C.R.S. Section 25.5-4-402
Providers

  • hospital reimbursement
  • hospital review program
  • rules

(1)

For all licensed or certified hospitals contracting for services under this article and articles 5 and 6 of this title, except those hospitals operated by the department of human services or those hospitals deemed exempt by the state board, the state department shall pay for inpatient hospital services pursuant to a system of prospective payment, generally based on the elements of a diagnosis-related group system. The state department shall develop and administer a system for ensuring appropriate utilization and quality of care provided by those providers who are reimbursed under this section. Subject to available appropriations, the state department may also make supplemental medicaid payments to certain hospitals. The state board shall promulgate rules to provide for the implementation of this section.

(2)

Intentionally left blank —Ed.

(a)

A hospital that receives payment under this article and articles 5 and 6 of this title for telemedicine services shall employ its existing quality-of-care protocols and patient confidentiality guidelines to ensure that such services meet the requirements of this article and articles 5 and 6 of this title.

(b)

The executive director of the state department shall adopt rules in furtherance of this subsection (2), including, without limitation, rules to:

(I)

Ensure the provision of appropriate care to patients;

(II)

Prevent fraud and abuse; and

(III)

Establish methods and procedures to avoid overuse of telemedicine services.

(3)

Intentionally left blank —Ed.

(a)

In addition to the reimbursement rate process described in subsection (1) of this section and subject to adequate funding being made available pursuant to section 25.5-4-402.4, the Colorado healthcare affordability and sustainability enterprise created in section 25.5-4-402.4 (3) shall pay an additional amount based upon performance to those hospitals that provide services that improve health-care outcomes for their patients. The state department shall determine this amount based upon nationally recognized performance measures established in rules adopted by the state board. The state quality standards must be consistent with federal quality standards published by an organization with expertise in health-care quality, including but not limited to, the federal centers for medicare and medicaid services, the agency for healthcare research and quality, or the national quality forum.

(b)

The amount of the payments made pursuant to this subsection (3) shall be computed annually. For the first two fiscal years that payments are made pursuant to this subsection (3), the total amount of the payments shall be up to five percent of the total reimbursements made to hospitals in the previous year. For each fiscal year after the first two fiscal years, the total amount of the payments shall be up to seven percent of the total reimbursements made to hospitals in the previous year.

(4)

Intentionally left blank —Ed.

(a)

Subject to federal approval, and notwithstanding any other provision of the “Colorado Medical Assistance Act”, the state department shall design and implement an evidence-based hospital review program to ensure appropriate utilization of hospital services.

(b)

Consistent with federal regulations set forth in 42 CFR 456, the hospital review program may include the following:

(I)

Preadmission review;

(II)

Continued stay review;

(III)

Transfer planning;

(IV)

Discharge planning;

(V)

Care coordination; and

(VI)

Retrospective claims review.

(c)

The following factors must be considered in any coverage determinations made pursuant to the hospital review programs:

(I)

Information provided, diagnosis determined, and treatment recommended by the treating provider or providers;

(II)

Evidence-based clinical coverage criteria and recipient coverage guidelines as established by the state department;

(III)

Nationally recognized utilization and technology assessment guidelines; and

(IV)

Industry standard criteria, as appropriate.

(d)

Intentionally left blank —Ed.

(I)

The state department shall consult with affected stakeholders prior to implementation of the hospital review program. At a minimum, the state department shall solicit feedback from recipients, hospitals within Colorado that participate in medicaid, providers participating in the accountable care collaborative pursuant to section 25.5-5-419, and the Colorado healthcare affordability and sustainability enterprise board established in section 25.5-4-402.4 (7). If the state department contracts with a third-party vendor to implement the hospital review program, the state department shall require the vendor to participate in the stakeholder outreach with hospitals required pursuant to this subsection (4)(d)(I).

(II)

Prior to implementation of the hospital review program, the state department shall provide an opportunity for hospitals to test connectivity to and workability of any new electronic interface created or implemented as part of this section. The state department shall select a limited group of hospitals to test any new requirements prior to full implementation.

(III)

The state department shall provide a report to the joint budget committee by November 1, 2018, on the status of the implementation of the hospital review program. The report must include the comments received as part of the stakeholder process described in subsection (4)(d)(I) of this section and a description of, and any available results from, the testing process described in subsection (4)(d)(II) of this section.

(IV)

The state department shall provide a report to the joint budget committee on November 1, 2019, and November 1, 2020, detailing the estimates of the cost savings achieved and the impact of the cost-control measures authorized pursuant to this section on recipients and recipients’ health outcomes.

(V)

Beginning in 2018, and every year thereafter through 2020, the state department shall report on the status of the implementation of the hospital review program, any cost savings estimated or achieved due to the program, and the impact on recipients and recipients’ outcomes of any cost-control measures as part of its “State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act” hearing required by section 2-7-203.

(e)

The state board shall adopt any rules necessary for the administration and implementation of this section.

