10 CCR 2505-10
DEPARTMENT OF HEALTH CARE POLICY AND FINANCING MEDICAL ASSISTANCE – SECTION 8.900 10 CCR 2505-10 8.900 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________
8.900 COLORADO INDIGENT CARE PROGRAM (CICP)
PROGRAM OVERVIEW The Colorado Indigent Care Program (CICP) is a program that distributes federal and State funds to partially compensate qualified health care providers for uncompensated costs associated with services rendered to the indigent population. Qualified health care providers who receive this funding render discounted health care services to Colorado residents, migrant workers and legal immigrants with limited financial resources who are uninsured or underinsured and not eligible for benefits under the Medicaid Program or the Children’s Basic Health Plan.
The Colorado Department of Health Care Policy and Financing (Department) administers the CICP by distributing funding to qualified health care providers who serve eligible persons who are indigent. The CICP issues procedures to ensure the funding is used to serve the indigent population in a uniform method. Any significant departure from these procedures will result in termination of the contract with, and the funding to, a health care provider. The legislative authority for this program was enacted in 1983 and is at 26-15-101, et seq., C.R.S., the “Reform Act for the Provision of Health Care for the Medically Indigent.”
The CICP does not offer a specified discounted medical benefit package or an entitlement to medical benefits or funding to individuals or medical providers. The CICP does not offer a health coverage plan as defined in Section 10-16-102 (22.5), C.R.S. Medically indigent persons receiving discounted health care services from qualified health care providers are subject to the limitations and requirements imposed by article 15, title 26, C.R.S.
8.901 DEFINITIONS
A. “Applicant” means an individual who has applied at a qualified health care provider to receive discounted health care services.
B. “Client” means an individual whose application to receive discounted health care services has been approved by a qualified health care provider.
C. “Emergency care” is treatment for conditions of an acute, severe nature which are life, limb, or disability threats requiring immediate attention, where any delay in treatment would, in the judgment of the responsible physician, threaten life or loss of function of a patient or viable fetus, Section 25.5-3-103, C.R.S.
D. “Urgent care” is treatment needed because of an injury or serious illness that requires immediate treatment because the client’s life or health may be in danger.
E. “General provider” means a general hospital, birth center, or community health clinic licensed or certified by the Department of Public Health and Environment pursuant to section 25-1.5- 103(1)(a)(I) or (1)(a)(II), C.R.S., a federally qualified health center, as defined in 42 U.S.C. 1395x (aa)(4), a rural health clinic, as defined in 42 U.S.C. 1395x (aa)(2), a health maintenance organization issued a certificate authority pursuant to section 10-16-402, C.R.S., and the University of Colorado Health Sciences Center when acting pursuant to section 25.5-3-108 (5)(a)(I) or (5)(a)(II)(A), C.R.S. For the purposes of the program, “general provider” includes associated physicians.
F. “Qualified health care provider” means any general provider who is contracted with the Department to provide, and receive funding for, discounted health care services under the Colorado Indigent Care Program.
G. “Hospital provider” means any “qualified health care provider” that is a general hospital licensed or certified by the Department of Public Health and Environment pursuant to C.R.S. §25-1.5-103 and which operates inpatient facilities.
H. “State-owned hospital provider” is any “hospital provider” that is either owned or operated by the State.
I. “Local-owned hospital provider” is any “hospital provider” that is either owned or operated by a government entity other than the State.
J. “Private-owned hospital provider” is any “hospital provider” that is privately owned and operated.
8.902 DISCOUNTED HEALTH CARE SERVICES
A. Funding provided under the CICP shall be used to provide clients with discounted health care services determined to be medically necessary by the qualified health care provider.
B. All health care services normally provided at the qualified health care provider should be available at a discount to clients. If health care services normally provided at the qualified health care provider are not available to clients at a discount, clients must be informed that the services can be offered without a discount prior to the rendering of such services.
