10 CCR 2505-10
DEPARTMENT OF HEALTH CARE POLICY AND FINANCING MEDICAL ASSISTANCE - SECTION 8.600 Case Management, Supports Intensity Scale, Laboratory and X-Ray 10 CCR 2505-10 8.600 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________
8.607 CASE MANAGEMENT SERVICES
8.607.2 DETERMINATION OF DEVELOPMENTAL DISABILITY
A. Any person, his/her legal guardian, parent(s) of a minor or such person(s) authorized by law may submit a written request for a determination of whether the applicant has a developmental disability.
B. A determination of developmental disability does not constitute a determination of eligibility for services or supports. The Case Management Agencies shall determine whether a person has a developmental disability and therefore may be eligible to receive services and supports pursuant to Sections 25.5-10-202(2) and 211, C.R.S., in accordance with criteria as specified by the Department.
Eligibility for Medicaid funded programs specific to persons with developmental disabilities shall be determined pursuant to Medical Services Board rules C. The developmental disability determination shall be made according to Department procedures, which shall identify the qualifications of person(s) making such a determination.
D. A request for determination of developmental disability shall be submitted to the Case Management Agency in the designated service area where the person resides, including temporary residence such as incarceration or hospitalization.
E. At the time of request, the Case Management Agency shall:
1. Provide the applicant any required forms and a list of the minimum required documents and information necessary for the determination of developmental disability; and, 2. Provide the applicant with information on where to obtain testing for the level of intellectual functioning and adaptive behavior, if requested. The responsibility for obtaining such assessments shall be with the applicant and/or legal guardian.
F. The applicant and/or legal guardian shall provide all documentation and information necessary for the determination of developmental disability within 90 calendar days of the request.
1. The Case Management Agency may request additional documentation and/or information, as needed, to complete the determination of developmental disability.
2. The applicant and/or legal guardian may have additional assessments completed and submitted to the Case Management Agency for consideration.
G. If the applicant and/or legal guardian has not provided the documentation and information necessary for the determination within 90 calendar days of the request, the Case Management Agency shall:
1. Close the request and notify the applicant in writing according to the procedures established at Section 8.607.2.L.4; or, 2. The Case Management Agency may, at the request of the applicant and/or legal guardian, extend the deadline for providing the necessary documentation and information by up to an additional ninety (90) calendar days.
H. For all applicants, the Case Management Agency shall enter into the Department's designated data system and shall permanently maintain a written and/or electronic record of the developmental disability determination on a Department prescribed form. The record, at a minimum, shall include:
1. The name of the applicant;
2. The applicant's date of birth;
3. The date of the determination of developmental disability;
4. A description of the rationale for the developmental disability determination including, at minimum, assessment scores and diagnoses;
5. The name(s) and title(s) of the person(s) involved in making the determination.
I. All information and assessments used to determine a developmental disability shall be current so as to accurately represent the applicant's abilities at the time of determination.
1. Assessments of adaptive behavior shall have been completed within three (3) years of the request.
2. Assessments of intellectual functioning shall have been completed as follows:
3. An established neurological condition shall be documented as follows:
4. The effects of mental illness or physical or sensory impairment must be considered to determine the extent to which such impairments are the sole contributing factor to the impairment of general intellectual functioning or limitations to adaptive behavior.
J. Prior to July 1, 2015, the Case Management Agency shall make the determination of developmental disability within 90 calendar days of the receipt of all necessary information. On or after July 1, 2015, the Case Management Agency shall make the determination of developmental disability within 30 calendar days of the receipt of all necessary information.
K. The date of the developmental disability determination shall be the date that the Department prescribed form and all documentation and information necessary for the determination of developmental disability was received by the Case Management Agency. If a delay to the determination of developmental disability is due to the actions or inactions of the Case Management Agency, the original date of request shall be used.
L. The Case Management Agency making the developmental disability determination shall, in writing, notify the applicant or legal guardian, and the authorized person requesting the determination, if other than the applicant or legal guardian, and other such persons as designated by the applicant, of the decision. Such notification shall:
1. Be mailed to the person within seven calendar days of the date of determination;
2. Be provided in such alternative means of communication as to reasonably ensure that the information has been communicated in an understandable form; and, 3. For persons determined to have a developmental disability, contain an explanation of the process that will occur and notice that, at a minimum, an Individualized Plan shall be developed upon enrollment into a developmental disability service;
4. For persons determined not to have a developmental disability or persons whose request is closed without the determination of a developmental disability, state the reasons for the determination or closure, and provide a written Long-Term Care Notice of Action form in accordance with the provisions of Section 8.057 regarding the applicant's right to appeal the decision to the Office of Administrative Courts.
M. Applicants determined not to have a developmental disability may request a new determination of developmental disability at any time upon receipt of new or missing required information, and a new request date shall be established.
N. A determination of developmental disability shall be accepted by other Case Management Agencies, service agencies and Regional Centers.
