10 Colo. Code Regs. § 2505-10-8.509
Current through Register Vol. 47, No. 24, December 25, 2024
Section 10 CCR 2505-10-8.509 - HOME AND COMMUNITY-BASED SERVICES FOR COMMUNITY MENTAL HEALTH SUPPORTS (HCBS-CMHS)8.509.18STATE PRIOR AUTHORIZATION OF SERVICESA. Upon receipt of the Prior Authorization Request (PAR), as described at Section 8.509.31, the state or its agent shall review the PAR to determine whether it is in compliance with all applicable regulations, and whether services requested are consistent with the Client's documented medical condition and functional capacity, and are reasonable in amount, frequency, and duration. Within ten (10) working days the State or its agent shall: 1.Approve the PAR and forward signed copies of the prior authorization form to the case management agency, when all requirements are met;2.Return the PAR to the case management agency, whenever the PAR is incomplete, illegible, unclear, or incorrect; or if services requested are not adequately justified;3.Disapprove the PAR when all requirements are not met Services shall be disapproved that are duplicative of other services that the Client is receiving or services for which the Client is receiving funds to purchase Services shall also be disapproved if all services, regardless of funding source, total more than twenty-four hours per day care.B. When services are disapproved, in whole or in part the Department or its agent shall notify the case management agency. The case management agency shall notify the Client of the adverse action and the appeal rights on a state-prescribed form, according to Section 8.057, et seq.C. Revisions received by the Department or its agent six (6) months or more after the end date shall always be disapproved.D. Approval of the PAR by the Department or its agent shall authorize providers of services under the case plan to submit claims to the fiscal agent and to receive payment for authorized services provided during the period of time covered by the PAR. Payment is also conditional upon the Client's financial eligibility for long-term care medical assistance (Medicaid) on the dates of service; and upon providers' use of correct billing procedures.8.509.20CASE MANAGEMENT AGENCIESA. The requirement at Section 8.390 et. seq. shall apply to the case management agencies performing the case management functions of the HCBS-CMHS program.46 CR 13, July 10, 2023, effective 7/30/202346 CR 17, September 10, 2023, effective 9/30/202346 CR 21, November 10, 2023, effective 11/30/202347 CR 16, August 25, 2024, effective 9/14/202447 CR 21, November 10, 2024, effective 11/30/2024