Professional services are reimbursed on a fee-for-service
basis in accordance with the CHP+ Fee Schedule and as specified in the
CHP+ Provider Manual.
Please refer to the below information to determine what services
are covered benefits for SMCN and what services require Pre-Authorization.
An updated co-pay table has also been provided below:
Inpatient Hospital Services additional information:
The Department or its designees(s) shall reimburse a
percentage calculation to the Contractor for all inpatient
hospital Covered Services based on the Colorado Medicaid
DRG reimbursement schedule as defined in
10 CCR 2505-10 8.300.5.A-D,
unless otherwise specified in this Agreement.
Outpatient Hospital Services:
The Department or its designee(s) shall reimburse a
percentage calculation to the Contractor for all outpatient
Covered Services based on the Colorado Medicaid outpatient
reimbursement methodology as defined in 10
CCR 2505-10 8.300.6.A.1 that is in effect on July 1st
each year, without additional revision, unless otherwise
specified in this Agreement.
Additional Reimbursement Information:
The reimbursement percentage calculation shall be updated
on the CHP+ Provider Website annually on or about
July 1st. The Department shall provide the Contractor
with at least 120 days prior written notice of any change
to the reimbursement amount specified on the CHP+ Provider Website.
When the Department or its designee(s) are made aware of
an increase or decrease in the Contractor's Medicare
cost-to-charge ratio greater than or equal to five (5%)
percent, then the Department will update the Contractor's
Medicare cost-to-charge ratio effective on the first of
the month following notice from the Contractor.
The CHP+ Fee Schedule is based on the Centers for
Medicare and Medicaid Service's (CMS) Resource Based
Relative Value Scale (RBRVS) as adjusted for Colorado.
CHP+ uses two separate conversion factors to
calculate reimbursement: a) Medical/Surgical/Laboratory
and b) Anesthesia. Most labs, durable medical
equipment, and injectable drugs are paid on a flat
fee basis. The Department may modify these rates during the
term of this Agreement in accordance with changes in
RBRVS by Medicare. In instances where the RBRVS
method does not set unit values, CHP+ uses a modified
Medicare fee schedule.
The allowed amounts listed do not guarantee payment
for non-covered services. Please refer to the
Provider Manual for questions regarding covered benefits.