O. A determination of developmental disability shall be permanent and shall not require renewal or review unless:
1. The member-identified team determines that developmental disability services are no longer needed due to improvement in a person's condition and recommends a redetermination; or, 2. Information from a new evaluation becomes available which demonstrates sufficient improvement in a person's condition such that the determination should be reviewed.
8.660 LABORATORY AND X-RAY
8.660.1 DEFINITIONS
Independent Certified Laboratory means a certified laboratory that performs diagnostic tests and is independent both of the attending or consulting physician's office and of a hospital except where a hospital laboratory has obtained Medicare certification as an independent laboratory and is billing for recipients who are not admitted as patients in the hospital. Clinical Laboratory Services mean microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, pathological or other examinations of fluids derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or the assessment of a medical condition.
Anatomical Laboratory Services mean examinations of tissues derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or the assessment of a medical condition.
Certified Clinical Laboratory means a provider who possesses a certificate of waiver or a certificate of registration from the Centers for Medicare and Medicaid Services or its designated agency as meeting Centers for Medicare and Medicaid Services guidelines and whose personnel and director are qualified to perform laboratory services.
X-Ray Services mean services performed by a provider whose x-ray equipment has been certified by the Colorado Department of Public Health and Environment as meeting Medicare guidelines and whose personnel and director are qualified to operate said equipment.
8.660.2 CONDITIONS OF PARTICIPATION
8.660.2. A Certified Clinical Laboratories and providers of X-Ray Services shall enroll as providers in the Medical Assistance Program.
8.660.2.B. All participating laboratories, including out-of-state independent clinical laboratories, shall be certified by the state agency to participate under Medicaid. All laboratories shall provide proof of certification status through the provision of the CLIA (Clinical Laboratory Improvement Amendments of 1988) number to the Department.
8.660.2.C. Providers of X-Ray Services shall be certified by the Colorado Department of Public Health and Environment and shall provide proof of Medicare certification on the Medicaid provider enrollment forms.
8.660.3 LIMITATIONS AND BENEFITS
8.660.3.A. Laboratory and X-Ray Services are a benefit under all of the following conditions:
1. The services have been authorized by a licensed physician.
2. The services are performed to diagnose conditions and illnesses with specific symptoms.
3. The services are performed to prevent or treat conditions that are benefits under the Medical Assistance Program.
4. The services are not routine diagnostic tests performed without apparent relationship to treatment or diagnosis for a specific illness, symptom, complaint or injury.
5. The laboratory services are performed by a certified laboratory in accordance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA).
6. The X-Ray Services are performed by a provider certified by the Colorado Department of Public Health and Environment and enrolled as a Medicaid provider. 8.660.3.B. Collection, handling and/or conveyance of specimens for transfer from physicians' offices to a Certified Clinical Laboratory is reimbursable to the physician. 8.660.3.C. Transfer of a specimen from one Certified Clinical Laboratory to another is a benefit and is reimbursable to the first certified laboratory if the laboratory's equipment is not functioning or the laboratory is not certified to perform the tests ordered by the physician.
8.660.4 BILLING PROCEDURES
8.660.4.A. Certified providers of clinical laboratory and X-Ray Services shall bill the Department directly using the designated billing method, the correct Current Procedural Terminology and Healthcare Common Procedure Coding System procedure codes and modifiers as required. Providers shall bill the amount of their usual and customary charges to the general public. 8.660.4.B. Laboratory tests and x-rays performed under the personal supervision of the authorizing physician must be billed directly on the physician's services claim form. 8.660.4.C. Laboratory tests and x-rays not performed by the authorizing physician or under his/her direct personal supervision cannot be billed by the physician except for physicians in a Certified Clinical Laboratory group practice. A Certified Clinical Laboratory group practice may only bill for those laboratory and X-Ray Services actually performed or supervised by a physician member of the group or performed by a qualified employee of the group. Payment shall be made to the authorizing physician or the group practice.
8.660.4.D. Laboratory and X-Ray Services performed by a hospital-based or independent laboratory or x-ray provider and submitted to an unrelated physician for interpretation may only be billed by the laboratory or x-ray provider for the technical component. 8.660.4.E. Practitioner and clinic providers rendering professional interpretation and not direct laboratory or X-Ray Services may only bill the professional component.
8.660.5 REIMBURSEMENT
8.660.5.A. Reimbursement for certified laboratory and X-Ray Services shall be the lowest of the following:
1. Submitted charges.
2. Fee schedule as determined by the Department.
8.660.5.B. Services rendered by a hospital-based laboratory during an inpatient stay are included in the hospital Diagnosis Related Group or inpatient rate and shall not be billed or reimbursed separately.
8.660.5.C. Each certified laboratory provider shall be reimbursed for only those tests performed in the specialties or sub-specialties for which it is certified. 8.660.5.D. Reimbursement for out-of-state certified independent clinical laboratory or X-Ray Services shall be subject to Department reimbursement rates. 8.660.5.E. The reimbursement methodology at 8.660.5.A - 8.660.5.D does not apply to payments for those services/procedures that are reimbursed under a capitated or contracted agreement accomplished through competitive bid or other arrangement. _________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the History link that appears above the text in 10 CCR 2505-10. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.
History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]