10 Colo. Code Regs. § 2505-10-8.200

Current through Register Vol. 47, No. 24, December 25, 2024

Section 10 CCR 2505-10-8.200 - PHYSICIAN SERVICES

8.200.1.ADEFINITIONS

1. Advanced Practice Nurse means a provider that meets the requirements to practice advanced practice nursing as defined in Article 38 of Title 12 of the Colorado Revised Statutes. In Colorado an Advanced Practice Nurse may have prescriptive authority.

2. Certified Family Planning Clinic means a family planning clinic certified by the Colorado Department of Public Health and Environment, accredited by a national family planning organization and staffed by medical professionals licensed to practice in the State of Colorado, including but not limited to, doctors of medicine, doctors of osteopathy, physicians' assistants, and advanced practice nurses.

3. Direct Supervision means the supervising provider shall be on-site during the rendering of services and immediately available to give assistance and direction throughout the performance of the service.

4. General Supervision means the supervising provider may not be on-site during the rendering of services, but is immediately available via telephonic or other electronic means to give assistance and direction throughout the performance of the service. Health Education Services means the provision of counseling, referral, instruction, suggestions, and support to maintain or improve health.

5. Licensed Psychologist means a provider that meets the requirements to practice psychology as defined in Part 3 of Article 43 of Title 12 of the Colorado Revised Statutes.

6. Medical Necessity is defined in Section 8.076.1.8.

8.200.2PROVIDERS

8.200.2.A. A doctor of medicine or a doctor of osteopathy may order and provide all medical care goods and services within the scope of their license that are covered benefits of the Colorado Medical Assistance Program.

1. A provider of covered dental care surgery may be enrolled as either a dentist or oral surgeon, but not as both. A dentist may order and provide covered dental care.

8.200.2.B. Physician services that may be provided by non-physician providers without a physician order.

1. Advanced Practice Nurses may provide and order covered goods and services in accordance with the scope of practice as described in the Colorado Department of Regulatory Agencies rules without a physician order.

2. Licensed Psychologists may provide and order covered mental health goods and services in accordance with the scope of practice as described in the Colorado Department of Regulatory Agencies rules without a physician order.

a. Services ordered by a Licensed Psychologist but rendered by a non-licensed mental health provider must be signed and dated by the Licensed Psychologist contemporaneously with the rendering of the service by a non-licensed mental health provider.

3. Optometrists may provide covered optometric goods and services within their scope of practice as described by the Colorado Department of Regulatory Agencies rules without a physician order.

4. Podiatrists may provide covered foot care services within their scope of practice as described by the Colorado Department of Regulatory Agencies rules without a physician order.

5. Licensed dental hygienists may provide unsupervised covered dental hygiene services in accordance with the scope of practice for dental hygienists as described in the Colorado Department of Regulatory Agencies rules without a physician order.

6. Licensed pharmacists may provide covered services, in accordance with the scope of practice for pharmacists as described by the Colorado Department of Regulatory Agencies rules, without a physician order.

8.200.2.C. Physician services that may be provided by a non-physician provider when ordered by a provider acting under the authority described in Sections 8.200.2.A. and 8.200.2.B.

1. Registered occupational therapists, licensed physical therapists, licensed audiologists, certified speech-language pathologists, and licensed physician assistants may provide services ordered by a physician.

a. Services must be rendered and supervised in accordance with the scope of practice for the non-physician provider described in the Colorado Department of Regulatory Agencies rules.

8.200.2.D. Physician services that may be provided by a non-physician provider when supervised by an enrolled provider.

