer check passes through the Xerox SHCH.
If the file contains syntactical error(s), the segment(s) and element(s) where the error(s) occurred will be reported. After validation, the Xerox SHCH will then return the X12N 835 Remittance Advice containing information related to payees, payers, dollar amount, and payments.
These X12N transactions will be returned to the Web Portal for retrieval by the trading partner, following the standard claims processing cycle.
Testing and Vendor Certification
Completion of the testing process must occur prior to submission of electronic batch claims to Xerox EDI Gateway. Assistance from Xerox EDI business analysts is available throughout this process.
Each test transmission is inspected thoroughly to ensure no formatting errors are present. Testing is conducted to verify the integrity of the format, not the integrity of the data; however, in order to simulate a production environment, EDI requests that providers send real transmission data.
The number of required test transmissions depends on the number of format errors on a transmission and the relative severity of these errors. Additional testing may be required in the future to verify any changes made to the MMIS system have not affected provider submissions.
Also, changes to the ANSI formats may require additional testing. In order to expedite testing, Xerox EDI Gateway requires providers to submit all X12N test transactions to EDIFECS prior to submitting them to Xerox EDI Gateway. The EDIFECS service is free to providers to certify X12N readiness. EDIFECS offers submission and rapid result turnaround 24 hours a day, 7 days a week.
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