C. Qualified health care providers receiving funding under the CICP shall prioritize the use of funding such that discounted health care services are available in the following order:
D. Additional discounted health care services may include:
E. Excluded Discounted Health Care Services Funding provided under the CICP shall not be used for providing discounted health care services for the following:
8.903 PROVISIONS APPLICABLE TO QUALIFIED HEALTH CARE PROVIDERS
A. Contract Requirements for Qualified Health Care Providers
B. Determination of Client Eligibility to Receive Discounted Health Care Services Under Available CICP Funds
C. Distribution of Available Funds to Providers
D. Audit Requirements The qualified health care provider shall provide the Department with an annual audit compliance statement as specified in the CICP Manual. The purpose of the audit requirement is to furnish the Department with a separate audit report, which attests to the qualified health care provider's compliance with the use of CICP funding and other requirements for participation. In addition, the audit report will furnish verification that the qualified health care provider accurately reported to the Department Medicaid-eligible inpatient days and total inpatient days used to calculate the distribution of available funds to providers defined under 8.903(C).
E. HIPAA The Department has determined that the Colorado Indigent Care Program (CICP) is NOT a “covered entity” under the Health Insurance Portability and Accountability Act of 1996 privacy regulations (45 C.F.R. Parts 160 and 164). Because the Colorado Indigent Care Program (CICP) is not a part of Medicaid, and its principal activity is the making of grants to providers who serve eligible persons who are medically indigent, CICP is not considered a covered entity under HIPAA. The state personnel administering the CICP will provide oversight in the form of procedures and conditions, to ensure funds provided are being used to serve the target population, but they will not be significantly involved in any health care decisions or disputes involving a qualified health care provider or client.
8.904 PROVISIONS APPLICABLE TO CLIENTS
A. Overview of Requirements In order to qualify to receive discounted health care services under available CICP funds, an applicant shall satisfy the following requirements:
B. Affidavit
C. Establishing Lawful Presence
D. Residence in Colorado An applicant must be a resident of Colorado. A Colorado resident is a person who currently lives in Colorado and intends to remain in the state.
E. Social security number(s) shall be required for all clients receiving discounted health care services under available CICP funding. If an applicant does not have a social security number, documentation that the applicant has applied for a social security number must be provided to complete the application to receive discounted health care services under available CICP funding. This section shall not apply to unborn children or homeless individuals who are unable to provide a social security number.
F. Applicants Not Eligible
G. Application
H. Applicants
I. Health Insurance Information The applicant shall submit all necessary information related to health insurance, including a copy of the insurance policy or insurance card, the address where the medical claim forms must be submitted, policy number, and any other information determined necessary.
J. Subsequent Insurance Payments If a client receives discounted health care services under available CICP funding, and their insurance subsequently pays for services, or if the patient is awarded a settlement, the insurance company or patient shall reimburse the qualified health care provider for discounted health care services rendered to the patient.
8.905 FINANCIAL ELIGIBILITY
General Rule: An applicant shall be financially eligible for discounted health care services under available CICP funding if the client's household income and resources (minus allowable deductions and adjustments) are no more than 250% of the most recently published federal poverty level (FPL) for a household of that size.
8.906 CICP RATING
The federal poverty levels or the ability-to-pay scale is divided into eleven ratings. The result of the calculated income and resources and the family household size are used to determine what percentage of the federal poverty level the family meets.
Ability-to-Pay Scale Percentage of Federal poverty levels CICP Rating Percent of Federal Further Descriptions Poverty Levels N 40% A 62% B 81% C 100% D 117% E 133% F 159% G 185% H 200% I 250% Z 40% Homeless Clients Only A qualified health care provider shall assign a CICP Rating or denial, and notify the applicant of his status within five working days of the applicant completing the application to receive discounted health care services. Members of applicant’s family household receiving discounted health care services under the same application shall all have the same CICP Rating.