1. With the exception of the non-physician providers described in Sections 8.200.2.A. through 8.200.2.C. and 8.200.2.D.1.a., a non-physician provider may provide covered goods and services only under the Direct Supervision of an enrolled provider who has the authority to supervise those services, according to the Colorado Department of Regulatory Agencies rules. If Colorado Department of Regulatory Agencies rules do not designate who has the authority to supervise, the non-physician provider must provide services under the Direct Supervision of an enrolled physician, with exception of doulas and Lactation Consultants (IBCLCs).

a. Registered Nurses (RNs) are authorized to provide delegated medical services within their scope of practice as described in the Colorado Department of Regulatory Agencies rules under General Supervision.

b. Non-physician providers are authorized to provide Health Education Services under General Supervision of a provider who has the authority to supervise them in accordance with Colorado Department of Regulatory Agencies rules.

c. Physical therapy assistants, occupational therapy assistants, and speech language pathology clinical fellows are authorized to provide services within their scope of practice, and under the General Supervision of an enrolled provider who has the authority to supervise them, in accordance with Colorado Department of Regulatory Agencies rules.

d. Speech language pathology assistants are authorized to provide services within their scope of practice only under the Direct Supervision of a licensed speech language pathologist who has the authority to supervise them, in accordance with Colorado Department of Regulatory Agencies rules.

8.200.2.E. Licensure and required certification for all physician services providers must be in accordance with their specific specialty practice act and with current state licensure statutes and regulations.

8.200.3BENEFITS

8.200.3.A Physician services are reimbursable when the services are a benefit of Medicaid and meet the criteria of Medical Necessity as defined in Section 8.076.1.8 and are provided by the appropriate provider specialty.

1. Physician services in dental care are a benefit when provided for surgery related to the jaw or any structure contiguous to the jaw or reduction of fraction of the jaw or facial bones. Service includes dental splints or other devices.

2. Outpatient mental health services are provided as described in Section 8.212.

3. Physical examinations are a benefit when they meet the following criteria:

a. Physical examinations are a benefit for preventive service, diagnosis and evaluation of disease or early and periodic screening, diagnosis and treatment for clients under the age of 21 as described in Section 8.280.

b. Physical examination as a preventive service for adults is a benefit limited to one per state fiscal year.

4. Physician services for the provision of immunizations are a benefit. Vaccines provided to enrolled children that are eligible for the Vaccines for Children program shall be obtained through the Colorado Department of Public Health and Environment. Immunization services are provided in accordance with Section 8.815.

5. Physician services for laboratory testing described in Section 8.660, are a benefit.

6. Occupational and physical therapy services are benefits.

7. Family planning services described in Section 8.730 are benefits.

8.200.3.B Physician services may be provided as telemedicine in accordance with Section 8.095.

8.200.3.C Services and goods generally excluded from coverage are identified in Section 8.011.11.

8.200.3.D Physician Services

Note: 8.200.3.D.1 Podiatry Services was moved to §8.810 01/2015.

2. Speech - Language and Hearing Services

a. ELIGIBLE PROVIDERS

i. Eligible providers include individual practitioners and those employed by home care agencies, children's developmental service agencies, health departments, federally qualified health centers (FQHC), clinics, or hospital outpatient services.

ii. Otolaryngologists, speech-language pathologists (speech therapists), and audiologists shall have a current and active license or registration and be current, active and unrestricted to practice.

iii. Providers shall be enrolled as a Health First Colorado provider in order to be eligible to bill for procedures, products and services in treating a Health First Colorado client.

iv. Rendering Providers include:

1. Otolaryngologist

2. Speech-language pathologist

3. Speech-language pathology assistant

4. Clinical fellows

5. Audiologist

b. PROVIDER AGENCY REQUIREMENTS

i. Providers of in-home health who employ therapists or audiologists shall apply for licensing through the Colorado Department of Public Health and Environment (CDPHE). (§ 25-27.5-103(1), C.R.S. and 6 CCR 1011-1, Chapter XXVI, Section 5.1) as a home care agency.

1. This rule does not apply to providers delivering Early Intervention Services under an Individual Family Service Plan (IFSP) and billing through contracts with the Community Centered Boards.

c. ELIGIBLE PLACES OF SERVICE

i. Eligible Places of Service shall include:

1. Office

2. Home

3. School

A. Therapies provided as part of a member's school requirement are not separately reimbursable. These services are paid for by the school district which is reimbursed by the Department. Providers may not submit claims for therapy services performed as part of a member's school requirement.

