Provider Support – Program Information
News and Updates
7/1/13 - New Key Performance Indicator: Well Child Visits
Since 2011, as part of the Accountable Care Collaborative (ACC) Program, Colorado Medicaid Regional Care Collaborative Organizations (RCCOs) and Primary Care Medical Providers (PCMPs) have had the opportunity to earn incentive payments based on three (3) Key Performance Indicators (KPIs):
- 30-day all-cause inpatient hospital readmissions
- Emergency Room (ER) visits
- High-cost imaging
Effective July 1, 2013 HCPF began measuring a fourth KPI, Well Child Visits, based on CMS-416 criteria. Beginning in early 2014, HCPF will begin to provide financial incentive payments to RCCOs and PCMPs for this KPI.
7/1/13 - Primary Care Medical Provider (PCMP) Agreement with the Department of Healthcare Policy and Financing Can be Completed Online
Effective immediately, providers can complete a Primary Care Medical Provider (PCMP) contract for the ACC Program through the Colorado Medical Assistance Program Web Portal. Please view the contracting instructions.
4/18/13 - The Colorado Beacon Consortium: Strengthening the Capacity for Health Care Delivery Transformation in Rural Communities - a case study by The Commonwealth Fund
6/29/12 - CMS Comprehensive Primary Care (CPC) Initiative Update from Rocky Mountain Health Plans
Download news release (PDF, 52.5 KB)
6/15/12 - CMS Comprehensive Primary Care (CPC) Initiative Application is Available Now!
Download news release (PDF, 63.4 KB)
4/11/12 - Colorado Selected as a Demonstration Site for Comprehensive Primary Care (CPC) Initiative
Download news release (PDF, 353 KB)
Important Operational Aspects about the Accountable Care Collaborative
Role of Medical Providers in the Accountable Care Collaborative
- Provide access to medically necessary health and medical care
- Work to support the creation of a medical neighborhood
- Participate at a community level to improve health outcomes
Verifying Member ACC Enrollment
Colorado Medicaid’s web portal will identify if the Medicaid client is enrolled in the ACC Program. The State’s web portal will also show the Member’s Regional Care Collaborative Organization (RMHP for Region 1). RMHP providers who are familiar with RMHP’s provider portal may also access the State’s Medicaid web portal through RMHP’s provider portal.
To help providers identify Medicaid patients who are in the ACC Program, RMHP began distributing ACC ID cards to enrolled ACC members in fall 2013. ACC Members are encouraged to show their RMHP ACC ID card AND their Medicaid ID card when they get care. The ACC ID card includes contact information and the member’s PCP.
An eligibility verification resource table is available to identify additional ways to check Member eligibility.
Claims and Provider Reimbursement
RMHP as an RCCO does NOT pay claims. All claims for ACC Members will be paid directly by the State of Colorado, or the local Behavioral Health Organization, in the same way that Medicaid claims are currently paid for Medicaid fee-for-service clients. Pharmacists should also continue to submit claims to Colorado Medicaid following all Colorado Medicaid requirements.
Regular Medicaid fees will be paid by Colorado Medicaid at Colorado Medicaid rates to all providers. Behavioral health providers should continue to submit claims to the Behavioral Health Organization. During the first year, participating Primary Care Providers will be paid a $4 per member per month (pmpm) by the Department of Health Care Policy and Financing. Providers that are certified as a Children’s Medical Home will not receive the $4 pmpm rate for assigned children, but will continue to receive the enhanced payment for EPSDT services rendered. If a certified Children’s Medical Home provider sees children and adults, they will receive the $4 pmpm payment for their assigned adult patients.
How do I submit claims?
The Medicaid claims submission process for the ACC Program is the same as the current Medicaid claims submission process. Providers should consult the Colorado Medicaid Provider Billing Manuals on the Department’s website for detailed information regarding claims submissions.
Prior Authorizations and Referral Requirements
RMHP as RCCO does not administer Medical Authorizations
Medical Authorizations will be reviewed and processed in the same way that Medical authorizations are administered today through Colorado Medicaid or a Medicaid-contracted vendor.
Information to Providers about PCP Referral Requirements
Colorado’s Department of Health Care Policy and Financing (the Department) has established Primary Care Provider (PCP) referral requirements. This includes PCPs referring patients to specialists when medically necessary, and PCPs providing their Medicaid Billing ID number to the specialist to ensure claims payment. Non-PCPs must have the assigned PCP Medicaid Billing ID number on the claim or the claim may not be paid.
PCP Referral Requirements
Participating Primary Care Providers (PCPs) are responsible for performing as a medical home. This includes providing appropriate preventive care, serving as a guide for patients when making decisions on the need of specialty care, and helping avoid unnecessary medical expenses.
PCPs should refer assigned Members to any other specialist or Medicaid provider, if the PCP determines that such a referral is appropriate to that Member’s care. When referring assigned Members to specialty care, the assigned PCP should provide his/her Medicaid Billing Provider ID and the reason for the referral. The assigned PCP’s Medicaid Billing Provider ID is included on the Member’s RMHP ACC ID card.
PCPs should refer their assigned Members to specialty care as appropriate, providing the referring PCP’s Medicaid billing provider identification number and communicating the reason for the referral. PCPs may refer Members to any specialists enrolled in Medicaid, or any other Medicaid provider, including those not associated with RMHP or another Regional Care Collaborative Organization. PCPs are not required to provide a referral when a Member receives any of the following services:
- Emergency Care
- Early and Periodic Screening, Diagnosis, and Treatment (ESPDT) Screenings
- Emergency and non-emergent medical transportation
- Anesthesiology services
- Dental services
- Vision services
- Family planning services
- Behavioral health services
- Obstetrical services and
- Home and Community-Based Waiver services covered by Colorado Medicaid
For Hospital Facilities
Notify us if a member is hospitalized.
Requirements for Participation as a Primary Care Medical Provider
Primary Care Medical Provider (PCMP) Requirements
In order to participate as a Primary Care Medical Provider, you must be an enrolled Medicaid provider that meets any one of these criteria:
- Certified by the Department as a provider in the Medicaid and CHP+ Medical Homes for Children program; OR
- A Federally Qualified Health Center (FQHC), Rural Health Clinic
(RHC) or a clinic or other group practice with a focus on primary care,
general practice, internal medicine, pediatrics, geriatrics, or
obstetrics and gynecology; OR
- An individual physician, advanced practice nurse or physician
assistant with a focus on primary care, general practice, internal
medicine, pediatrics, geriatrics, or obstetrics and gynecology
The PCMP must sign two documents:
- A written agreement between the Primary Care Medical Provider and a Regional Care Collaborative Organization (RCCO). The RCCO for Region 1 is Rocky Mountain Health Plans. Call RMHP for a copy of the Accountable Care Collaborative Program PCMP agreement with Rocky Mountain Health Plans.
- A written agreement between the Primary Care Medical Provider and the State of Colorado. Effective August 2013, the State version of the PCMP agreement can be completed online. Please read and follow the step by step PCMP Online Contract Instructions.
All other medical providers only need to be a Colorado Medicaid provider to participate. Please contact RMHP to verify that your name, specialty and contact information is correct.