Source: Section 25.5-4-402 — Providers - hospital reimbursement - hospital review program - rules, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­5.­pdf (accessed Oct. 20, 2023).

25.5‑4‑101
Short title
25.5‑4‑102
Legislative declaration
25.5‑4‑103
Definitions
25.5‑4‑104
Program of medical assistance - single state agency
25.5‑4‑105
Federal requirements under Title XIX
25.5‑4‑106
Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services
25.5‑4‑107
Retaliation definition
25.5‑4‑201
Cash system of accounting - financial administration of medical services premiums - medical programs administered by department of human services - federal contributions - rules
25.5‑4‑203
Advisory council established
25.5‑4‑204
Automated medical assistance administration
25.5‑4‑205
Application - verification of eligibility - demonstration project - rules - repeal
25.5‑4‑205.5
Confined persons - suspension of benefits
25.5‑4‑206
Reimbursement to counties - costs of administration
25.5‑4‑207
Appeals - rules - applicability
25.5‑4‑208
County duties - transitional medicaid
25.5‑4‑209
Payments by third parties - copayments by recipients - review - appeal - children’s waiting list reduction fund - rules - repeal
25.5‑4‑210
Purchase of health insurance for recipients
25.5‑4‑211
Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year
25.5‑4‑212
Medicaid client correspondence improvement process - legislative declaration - definition
25.5‑4‑213
Audit of medicaid client correspondence - definition
25.5‑4‑215
Study - benefits for persons on work release - repeal
25.5‑4‑216
Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal
25.5‑4‑300.4
Last resort for payment - legislative intent
25.5‑4‑300.7
Prevention of coding errors - prepayment review of claims
25.5‑4‑300.9
Explanation of benefits - medicaid recipients - legislative declaration
25.5‑4‑301
Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - repeal
25.5‑4‑302
Recovery of assets
25.5‑4‑303
State income tax refund intercept - garnishment of earning - failure to provide medical support for child
25.5‑4‑303.3
Provider fraud - attorney general report
25.5‑4‑303.5
Short title
25.5‑4‑304
Definitions
25.5‑4‑305
False medicaid claims - liability for certain acts
25.5‑4‑306
Civil actions for false medicaid claims
25.5‑4‑307
False medicaid claims procedures - statute of limitations
25.5‑4‑308
False medicaid claims jurisdiction
25.5‑4‑309
False medicaid claims civil investigation demands
25.5‑4‑310
Medicaid false claims report
25.5‑4‑401
Providers - payments - rules
25.5‑4‑401.2
Performance-based payments - reporting - repeal
25.5‑4‑401.5
Review of provider rates - advisory committee - recommendations - repeal
25.5‑4‑402
Providers - hospital reimbursement - hospital review program - rules
25.5‑4‑402.4
Hospitals - healthcare affordability and sustainability fee - legislative declaration - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - rules - reports - repeal
25.5‑4‑402.5
Providers - state university teaching hospitals
25.5‑4‑402.8
Hospital transparency report - definitions
25.5‑4‑403
Providers - behavioral health safety net providers - reimbursement
25.5‑4‑403.1
Providers - community mental health centers - cost reporting
25.5‑4‑404
Payments for clinic services - restrictions on use
25.5‑4‑405
Mental health managed care service providers - requirements
25.5‑4‑406
Rate setting - medicaid residential treatment service providers - monitoring and auditing - report
25.5‑4‑407
Services by licensed psychologists without a doctor’s referral
25.5‑4‑408
Services provided by licensed psychologists - cost containment program
25.5‑4‑409
Authorization of services - nurse anesthetists - advanced practice registered nurses
25.5‑4‑410
Services of audiologists and speech pathologists without supervision
25.5‑4‑411
Authorization of services provided by dental hygienists
25.5‑4‑412
Family planning services - family-planning-related services - rules - definitions
25.5‑4‑413
Certain providers to inform patients of rights concerning advance medical directives
25.5‑4‑414
Providers - physicians - prohibition of certain referrals - definitions
25.5‑4‑415
No public funds for abortion - exception - definitions - repeal
25.5‑4‑416
Providers - medical equipment and supplies - requirements
25.5‑4‑417
Provider fee - medicaid providers - state plan amendment - rules - definitions
25.5‑4‑420
Providers to obtain unique NPI - service site - provider type - definitions
25.5‑4‑422
Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules
25.5‑4‑423
Targets for investments in primary care
25.5‑4‑425
Providers - health-care services related to labor and delivery - reimbursement
25.5‑4‑427
Supplemental state payment to the Denver health and hospital authority - repeal
25.5‑4‑428
Prior authorization for a step-therapy exception - rules - definition
25.5‑4‑429
Hospital and provider billing requirements - description of service provided - rules
25.5‑4‑430
Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates
25.5‑4‑503
Waiver applications - authorization
25.5‑4‑505
Federal authorization related to persons involved in the criminal justice system - assessment - report - repeal
25.5‑4‑506
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

§ 25.5-4-402’s source at colorado​.gov