4. FQHC

5. Outpatient Hospital

6. Community Based Organization

7. Telemedicine in accordance with Section 8.095.

d. ELIGIBLE CLIENTS

i. Eligible Clients include enrolled clients ages twenty (20) and under and adult clients who qualify under medically necessary services. Qualifying adult clients may receive services for non-chronic conditions and acute illness and injuries.

e. COVERED SERVICES

i. Newborn Screening

1. Screening shall include a comprehensive health assessment performed soon after birth or as early as possible in a child's life and repeated at periodic intervals of time as recommended by the Colorado Early & Periodic Screening & Diagnostic and Treatment (EPSDT) periodicity schedules.

ii. Early Language Intervention

1. Early language intervention for children 0 through three with a hearing loss may be provided by audiologists, speech therapists, or Colorado Home Intervention Program (CHIP) providers.

iii. Audiology Services

1. Audiological benefits include identification, diagnostic evaluation and treatment for members 20 and under with hearing loss, neurologic, dizziness/vertigo, or balance disorders. Conditions treated may be either congenital or acquired.

2. Assessment - Service may include testing or clinical observation or both, as appropriate for chronological or developmental age, for one or more of the following areas, and must yield a written evaluation report.

a. Auditory sensitivity (including pure tone air and bone conduction, speech detection and speech reception thresholds).

b. Auditory discrimination in quiet and noise.

c. Impedance audiometry (tympanometry and acoustic reflex testing).

d. Hearing aid evaluation (amplification selection and verification).

e. Central auditory function.

f. Evoked otoacoustic emissions.

g. Brainstem auditory evoked response.

h. Assessment of functional communicative skills to enhance the activities of daily living.

i. Assessment for cochlear implants (for members age 20 and under).

j. Hearing screening.

k. Assessment of facial nerve function.

l. Assessment of balance function.

m. Evaluation of dizziness/vertigo.

3. Treatment - Service may include one or more of the following, as appropriate:

a. Auditory training.

b. Speech reading.

c. Augmentative and alternative communication training including training on how to use cochlear implants for members ages 20 and under. Adults with chronic conditions may qualify for augmentative and alternative communication services when justified and supported by medical necessity to allow the individual to achieve or maintain maximum functional communication for performance of Activities of Daily Living.

d. Purchase, maintenance, repairs and accessories for approved devices.

e. Selection, testing and fitting of hearing aids for members 20 and under with bilateral or unilateral hearing loss; and auditory training in the use of hearing aids.

f. Purchase and training on Department approved assistive technologies.

g. Balance or vestibular therapy.

iv. Cochlear Implants

1. Bilateral and unilateral cochlear implants are covered for members aged 20 years and under in accordance with Section 8.280. The following prior-authorization criteria must be met:

a. The proposed use of the device must be in accordance with FDA guidelines applicable to the member's age.

b. Bilateral and unilateral hearing loss with unaided pure tone average thresholds of 60 dB or greater.

c. Minimal speech perception may be measured using recorded standardized stimuli-speech discrimination scores of 50-60% or below with optimal amplification at 1000, 2000 and 4000 Hz.

d. Family support and motivation to participate in a post-cochlear aural, auditory and speech language rehabilitation program.

e. Assessment by an audiologist and otolaryngologist experienced in cochlear implants.

f. No medical contraindications.

g. Up-to-date-immunization status as determined by the Advisory Committee on Immunization Practices (ACIP).

h. Replacement of an existing cochlear implant for all ages is a benefit when the currently used internal or external component is no longer functioning and cannot be repaired. For members age 20 and younger, please see 8.280 for additional guidance.

v. Speech-language Services

1. Assessment - Service may include testing and/or clinical observation, as appropriate for chronological or developmental age, for one or more of the following areas, and must yield a written evaluation report:

a. Expressive language.

b. Receptive language.

c. Cognition.

d. Augmentative and alternative communication.

e. Voice disorder.

f. Resonance patterns.

g. Articulation/phonological development.

h. Pragmatic language.

i. Fluency.

j. Feeding and swallowing.

k. Hearing status based on pass/fail criteria.

l. Motor speech.

m. Aural rehabilitation (defined by provider's scope of practice.)

