C.R.S. Section 25.5-4-300.9
Explanation of benefits

  • medicaid recipients
  • legislative declaration


Intentionally left blank —Ed.


The general assembly finds and declares that:


Colorado’s medicaid program provides critical medical services to the state’s poorest and most vulnerable residents;


Funding for these services is provided through a financial partnership between Colorado and the federal government;


For the 2015-16 state budget year, the general assembly appropriated $8,891,000,000 for Colorado’s medicaid program, of which $2,508,000,000 is from the general fund and $677,000,000 is from the hospital provider fee, with the remainder from federal money;


It is in the best interest of Colorado to do everything possible to minimize error, inefficiency, and fraud in providing medicaid services to ensure the long-term viability of this safety net program;


In the private sector, as well as the medicare program, insurers routinely provide an explanation of benefits to their clients, listing claims submitted by providers for services rendered to the client even when the insurer is not seeking a co-payment for the service and the provider is not claiming an amount due from the client;


While creating an explanation of benefits is not without cost to the health- care system, only the client receiving medical services or his or her authorized representative is in the position to verify whether the claimed medical services were actually provided and for whom they were provided, which is a necessary first step in containing health-care costs;


While medicaid clients may not appear to be affected financially by billing errors or fraudulent claims, medicaid clients who rely on these services for survival and independence are most severely affected by the inappropriate use of scarce resources; and


Further, medicaid clients and medicaid advocates for low-income and vulnerable Coloradans want the opportunity to partner with the state department and providers to ensure a well-run and fraud-free medicaid program in Colorado.


Therefore, the general assembly declares that creating an explanation of benefits for recipients of medicaid-funded services is a necessary step in managing the state’s medicaid program and in safeguarding the significant public investment, both state and federal, in meeting the health-care needs of low-income and vulnerable Coloradans.


By or before July 1, 2017, the state department shall develop and implement an explanation of benefits for recipients of medical services pursuant to articles 4 to 6 of this title. The purpose of the explanation of benefits is to inform a medicaid client of a claim for reimbursement made for services provided to the client or on his or her behalf, so that the client may discover and report administrative or provider errors or fraudulent claims for reimbursement.


The explanation of benefits is required for all acute and long-term care services for which a provider is seeking reimbursement under a fee-for-service model.


The explanation of benefits must include, at a minimum:


The name of the medicaid client receiving the service;


The name of the service provider;


A description of the service provided;


The billing code for the service;


The date of service, or range of dates for services, if multiple services are provided in a set period of time, such as personal care services;


A clear statement to the medicaid client that the explanation of benefits is not a bill, but is only provided for the client’s information and to make sure that a provider is being reimbursed only for services actually provided;


Information regarding at least one verbal and one written method for the medicaid client to report errors in the explanation of benefits that are relevant to provider reimbursement; and


Any other information that the state department determines is useful to the medicaid client or for purposes of discovering administrative or provider error or fraud.


The state department shall develop the form and content of the explanation of benefits in conjunction with medicaid clients and medicaid advocates to ensure that medicaid clients understand the information provided and the purpose of the explanation of benefits. The state department shall also work with medicaid clients and medicaid advocates to develop educational materials for the state department’s website and for distribution by advocacy and nonprofit organizations that explain the process for reporting errors and encourage clients to take responsibility for reporting errors.


The state department shall provide the explanation of benefits to a medicaid client not less frequently than once every two months, if services have been provided to or on behalf of the client during that time period. The state department shall determine the most cost-effective means for producing and distributing the explanation of benefits to medicaid clients, which may include e-mail or web-based distribution, with mailed copies by request only. Further, the state department may include the explanation of benefits with an existing mailing or existing electronic or web-based communication to medicaid clients.


Nothing in this section requires the state department to produce an explanation of benefits form if the information required to be included in the explanation of benefits pursuant to subsection (4) of this section is already included in another format that is understandable to the medicaid client.

Source: Section 25.5-4-300.9 — Explanation of benefits - medicaid recipients - legislative declaration, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­5.­pdf (accessed Oct. 20, 2023).

Short title
Legislative declaration
Program of medical assistance - single state agency
Federal requirements under Title XIX
Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services
Retaliation definition
Cash system of accounting - financial administration of medical services premiums - medical programs administered by department of human services - federal contributions - rules
Advisory council established
Automated medical assistance administration
Application - verification of eligibility - demonstration project - rules - repeal
Confined persons - suspension of benefits
Reimbursement to counties - costs of administration
Appeals - rules - applicability
County duties - transitional medicaid
Payments by third parties - copayments by recipients - review - appeal - children’s waiting list reduction fund - rules - repeal
Purchase of health insurance for recipients
Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year
Medicaid client correspondence improvement process - legislative declaration - definition
Audit of medicaid client correspondence - definition
Study - benefits for persons on work release - repeal
Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal
Last resort for payment - legislative intent
Prevention of coding errors - prepayment review of claims
Explanation of benefits - medicaid recipients - legislative declaration
Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - repeal
Recovery of assets
State income tax refund intercept - garnishment of earning - failure to provide medical support for child
Provider fraud - attorney general report
Short title
False medicaid claims - liability for certain acts
Civil actions for false medicaid claims
False medicaid claims procedures - statute of limitations
False medicaid claims jurisdiction
False medicaid claims civil investigation demands
Medicaid false claims report
Providers - payments - rules
Performance-based payments - reporting - repeal
Review of provider rates - advisory committee - recommendations - repeal
Providers - hospital reimbursement - hospital review program - rules
Hospitals - healthcare affordability and sustainability fee - legislative declaration - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - rules - reports - repeal
Providers - state university teaching hospitals
Hospital transparency report - definitions
Providers - behavioral health safety net providers - reimbursement
Providers - community mental health centers - cost reporting
Payments for clinic services - restrictions on use
Mental health managed care service providers - requirements
Rate setting - medicaid residential treatment service providers - monitoring and auditing - report
Services by licensed psychologists without a doctor’s referral
Services provided by licensed psychologists - cost containment program
Authorization of services - nurse anesthetists - advanced practice registered nurses
Services of audiologists and speech pathologists without supervision
Authorization of services provided by dental hygienists
Family planning services - family-planning-related services - rules - definitions
Certain providers to inform patients of rights concerning advance medical directives
Providers - physicians - prohibition of certain referrals - definitions
No public funds for abortion - exception - definitions - repeal
Providers - medical equipment and supplies - requirements
Provider fee - medicaid providers - state plan amendment - rules - definitions
Providers to obtain unique NPI - service site - provider type - definitions
Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules
Targets for investments in primary care
Providers - health-care services related to labor and delivery - reimbursement
Supplemental state payment to the Denver health and hospital authority - repeal
Prior authorization for a step-therapy exception - rules - definition
Hospital and provider billing requirements - description of service provided - rules
Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates
Waiver applications - authorization
Federal authorization related to persons involved in the criminal justice system - assessment - report - repeal
Coverage for doula services - stakeholder process - federal authorization - scholarship program - training - report - definitions - repeal
Green check means up to date. Up to date

Current through Fall 2024

§ 25.5-4-300.9’s source at colorado​.gov