The rating letter or letter denying the application to receive discounted health care services shall include a statement informing the applicant that s/he has 15 days to appeal the denial or CICP Rating. The CICP Rating determines a family’s copayment and client copayment annual cap. CICP Ratings are effective for a maximum of one year from the date of the rating, unless the client’s financial or family situation changes or the rating is a result of a qualified health care provider management exception, according to Section 8.908 (E) of these regulations.
Any family member eligible for the Children's Basic Health Plan may only receive a CICP Rating on a temporary basis. The CICP Rating is retroactive for services received 90 days prior to the application to receive discounted health care services and valid for a temporary basis from the application date.
A. Determining the CICP Rating The CICP Rating of an eligible client shall be determined by matching the family's net CICP income and resources to the appropriate bracket on the ability-to-pay scale, taking into account the current federal poverty level for a household of the same size.
B. CICP Re-rating A client is required to receive a re-rating because his/her financial or family situation has changed since the initial rating. To re-rate a client, the qualified health care provider must complete a new application. Client re-ratings affect only future charges. Therefore, bills incurred after the initial rating but prior to the re-rating shall be discounted based on the client’s initial rating. If the client requests a re-rating and can document that relevant circumstances have changed since the initial rating, the qualified health care provider must re-rate the client. Reasons that justify the client to request or require the client to receive a re-rating include but are not limited to:
8.907 CLIENT COPAYMENT
A. Client Copayments - General Policies A client is responsible for paying a portion of his/her medical bills. The client’s portion is called the “client copayment”. Qualified health care providers are responsible for charging the client a copayment. The maximum allowable client copayments by service are shown below in the Client Copayment Table. Qualified health care providers may require clients to pay their copayment prior to receiving care (except for emergency care).
B. Z-Rating. These are homeless clients, clients living in transitional housing, clients residing with others, or recipients of Colorado’s Aid to the Needy Disabled financial assistance program, who are at or below 40% of the Federal Poverty Level (qualify for an N-Rating). These clients are exempt from client copayments and are rated with the Z-rating.
C. Client Annual Copayment Cap
D. Determining Client Copayments The client's copayment shall be determined by matching the client's CICP rating with the corresponding rate on the CICP copayment table.
E. The patient must pay the lower of the copayment listed or actual charges.
F. Clients shall be notified at or before time of services rendered of their copayment responsibility.
G. Grants for Client Copayments Grants from foundations to clients from non-profit, tax exempt, charitable foundations specifically for client copayments are not considered other medical insurance or income. The provider shall honor these grants and may not count the grant as a resource or income.
8.908 APPEAL PROCESS
A. If an applicant or client feels that a rating or denial is in error, the applicant/client shall only challenge the rating or denial by filing an appeal with the qualified health care provider who completed the application to receive discounted health care services under available CICP funding pursuant to this section 8.908. There is no appeal process available through the Office of Administrative Courts.
B. Instructions for Filing an Appeal The qualified health care provider shall inform the applicant or client that s/he has the right to appeal the rating or denial if s/he is not satisfied with the qualified health care provider's decision. If the applicant or client wishes to appeal the rating or denial of the application, the applicant or client shall submit a written request for appeal, which includes any documentation supporting the reasons for the request.
C. Appeals An applicant or client may file an appeal if the applicant or client wishes to challenge the accuracy of his or her initial rating.
If the manager finds that the initial rating or denial is not accurate, the designated manager shall correct the application to receive discounted health care services under available CICP funding and assign the correct rating to the applicant or client. The correct rating is effective retroactive to the initial date of application, and charges incurred 90 days prior to the initial date of application must be discounted. The qualified health care provider shall notify the applicant or client in writing of the results of an appeal within 15 working days following receipt of the appeal request from the client.