2. Treatment - Service may include one or more of the following, as appropriate:

a. Articulation/phonological therapy

b. Language therapy including expressive, receptive, and pragmatic language.

c. Augmentative and alternative communication therapy. Adults with chronic conditions may qualify for augmentative and alternative communication services when justified and supported by medical necessity to allow the individual to achieve or maintain maximum functional communication for performance of Activities of Daily Living

d. Auditory processing/discrimination therapy

e. Fluency therapy.

f. Voice therapy.

g. Oral motor therapy.

h. Swallowing therapy.

i. Speech reading.

j. Cognitive treatment.

k. Necessary supplies and equipment.

l. Aural rehabilitation (defined by provider's scope of practice)

f. DOCUMENTATION

i. General Requirements for Client's Record of Service:

1. Rendering providers shall document all evaluations, re-evaluations, services provided, client progress, attendance records, and discharge plans. All documentation must be kept in the client's records along with a copy of the referral or prescribing provider's order.

2. Documentation shall support both the medical necessity of services and the need for the level of skill provided.

3. Rendering providers shall copy the client's prescribing provider and medical home/primary care provider on all relevant records.

ii. Documentation shall include all of the following:

1. The client's name and date of birth.

2. The date and type of service provided to the client.

3. A description of each service provided during the encounter including procedure codes and time spent on each.

4. The total duration of the encounter.

5. The name(s) and title(s) of the person(s) providing each service and the name and title of the therapist supervising or directing the services.

iii. Documentation categories

1. Provider shall keep documentation for the following episodes of care: Initial Evaluation, Re-evaluation, Visit/Encounter Notes, and Discharge Summary.

2. Written documentation of the Initial Evaluation shall include the following:

a. The reason for the referral and reference source.

b. Diagnoses pertinent to the reason for referral, including:

i. Date of onset;

ii. Any cognitive, emotional, or physical loss necessitating referral, and the date of onset, if different from the onset of the relevant diagnoses;

iii. Current functional limitation or disability as a result of the above loss, and the onset of the disability;

iv. Pre-morbid functional status, including any pre-existing loss or disabilities;

v. Review of available test results;

vi. Review of previous therapies/interventions for the presenting diagnoses, and the functional changes (or lack thereof) as a result of previous therapies or interventions.

c. Assessment: Include a summary of the client's impairments, and functional limitations and disabilities, based on a synthesis of all findings gathered from the evaluation. Highlight pertinent factors which influence the treatment diagnosis and prognosis, and discuss the inter-relationship between the diagnoses and disabilities for which the referral was made must be discussed.

d. Plan of Care: A detailed Plan of Care must include the following

i. Specific treatment goals for the entire episode of care which are functionally-based and objectively measured.

e. Proposed interventions/treatments to be provided during the episode of care.

f. Proposed duration and frequency of each service to be provided.

g. Estimated duration of episode of care.

7. The therapist's Plan of Care must be reviewed, revised if necessary, and signed, as medically necessary by the client's physician, or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law at least once every 90 days. The Plan of Care must not cover more than a 90-day period or the time frame documented in the Individual Family Service Plan (IFSP). (27-10.5-702(7), C.R.S. (2017) states the IFSP "shall qualify as meeting the standard for medically necessary services." Therefore no physician is required to sign a work order for the IFSP.)

8. A Plan of Care must be certified. Certification is the physician's, physician's assistant or nurse practitioner's approval of the Plan of Care. Certification requires a dated signature on the Plan of Care or some other document that indicates approval of the Plan of Care. If the service is a Medicare covered service and is provided to a recipient who is eligible for Medicare, the Plan of Care must be reviewed at the intervals required by Medicare.

