Code of Colorado Regulations
2505 - Department of Health Care Policy and Financing
2505 - Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)
10 CCR 2505-10-8.000 - MEDICAL ASSISTANCE - SECTION 8.000 Emergency Medical Transportation, Program Integrity
Section 10 CCR 2505-10-8.049 - RECONSIDERATION/APPEAL OF ADVERSE ADMINISTRATIVE ACTION
Universal Citation: 2505 CO Code Regs 10 CCR 2505-10-8.049
Current through Register Vol. 47, No. 5, March 10, 2024
8.049.01 ROLE OF THE FISCAL AGENT
A. The fiscal agent is
authorized by the Colorado Department of Social Services to recognize and apply
all applicable State and Federal rules and regulations to process claims to
satisfactory claim payment. Adverse administrative action by the fiscal agent
through routine fiscal agent operations which results in the reduction or claim
denial to a Medicaid provider may be submitted for reconsideration. Providers
shall submit rebills and adjustment requests through routine fiscal agent
operations until all routine processing procedures have been
exhausted.
B. If satisfactory
resolution is not obtained through routine fiscal agent operations, the
provider may file a written reconsideration with the fiscal agent's Medicaid
Exceptions Unit. The provider must provide documentation essential to review
the request for reconsideration. Copies of all Medicaid Remittance Statements
(RS) and other written notification of adverse action documenting initial and
subsequent timely filing, along with a signed copy of the original claim
(including original attachments), and a brief explanation of the nature of the
reconsideration must be submitted. The Request for Reconsideration must clearly
be identified by attaching a designated Request for Reconsideration form to the
claim or by identifying the word "Reconsideration" on the face of the claim
form. Requests for reconsideration that do not include a completed claim form
will be returned to the provider.
C. Requests for reconsideration will be
reviewed and the result of the review will, upon completion, be reported on the
Medicaid Remittance Statement.
8.049.02 FINAL ADMINISTRATIVE APPEAL
Adverse decisions of the fiscal agent's Medicaid Exceptions Unit or decisions made by state Medicaid in exceptional circumstances may be appealed to the Office of Administrative Courts, as set forth in the PROVIDER APPEALS AND HEARING section of this manual.
Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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