Claims Basics
Where can you find instructions, forms, and resources to help with claim submission and troubleshooting for Health First Colorado?
On the Department website, specifically under the For Our Providers page.
What steps should you follow to authenticate a provider when using interChange for claims inquiries?
Confirm the provider’s National Provider ID (NPI), Health First Colorado ID (Medicare Coverage Database ID), and active contract.
What details can you find in the Payment History applet in Salesforce?
You can view payment issue date, payment ID, payment amount, payment method, and RA number.
What is a Trading Partner ID (TPID), and who needs to obtain one?
TPID is a unique identifier for trading partners (clearinghouses or billing agents) who submit or receive batch files via EDI. Providers using batch submissions need a TPID.
What information is included on a Remittance Advice (RA)?
Claim status, adjustments, amounts paid/not paid, policy changes, Department alerts.
What are the three most common ways claims are submitted to Health First Colorado?
Paper, batch (EDI), and Provider Web Portal.
How can you determine the status of a claim (Pay, Suspend, Deny) in interChange, and what do these statuses mean?
Check the claim status field.
Pay means the claim paid in full/part.
Suspend means the claim is flagged for manual review (e.g., duplicate, manual pricing, eligibility issues, timely filing)
Deny means the claim must be rebilled and resubmitted.
How can agents use Salesforce to identify the reason for a claim denial?
Agents can review the “Error” or “Error Code” tab in Salesforce, which displays the denial or error codes associated with the claim. The tab provides descriptions that help agents explain the denial reason to providers and guide them on next steps.
What is the role of Secure File Transfer Protocol (SFTP) in EDI, and why is it important for trading partners?
SFTP is used for securely transmitting batch files (claims, eligibility requests) between trading partners and the Department. It ensures HIPAA-compliant, secure data exchange and will be required for all trading partners.
What is the difference between Capitation and Fee For Service (FFS) pricing?
Capitation pays a set amount per patient per month for a set of services, while FFS pays for each individual service provided.
What is an Internal Control Number (ICN) and why is it important for claims processing?
The ICN is a unique 13-digit claim number assigned to each claim. It helps identify how and when the claim was received and is used for tracking and researching claims throughout their lifecycle.
How do region codes in the Internal Control Number (ICN) help you understand how a claim was received and processed in interChange?
Region codes are the first two digits of the ICN and indicate how Health First Colorado received the claim.
How can agents determine if a claim involved coordination of benefits using Salesforce?
Agents can check the “Institutional Other Subscribers” or “Dental Other Subscribers” tabs in Salesforce. These tabs show information about other insurance that paid on the claim, including adjustments made by other payers.
Explain the process for a new trading partner to enroll for EDI transactions with Health First Colorado. What steps and documentation are required?
The trading partner must complete an enrollment application, pass test transactions for HIPAA compliance, and provide accurate profile information. Only one application is needed per trading partner, even if submitting for multiple providers. Upon approval, they receive a TPID.
What is a Medicare crossover claim and how does Health First Colorado process it?
A Medicare crossover claim is sent from Medicare to Health First Colorado as secondary payer; Health First Colorado pays the difference between Medicare’s payment and the Medicaid allowed amount, using “lower of pricing” logic.
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).
How do you access Member Third Party Liability (TPL) coverage information in interChange?
Main Menu > TPL > Search by Client ID.
What information does the “Procedure Information” tab provide in Salesforce, and why is it important?
The “Procedure Information” tab lists procedure codes and dates for services performed on the member. This is important for verifying what treatments or procedures were billed and helps resolve provider inquiries about specific services.
If a provider wants to authorize a trading partner to access their data, what instructions would you give them for completing this process through the Provider Web Portal?
Instruct the provider to follow the “Instructions for Adding Trading Partner ID (TPID) Authorization” guide available on the Provider Web Portal. They must log in, navigate to the appropriate section, and authorize the trading partner for access.
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 is the standard timely filing period for Medicaid claims, and what happens if a provider misses this deadline?
Providers have 365 days from the Date of Service (DOS) to submit a claim. If missed, claims may be denied unless an override is approved for specific circumstances.
What is the process for resolving a denied claim due to manual pricing error code 6000 in interChange?
Go to the Attachments tab, ensure required invoice/MSRP is attached. If missing or invalid, refer to billing manuals for requirements and have provider resubmit with correct documentation.
What is the significance of the “Service Lines” tab in Salesforce for outpatient or dental claims?
The “Service Lines” tab shows the actual claim line for each procedure code billed, including modifiers, service descriptions, and amounts charged. It also indicates if there was a service line adjustment or a referring/rendering provider, which is crucial for resolving detailed billing questions.
With the upcoming transition to Edifecs as the new EDI vendor, what changes should trading partners expect, and what will remain the same?
Trading partners will need to follow a new X12 file naming convention, use new SFTP credentials, and sign new agreements. Edifecs will handle EDI batch processing and trading partner enrollment. TPIDs will remain the same, and Gainwell will continue to operate the main MMIS functions.
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.