9. Re-evaluation. A re-evaluation must be done whenever there is an unanticipated change in the client's status, a failure to respond to interventions as expected or there is a need for a new Plan of Care based on new problems and goals that require significant changes to the Plan of Care. The documentation for a re-evaluation need not be as comprehensive as the initial evaluation, but must include at least the following: Reason for re-evaluation; client's health and functional status reflecting any changes; findings from any repeated or new examination elements; and, changes to Plan of Care.

iv. Visit/Encounter Notes

1. Written documentation of each encounter must be in the client's record of service. These visit notes document the implementation of the Plan of Care established by the therapist at the initial evaluation. Each visit note must include the following:

a. The total duration of the encounter.

b. The type and scope of treatment provided, including procedure codes and modifiers used.

c. The time spent providing each service. The number of units billed/requested must match the documentation.

d. Identification of the short or long term goals being addressed during the encounter.

2. In addition to the above required information, the visit note must include the following elements:

a. A subjective element which includes the reason for the visit, the client or caregiver's report of current status relative to treatment goals, and any changes in client's status since the last visit;

b. An objective element which includes the practitioner's findings, including abnormal and pertinent normal findings from any procedures or tests performed;

c. An assessment component which includes the practitioner's assessment of the client's response to interventions provided, specific progress made toward treatment goals, and any factors affecting the intervention or progression of goals; and d. A plan component which states the plan for next visit(s).

v. Discharge Summary

1. At the conclusion of therapy services, a discharge summary must be included in the documentation of the final visit in an episode of care. This may include the following:

a. Highlights of a client's progress or lack of progress towards treatment goals.

b. Summary of the outcome of services provided during the episode of care.

g. NON-COVERED SERVICES AND GENERAL LIMITATIONS

i. Health First Colorado does not cover items and services which generally enhance the personal comfort of the eligible person but are not necessary in the diagnosis of, do not contribute meaningfully to the treatment of an illness or injury, or the functioning of a malformed body member.

ii. Maintenance programs beginning when the therapeutic goals of a treatment plan have been achieved and no further functional progress is apparent or expected to occur, are not covered for adult clients.

iii. Services provided without a written referral from a physician or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law are not covered, unless they are covered by an IFSP.

iv. Treatment of speech and language delays not associated with an acquired or chronic medical condition, neurological disorder, acute illness, injury, or congenital defect are not covered, unless they are covered by an IFSP.

v. Any service that is not determined by the provider to be medically necessary according to the definition of medical necessity in Section 8.076.1.8.

vi. Hearing aids for adults are not a covered service.

vii. Hearing exams and evaluations are a benefit for adults only when a concurrent medical condition exists.

viii. Initial placement of cochlear implants for adults is not covered.

ix. The upgrading of a cochlear implant system or component (e.g., upgrading processor from body worn to behind the ear, upgrading from single to multi-channel electrodes) of an existing properly functioning cochlear implant is not covered.

x. Services not documented in the client's Plan of Care are not covered.

xi. Services specified in a plan of care that is not reviewed and revised as medically necessary by the client's attending physician or by an IFSP are not covered.

xii. Services that are not designed to improve or maintain the functional status of a recipient with a physical loss or a cognitive or psychological deficit are not covered.

xiii. A rehabilitative and therapeutic service that is denied Medicare payment because of the provider's failure to comply with Medicare requirements is not covered.

xiv. Vocational or educational services, including functional evaluations, except as provided under IEP-related services are not covered.

xv. Services provided by unsupervised therapy assistants as defined by the American Speech-Language Hearing Association (ASHA) are not covered.

xvi. Treatment for dysfunction that is self-correcting (for example, natural dysfluency or developmental articulation errors) is not covered.

xvii. Psychosocial services are not covered.

xviii. Costs associated with record keeping documentation and travel time are not covered.

xix. Training or consultation provided by an audiologist to an agency, facility, or other institution is not covered.

xx. Therapy that replicates services that are provided concurrently by another type of therapy is not covered. Particularly, occupational therapy which should provide different treatment goals, plans, and therapeutic modalities from speech therapy.

8.200.4CERTIFIED FAMILY PLANNING CLINICS

8.200.4.A Laboratories at Certified Family Planning Clinics providing services must meet all Clinical Laboratory Improvement Amendment requirements.

8.200.4.B Services at a Certified Family Planning Clinic shall be rendered under the General Supervision of a physician. General Supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.

