10 Colo. Code Regs. § 2505-10-8.064

Current through Register Vol. 47, No. 4, February 25, 2024
Section 10 CCR 2505-10-8.064 - DATA PROVISION AND CLAIMS REQUIREMENTS
8.064.1DATA PROVISION FROM THIRD PARTIES
8.064.1.A. All third parties, as a condition of doing business in the state, shall provide on a monthly basis, and within 60 days of request, to the Department or its Business Associate or designee, including Medicaid MCO plans, an electronic file from the third party's database containing eligibility records of all persons covered by the third party containing the minimum necessary data elements to enable the Department or its Business Associate or designee to achieve a satisfactory data match. The Department or its Business Associate or designee has the right, in their sole discretion, to request additional data from any third party if the file provided does not result in a satisfactory data match that enables the Department or its Business Associate to determine which persons are dually eligible for medical assistance and the coverage provided by the third party necessary to prepare HIPAA compliant bills and for the purpose of cost avoidance. Such request will be cumulative and the third party will be required to submit monthly eligibility records with all requested data elements.
8.064.1.B Third parties are encouraged to work with the Department or its Business Associate or designee to enter into Data Use Agreements on a case by case basis. Execution of a Data Use Agreement with the Department or its Business Associate shall satisfy the Minimum Necessary requirement.
8.064.1.C. "Satisfactory Data Match" means obtaining results from the data match that enable the Department to achieve cost avoidance and that will provide medical providers with adequate information to bill the third party and have their claims adjudicated without request for further information from the third party and that enables the Department or its Business Associate or designee to bill previously paid claims to the third party resulting in proper adjudication without requests for further information from the third party to proceed with adjudication.
8.064.1.D. "Third Party" means a health insurer, self-insured plan, group health plan as defined in 29 U.S.C. Sec 1167(1), service benefit plan, managed care organization, pharmacy benefit manager, or other party, that is by statute, contract, or agreement legally responsible for payment of a claim for a health care item or service, such as third party administrators.
8.064.1.E. "Minimum Necessary" is defined as those data elements necessary to achieve a satisfactory match, and includes, but is not limited to the following:
1. First name, Middle initial, and Last name;
2. Date of Birth;
3. Sex code (M or F);
4. Social Security number or policy number if a crosswalk to actual social security numbers is provided contemporaneously, or the last 4 digits of the SSN;
5. Policy and Group number;
6. Group Name/Employer Name;
7. Begin and end dates of coverage;
8. Coverage types provided to each member and dependent;
9. Pharmacy Indicator and PBM information including a crosswalk to PBMs if multiple PBMs;
10. Subscriber Full address;
11. Dependent(s) First name, Middle Initial, and Last name;
12. Dependent(s) DOB;
13. Dependent(s) SSN or last 4 digits of SSN;
14. Dependent(s) Sex Code.
8.064.1.F. "Business Associate" shall have the same meaning as provided in 45 CFR 160.103.
8.064.1.G. Third parties shall accept and respond to inquiries and contact, either in writing or telephonically for verification purposes or otherwise, regarding members and coverage from the Department or its Business Associate or its designee including the provision of applicable NPI numbers.
8.064.2CLAIMS REQUIREMENT
8.064.2.A. Third parties shall accept the Department's right of recovery and assignment of benefits from any individual or entity to the extent that such item or service is covered by the third party.
8.064.2.B. Claims shall not be denied for lack of preauthorization.
8.064.2.C. Claims shall not be denied for the type of format of the claim form.
8.064.2.D. Claims shall not be denied for a failure to present proper documentation at the point-of-sale that is the basis for the claim if the claim is presented within three years of the date that the item or service is furnished, and any action by the Department to enforce its right is commenced within six years after the Department's submission of the claim.
8.064.2.E. Third parties are required to accept and adjudicate claims submitted by the Department or its Business Associate and it is the duty of the third party to inform its clients that they intend to accept and adjudicate claims with or without specific authorization from its clients.

10 CCR 2505-10-8.064