D. Provider Management Exception At the discretion of the qualified health care provider and for good cause shown, the designated manager may grant the applicant or client a provider management exception. A client may request and a qualified health care provider may grant a provider management exception if the client can demonstrate that there are unusual circumstances that may have affected his or her initial rating. Provider Management Exceptions shall always result in a lower client rating. Provider Management Exceptions shall not be used for applicants who do not qualify to receive discounted health care services under available CICP funding due to being over- resourced.
8.930 Repealed effective 8/12/2011.
8.940 OLD AGE PENSION HEALTH CARE PROGRAM
8.941 EXTENT AND LIMITATIONS OF MEDICAL CARE
8.941.1 GENERAL DESCRIPTION - OLD AGE PENSION HEALTH CARE PROGRAM
In accordance with the Constitution of Colorado, Article XXIV, Section 7, and the Colorado Social Services Act, an Old Age Pension Health Care Program is established to provide necessary medical care for the Old Age Pension recipients who do not qualify for Medicaid under Title XIX of the Social Security Act and Colorado statutes. The State Department is designated as the single State agency to administer the program.
A. The Old Age Pension Health Care Program provides optional benefits to clients who qualify for (State only) OAP-A and (State only) OAP-B pensions who do not qualify for Federal Financial Participation in the Colorado Medicaid Program. These cases are coded with Supplemental Income Status Code (SISC) C.
B. Under the Old Age Pension Health Care Program, only the following State funded benefits are provided: physician and practitioner services, inpatient hospital, outpatient services, lab and x- ray, emergency transportation, emergency dental, dental, pharmacy, home health services and supplies, and Medicare cost sharing.
C. All other medical benefits not listed in paragraph B are excluded under the Old Age Pension Health Care Program. Inpatient care in an institution for tuberculosis or mental diseases, skilled and intermediate nursing facility services, and home and community based services are also excluded.
D. The Old Age Pension Health Care Program eligibility shall not be retroactive. Eligibility shall begin with the date of application or date eligibility is established, whichever is later.
E. The Executive Director of the Department of Health Care Policy and Financing, under the direction of the State Medical Services Board, shall manage the Old Age Pension Health and Medical Care fund to assure that utilization controls and other mechanisms are in place in order to hold expenditures within the constitutional and statutory limits. Should the Executive Director, at any time during the course of a fiscal year, determine that expenditures will exceed the available funds, he/she shall take action to reduce expenditures as needed by reducing, suspending, or eliminating payments for covered benefits. The Executive Director shall consider reducing, suspending or eliminating benefits, individually or in any combination, based upon the shortest duration of time and considering the least impact on the client. The Executive Director shall report to the Board whenever such action is required, specifying the dollar impact, length of time for the reduction, and the number of clients and providers affected. In addition, the Executive Director shall report to the Board on the feasibility of other cost reduction options.
F. Counties shall provide information to Old Age Pension Health Care Program clients regarding the disposal of excess resources in order to qualify for the Medicaid program. Such information shall include advisements concerning the prohibition of transfer of assets without fair consideration.
G. If Medicare pays for a medical service that is a non-benefit for this group, the co-insurance and deductible will not be paid by the Old Age Pension Health Care Program.
8.941.2 DEFINITION
Throughout this section of the rules, all references to “medical” shall mean the Old Age Pension Health Care Program. Exceptions will be noted in the specific rule. All forms of communication to providers, counties and recipients (Provider bulletins, claim forms, authorization forms, Medicaid Authorization Card (MAC etc.), shall include Colorado Medical Assistance Program, and Old Age Pension Health Care Program.
8.941.3 GROUPS ASSISTED UNDER THE OLD AGE PENSION HEALTH CARE PROGRAM
Old Age Pension Health Care Program benefits are provided to persons receiving OAP A, OAP-B, and OAP refugees who do not meet SSI eligibility criteria, but do meet the State eligibility criteria for the Old Age Pension Health Care Program. These persons qualify for a SISC Code C.