8.200.4.C The Certified Family Planning Clinic shall contact the client's Primary Care Provider or Primary Care Medical Provider or managed care organization, if applicable, prior to rendering services that require a referral.

8.200.5REIMBURSEMENT

8.200.5.A The amount of reimbursement for physician services is the lower of the following:

1. Submitted charges; or

2. Fee schedule as determined by the Department of Health Care Policy and Financing which may be a manual pricing.

8.200.5.B Reimbursement for services may be made directly to Advanced Practice Nurses, registered occupational therapists, licensed physical therapists, licensed audiologists, certified speech-language pathologists, and licensed psychologists unless the non-physician practitioner is acting within the scope of his/her contract with a physician or public or private institution or employment as a salaried employee of a physician or public or private institution.

8.200.5.C Dental hygienists may be directly reimbursed for unsupervised dental hygiene services.

a. Hygienists employed by a dentist, clinic, or institution shall submit claims under the employer's provider identification number.

8.200.5.D The amount of reimbursement for Certified Family Planning Clinic services may be paid directly to the clinic and is the lower of the following:

1. Submitted charges; or

2. Fee schedule as determined by the Department of Health Care Policy and Financing which may be a manual pricing.

8.200.5.E A provider shall not be reimbursed directly for services if the provider is acting as a contract agent or employee of a nursing home, hospital, Federally Qualified Health Center, Rural Health Center, clinic, home health agency, school, or physician.

8.200.5.F A provider shall not be reimbursed for services as a billing provider if the provider is a student in a graduate education program and the facility where the provider delivers services receives Graduate Medical Education payments pursuant to Colorado Revised Statutes Section 25.5-4-402.5 or 10 C.C.R. 2505-10, Sections 8.300.7.

8.200.6INCREASED MEDICAL PAYMENTS TO PRIMARY CARE PHYSICIANS PROGRAM

The Increased Medical Payments to Primary Care Physicians Program provides reimbursement above the fee schedule to defined and attested primary care physicians for certain services provided in calendar years 2013 and 2014.

8.200.6.A Authority

This rule is made pursuant to title 42 of the Code of Federal Regulations, Section 438.6, Section 438.804, Part 441 Subpart L, and Part 447 Subpart G (2012).

8.200.6.B Definitions

1. Primary Care Physician means a medical doctor who attests to the Department that he or she has a primary specialty designation of family medicine, general internal medicine, or pediatric medicine or a subspecialty recognized by the American Board of Medical Specialties, the American Board of Physician Specialties, or the American Osteopathic Association.

2. Personal Supervision means the physician accepts professional responsibility and legal liability for the services provided by the non-physician provider. Personal Supervision does not require physical presence at the location of the services.

8.200.6.C Attestation

1. A Primary Care Physician is required to self-identify, using the form available on the www.colorado.gov/hcpf, provider's web page, to a specialty designation of family medicine, general internal medicine or pediatric medicine or a subspecialty recognized by the American Board of Medical Specialties, the American Board of Physician Specialties or the American Osteopathic Association. A physician must self-attest that he/she:

a. Is Board certified with such a specialty or subspecialty; and/or

b. Has furnished evaluation and management services and vaccine administration services under codes described in 8.200.6.E that equal at least 60 percent of the Medicaid codes he or she has billed during the most recently completed calendar year or, for newly eligible physicians, the prior month.

8.200.6.D Reimbursable Services

1. Primary care services with procedure codes listed in 8.200.6.E provided by a Primary Care Physician, as defined in 8.200.6.B.1, are eligible for increased reimbursement.

2. Primary care services with procedure codes listed in 8.200.6.E provided by a Physician Assistant or Advanced Nurse Practitioner under the personal supervision of a Primary Care Physician, as defined in 8.200.6.B.1, are eligible for increased reimbursement.

a. For this program, when services by a non-physician provider are provided under the personal supervision of a physician, the physician may be identified as the rendering provider on claims.

