Provider Support – Program Information

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 is distributing ACC ID cards to enrolled ACC members. ACC Members are directed 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.

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.

PCP Requirements for Participation

Primary Care Provider (PCP) Requirements To participate as a Primary Care Provider, a primary care provider must meet PCP eligibility requirements and sign two documents.

PCP Eligibility Requirements

Sign two agreements:

• 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.
• PCMP agreement with Colorado’s Department of Health Care Policy and Financing. Colorado Medicaid also has responses to inquiries from PCPs about this contract on this webpage.

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.

 

News

4/11/12 - Colorado Selected as a Demonstration Site for Comprehensive Primary Care Initiative (CPCI)