A. SISC Code C – this code is for persons eligible to receive financial assistance under OAP-A, OAP-B, or OAP Refugee Assistance, who do not receive an SSI payment, and do not otherwise qualify for the Colorado Medicaid Program. Code C signifies that no FFP is available in medical assistance program expenditures.
B. Recipients of financial assistance under State AND, State AB or OAP “C” are not eligible for assistance under the Old Age Pension Health Care Program.
8.941.4 FINANCIAL ASSISTANCE
All rules applicable to Old Age Pension financial assistance program payments (as set forth in the Department of Human Services rules at 9 CCR 2503-3 shall apply to the Old Age Pension Health Care Program.
8.941.5 CERTIFICATION OF PAYMENT FOR PROVIDERS
All providers of medical services in their submission of claim to the Old Age Pension Health Care Program certify that, “I will accept as payment in full, payment made under the Old Age Pension Health Care Program, and certify that no supplemental charges have been, or will be, billed to the patient, except for those non-covered items, or services, if any, which are not reimbursable under the Old Age Pension Health Care Program.”
8.941.6 GENERAL EXCLUSIONS
In addition to any specific exclusion defined in this manual, the general exclusions from coverage of the Old Age Pension Health Care Program defined by the rules of the Department of Human Services (9 CCR 2503-1) are also excluded.
8.941.7 OUT-OF-STATE MEDICAL CARE
All requirements for out- of- state medical care as defined by 10 CCR 2505-10, Section 8.013 apply to the Old Age Pension Health Care Program for covered services with the exception that any reduction, suspension or elimination of benefits must be applied.
8.941.8 SUBMISSION OF CLAIMS
Rules governing the submission or payment of claims, provider or recipient appeals, third party liability, overpayment, fraud and abuse, and State identification numbers as defined in 10 CCR 2505-10, Section 8.000, et seq. apply to the Old Age Pension Health Care Program for covered services with the exception that any reduction, suspension or elimination of benefits provided must also be applied.
8.941.9 REIMBURSEMENT TO PROVIDERS
In accordance with 8.941.1(E), the Executive Director may alter the reimbursement for any service with the condition that expenditures remain within the constitutional and statutory limits. Reimbursement rates shall be published on the Department’s website. When reimbursement rates are modified, notification will be published in the Provider Bulletin.
8.941.10 CLIENT CO-PAYMENT
Recipients of benefits under the OAP Health Care Program shall be responsible for paying directly to providers a set portion of the cost of services according to the regulations and fee schedule as defined for the Medical Assistance and described in10 CCR 2505-10, Section 8.754.1. This charge to the recipient will be called co-payment.
Those recipients whose co-payments reach a limit of $300.00 within a January 1 through December 31 calendar year will be exempted from further co-payments during that year. The exemption will begin on the date of payment for the claim, which indicates that the cumulative maximum has been reached. It will be a recipient responsibility to present the Medical ID Card to the provider at the time a service is rendered in order to claim exemption from copayment for that service.
8.942 CHANGE OF SUPPLEMENTAL INCOME STATUS CODE (SISC) TO MEDICAID
8.942.1 MEDICAID QUALIFICATION
When a recipient of OAP-A or OAP-B and the OAP Health Care Program or Old Age Pension Health Care Supplemental Program subsequently qualifies for Medicaid, his/her SISC code must be changed to indicate Medicaid benefits. Additionally, the county must backdate the Medicaid benefits to the date the individual became eligible for Medicaid even if the recipient was eligible for the OAP Health Care Program or the Old Age Pension Health Care Supplemental Program at the time. Some reasons for Medicaid eligibility are: receipt of Supplemental Security Income, receipt of Social Security disability benefits, attainment of age 65, changes in alien status or reduction of resources that caused the individual to be ineligible for Medicaid.