8.200.6.E Procedure Codes

The procedure codes covered by the Colorado Medical Assistance program designated in the Healthcare Common Procedure Coding System (HCPCS) for increased reimbursement shall be 99201-99499 and Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474.

8.200.6.F Supplemental Payment Procedure

1. Supplemental payments to eligible providers are calculated in the manner defined in 42 C.F.R. part 447.405 and identified in the schedule of maximum payments published on the website of the Department of Health Care Policy and Financing. Title 42 of the Code of Federal Regulations, Part 447.405 (2012) is hereby incorporated by reference into this rule. Such incorporation, however, excludes later amendments to or additions of the referenced material. These regulations are available for public inspection at the Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203.

2. Supplemental payments will be made on a quarterly basis.

3. The initial supplemental payment will be made after approval of the State Plan Amendment approving the increase.

8.200.6.G Audits

1. Eligible providers shall maintain all increased payment to primary care provider program-related records including documentation to support attestations.

2. Eligible providers shall permit the Department, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency:

a. To audit, inspect, examine, excerpt, copy and/or transcribe the records related to this incentive program, to assure compliance with the program requirements, Corrective Action Plans and attestations.

b. To access the provider's premises, to inspect and monitor, at all reasonable times, the provider's compliance with program requirements, Corrective Action Plans and attestations. Monitoring includes, but is not limited to, internal evaluation procedures, examination of program data, special analyses, on-site checking, observation of employee procedures and use of electronic health information systems, formal audit examinations, or any other procedure.

3. Eligible providers shall cooperate with the State, the federal government, the Medicaid Fraud Control Unit and any other duly authorized agent of a governmental agency seeking to audit a provider's compliance with program requirements.

4. The Department may recoup by offset from any payment due to the provider any supplemental payment made to the provider for services rendered during the period that the provider did not meet the requirements for attestation in 8.200.6.C or does not have documentation supporting the required attestation. The Department may recoup by offset any improper or overpaid medical services paid to or on behalf of an eligible provider.

8.200.6.H Informal Reconsideration and Appeal

1. A provider may request an informal reconsideration of his or her exclusion from participation in the Increased Medical Payments to Primary Care Providers Program by submitting a written request within 30 days of date of notice that the provider is not eligible to participate in the program.

2. A provider may request an informal reconsideration of the supplemental payment amount by submitting a written request within 30 days of the receipt of the supplemental payment.

3. The Department shall respond to the request for informal reconsideration with a decision no later than 45 days after receipt of the request.

4. A provider dissatisfied with the Department's decision may appeal the informal reconsideration decision according to the procedures set forth in 10 C.C.R. 2505-10 Section 8.050.3 PROVIDER APPEALS.

8.200.7PROSPECTIVE MEDICAL PAYMENTS TO PRIMARY CARE MEDICAL PROVIDERS

8.200.7.A Definitions

1. APM code set refers to a set of Evaluation and Management (E&M) codes that are defined by the Department and included on the Department's Primary Care Alternative Payment Model Fee Schedule (https://www.colorado.gov/pacific/hcpf/provider-rates-fee-schedule)

2. Gain sharing refers to upside only shared savings, where a participating PCMP can earn additional reimbursement for meeting metrics/thresholds that are defined by the Department.

3. Primary Care Medical Provider (PCMP) refers to an individual physician, advanced practice nurse or physician assistant, who participates in the Accountable Care Collaborative (ACC) as a Network Provider, with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology.

4. Prospective Payments refer to monthly payments made at the beginning of each month that are intended to cover primary care services for a PCMP's attributed members.

5. Reconciliation refers to a process established by the Department to correct under- or overpayment for services rendered in the APM code set.

8.200.7.B Eligibility for Participation

1. Primary Care Medical Providers (PCMPs) enrolled in the ACC.

2. PCMPs must exceed a mathematical standard which is determined by the Department's actuary and this standard will be communicated to interested participants before the program starts.

3. This payment methodology is voluntary and PCMPs must elect to participate. The Department will send a letter to confirm a PCMP's intent to join the program. The PCMP then has 10 business days from the date of receipt of the letter to confirm or deny participation.

