Claim Types and Submission Methods
What is required for batch claim submission?
Enrollment as an EDI trading partner with a TPID.
What is prior authorization and when should it be submitted?
Prior authorization is the process where a health care provider must obtain approval before certain services are delivered in order for the service to be considered for payment. If required, the PA must be approved before a claim can be submitted.
What is an ATN?
Application Tracking Number used to track enrollment, maintenance, or revalidation requests.
What is the difference between an appeal and a reconsideration?
An appeal is a legal court‑based process; a reconsideration is correcting and resubmitting a claim.
What information is included on an RA?
Claim status, adjustments, amounts paid/not paid, policy changes, Department alerts.
Which providers do NOT submit claims through the Provider Web Portal?
Dental providers and pharmacy providers, who use DentaQuest and Prime Therapeutics portals.
What portal is used for medical prior authorization requests (PARs)?
You should direct the provider to the Acentra (Atrezzo) Provider Portal, which is used to submit and track covered medical PARs under ColoradoPAR.
How often must providers revalidate enrollment?
Every five years.
When should cases be routed to management?
When policy review, timely filing overrides, or unresolved denials are involved.
What is a recoupment?
Recovery of money previously paid due to overpayment or correction.
What is required before a provider can submit paper claims?
Approval using the Request to Submit Paper Claims form, and submission of no more than five claims per month.
Who receives PA approval or denial notices?
Notifications are sent to:
How are providers notified of revalidation approval or denial?
By email and Provider Web Portal status.
What is the primary goal before escalation to appeal?
Resolve the claim through correction and resubmission.
What type of files do trading partners submit?
X12 transaction files.
What region code generally indicates a web‑submitted claim?
Region codes beginning with 22 or 23.
A provider from an outpatient hospital calls to ask whether a hospital specialty drug requires prior authorization and where the PA request form should be sent.
Which resource should you use to assist them?
Appendix Z – Hospital Specialty Drugs
What happens if provider data does not match federal records?
Enrollment may be returned to provider (RTP).
Why should agents review ICN history before escalation?
Prior adjustments may already address the issue.
How are DRG payments calculated and where can you find DRG information in interChange?
DRG payments are based on diagnosis-related groups and severity of illness; DRG information is found under the DRG tab in interChange.
What are the two main types of claims, and how do they differ?
The two main types are professional claims (filed by individual providers for services rendered) and institutional claims (filed by facilities such as hospitals or nursing homes for services provided at their location).
A provider asks if a specific procedure code requires prior authorization.
What resources should you use, or guide providers to, that can help answer this inquiry?
You should guide them to:
List and define 5 of the statuses associated with ATNs.
C – Returned to Provider for Additional Information
D – Denied
F – Provider Enrollment Approved
H – Site Survey
I – Incomplete
J – State Review
L – Under Review
M – Additional Review
U – FCBS Review
X – Screening Review
Z – QA Review
What information is required for the Timely Filing Waiver?
ICNs, DOS, and a timeline of events.
What is the purpose of EAPG weight tables and where can they be accessed?
EAPG weight tables are used to reimburse hospitals for outpatient services based on resource utilization; they can be accessed on the Department website under Outpatient Hospital Payment.