8.943 IDENTIFICATION AND AFFIDAVIT REQUIREMENTS [Emer. Rule eff. 10/1/06; Perm. Rule eff. 10/30/06] 8.943.1 Effective August 1, 2006, each applicant eighteen (18) years of age or older shall produce the following identification:
A. A valid Colorado Driver’s License or a Colorado Identification Card, issued pursuant to Article 2 of Title 42, C.R.S.;
B. A United States Military Card or a Military Dependents’ Identification Card;
C. A United States Coast Guard Merchant Mariner Card;
D. A Native American Tribal Document; OR E. Other forms of identification or a waiver process to ensure that an individual proves lawful presence in the United States as authorized by the Executive Director of the Colorado Department of Revenue pursuant to Section 24-76.5-130(5)(a), C.R.S.
8.943.2 Effective August 1, 2006, each applicant eighteen (18) years of age or older shall execute an affidavit stating:
A. That he or she is a United States Citizen or legal permanent resident; OR B. That he or she is otherwise lawfully present in the United States pursuant to Federal Law. 8.943.3. For an applicant who has executed an affidavit stating that he or she is an alien lawfully present in the United States under 8.943.2.B, the following shall apply:
A. Verification of lawful presence shall be made through the Federal Systematic Alien Verification of Entitlement Program operated by the United States Department of Homeland Security or a successor program designated by the United States Department of Homeland Security.
B. Until such verification of lawful presence is made, the affidavit may be presumed to be proof of lawful presence.
C. The county or medical assistance site shall perform the verification of lawful presence no more than 30 days after receipt of the affidavit stating that the applicant is otherwise lawfully present in the United States pursuant to Federal Law.
8.943.4 Photocopies of the identification listed in 8.943.1 shall be acceptable identification if the photocopies meet the following criteria:
A. A notary public must have certified on the photocopy or an attachment that individually identifies the original document that he or she saw the original document and that the photocopy is a true copy of that original; OR B. Photocopies made by a county caseworker or medical assistance site worker who attests in writing on the photocopy that he or she saw the original documentation and that the photocopy is a true copy of that original.
8.943.5 The county shall retain a photocopy of the documentation required under section 8.943. 8.943.6.A. If an applicant does not have the required documentation, he or she must be given a reasonable opportunity period of up to ten (10) business days to provide the required documentation. If the applicant does not provide the required documentation within those ten (10) business days, then the application shall be denied.
8.943.6.B. If an applicant whose benefits are terminated on the basis of not having the documents required by 8.943.1 provides such documentation within ten (10) weeks of the date of denial, the denial shall be rescinded, and the client made eligible back to the data of application, provided he or she meet all other eligibility requirements.
8.950 PRIMARY CARE FUND
8.950.1 GENERAL DESCRIPTION
8.950.1.A. In accordance with Section 21 of Article X (Tobacco Taxes for Health Related Purposes) of the State Constitution, an increase in Colorado’s tax on cigarettes and tobacco products became effective January 1, 2005, and created a cash fund that was designated for health related purposes. House Bill 05-1262 divided the tobacco tax cash fund into separate funds, assigning 19% of the moneys to establish the Primary Care Fund, set forth how the funds will be allocated and designated the Department of Health Care Policy and Financing (the Department) as the administrator of the Primary Care Fund.
8.950.1.B. The Primary Care Fund provides an allocation of moneys to health care providers that make basic health care services available in an outpatient setting to residents of Colorado who are considered medically indigent. Moneys shall be allocated based on the number of medically indigent patients in an amount proportionate to the total number of medically indigent patients served by all health care providers who qualify for moneys from this fund.
8.950.2 DEFINITIONS
8.950.2.A. Arranges For - Demonstrating Established Referral Relationships with health care providers for any of the Comprehensive Primary Care services not directly provided by the provider.
8.950.2.B. Children’s Basic Health Plan also known as Child Health Plan Plus (CHP+) - As specified in Article 19 of Title 26, C.R.S.