8.200.7.C Prospective Per Member Per Month (PMPM) Payments

1. PCMPs will earn monthly prospective payments for services in the APM code set

a. The prospective PMPM payments will be PCMP specific.

b. The PCMP will elect what percentage of their revenue for primary care services they will earn as a prospective PMPM payment.

i. The amount of PMPM payment a PCMP will receive will be indicated in the letter sent by the Department to confirm participation in the program.

c. PCMPs will earn the rest of their revenue from reduced fee for service in the corresponding percentage for the APM code set.

i. The percentage reduction for the services included in the APM code set received, will be indicated in the letter sent by the Department to confirm participation in the program.

8.200.7.D Gainsharing

1. PCMPs will be eligible to earn extra revenue for participating in gainsharing.

a. Gainsharing thresholds will be specific to each PCMP.

b. The Department will publish thresholds for gainsharing that show the targets PCMPs must meet to be eligible to receive extra payments. Services that comprise the targets will also be published.

i. PCMPs will agree to the thresholds and services for gainsharing in the letter sent by the Department which confirms participation in the program.

2. The PCMP may contest the Department's determination of the gainsharing payments. PCMPs who contest the Department's determination must first submit in writing to the Department the reason for contesting the determination within 60 days of receiving the gainsharing payment. The Department will review all contested determinations within 30 calendar days of receipt of the notice and will respond to the PCMP with its final decision. If the PCMP does not agree with the Department's final decision, the PCMP has the right to file an appeal with the Office of Administrative Courts in accordance with Section 8.050.3.

8.200.7.E Reconciliation

1. A PCMP will be responsible for meeting quality minimums that are established and accepted by the PCMP in the letter sent by the Department which confirms participation in the program. The quality minimums must be met for a PCMP to earn their full prospective PMPM payments.

a. If the PCMP exceeds the quality minimums then they will not be subject to reconciliation.

b. If the PCMP does not meet quality minimums then the Department will reduce the PMPM payment to equal the corresponding amount which would have been earned had the PCMP been reimbursed the fee schedule payment.

2. Appeals Process for Prospective PMPM Payments

a. The PCMP may contest the Department's determination for reconciliation of prospective PMPM payments. PCMPs who contest the Department's determination must submit in writing to the Department the reason for contesting the determination within 60 days of receiving the notice of reconciliation of prospective PMPM payments. The Department will review all contested determinations within 30 calendar days of receipt of the notice and will respond to the PCMP with its final decision. If the PCMP does not agree with the Department's final decision, the PCMP has the right to file an appeal with the Office of Administrative Courts in accordance with Section 8.050.3.

8.200.7.F Withdrawal from Program Participation

1. A PCMP may choose to voluntarily withdraw from the program at any time so long as proper notification is given to the Department.

a. A PCMP must give 30 days written notice to the Department to be withdrawn from the program. The PCMP will be withdrawn from the program on the first day of the month following the end of the 30 day notice period.

b. If a PCMP chooses to voluntarily withdraw from the program before the end of the program year, the PMPM and gainsharing payments will be prorated to reflect months of participation in the program.

2. A PCMP may involuntarily be withdrawn from the program in the event the PCMP is terminated as a Medicaid provider and the PCMP will not be eligible to contest the determination. Involuntary withdrawal on this basis will be effective immediately. The Department will notify the PCMP in writing within 10 business days if this occurs.

3. The Department reserves the right to terminate the participation of a PCMP in the program at any time without cause. The Department will notify the PCMP of their termination in writing within 10 business days and the termination will become effective the first day of the month following 30 days of the notice. (Add not appealable)

10 CCR 2505-10-8.200

44 CR 11, June 10, 2021, effective 6/30/2021

46 CR 11, June 10, 2023, effective 6/30/2023

47 CR 01, January 10, 2024, effective 1/30/2024

47 CR 11, June 10, 2024, effective 5/10/2024, exp. 9/7/2024 (Emergency)

47 CR 17, September 10, 2024, effective 9/30/2024

47 CR 21, November 10, 2024, effective 11/30/2024