8.950.2.C. Colorado Indigent Care Program (CICP) - As specified in Article 15 of Title 26, C.R.S. 8.950.2.D. Comprehensive Primary Care - Basic, entry-level health care provided by health care practitioners or non-physician health care practitioners that is generally provided in an outpatient setting. At a minimum, this includes providing or arranging for the provision of the following services on a Year-Round Basis: primary health care; maternity care, including prenatal care; preventive, developmental, and diagnostic services for infants and children; adult preventive services, diagnostic laboratory and radiology services; emergency care for minor trauma; Pharmaceutical Services; and coordination and follow-up for hospital care. It may also include optional services based on a patient’s needs such as dental, behavioral health and eyeglasses. 8.950.2.E. Cost-Effective Care - Provides or Arranges For Comprehensive Primary Care that is appropriate and at a reasonable average cost per patient Visit/Encounter. 8.950.2.F. Eligible Qualified Provider - A qualified Provider who is identified by the Department to receive funding from the Primary Care Fund.
8.950.2.G. Established Referral Relationship - A formal, written agreement in the form of a letter, a memorandum of agreement or a contract between two entities which includes:
8.950.2.H. Medical Assistance Program (Medicaid) - As specified in Article 4 of Title 26, C.R.S. 8.950.2.I. Medically Indigent Patient - A patient receiving medical services from a Qualified Provider and:
8.950.2.J. Medically Underserved Area - A federal government designation given to a geographical area based on the ratio of medical personnel (physicians, dentists, behavioral health workers, etc.) to the population. These areas have fewer than a generally accepted minimum number of medical personnel per thousand population resulting in insufficient health resources (personnel and/or facilities) to meet the medical needs of the resident population. Such areas are also defined by measuring the health status of the resident population; an area with an unhealthy population being considered underserved.
8.950.2.K. Medically Underserved Population - A federal government designation given to a human population that does not receive adequate medical attention or have access to health care facilities.
8.950.2.L. Outside Entity - A business or professional that is not classified as an employee of the provider or the Department and does not have a direct or indirect financial interest with the provider. The business or professional shall have auditing experience or experience working directly with the Medical Assistance Program or similar services or grants for Medically Indigent Patients.
8.950.2.M. Pharmaceutical Services - Provides prescription drugs, or coordinates access to or Arranges For client to receive prescription drugs prescribed by the Qualified Provider on a Sliding Fee Schedule or at no charge.
8.950.2.N. Qualified Provider - An entity that provides Comprehensive Primary Care in Colorado and that:
8.950.2.P. Sliding Fee Schedule - A tiered co-payment system that determines the level of patient’s financial participation and guarantees that the patient financial participation is below usual and customary charges. Factors considered in establishing the tiered co-payment system shall only be financial status and the number of members in the patient’s family unit. 8.950.2.Q. Third Party Payments or Third Party Payer - Any individual, entity or program with a legal obligation to pay for some or all health-related services rendered to a patient. Examples include the Medical Assistance Program; the Children’s Basic Health Plan; Medicare; commercial, individual or employment-related health insurance; court-ordered health insurance (such as that required by non-custodial parents); workers' compensation; automobile insurance; and long-term care insurance. The Colorado Indigent Care Program is not considered a Third Party Payer and payments received from the Colorado Indigent Care Program are not considered Third Party Payments.
8.950.2.R. Track Record - Evidence of providing Comprehensive Primary Care covering at least a consecutive 52-week period prior to the submission of the application. 8.950.2.S. Unduplicated User/Patient Count - The sum of patients who have had at least one Visit/Encounter and received at least one of the services under the Comprehensive Primary Care definition during the applicable calendar year, but does not include the same patient more than once. The sum shall be calculated on a specific point-in-time occurring between the end of the applicable calendar year and prior to the submission of the application. Each patient shall be counted once under only one payment source designation (Third Party Payer or Medically Indigent Patient). The patient’s payment source designation shall be the payment source designation listed for the patient at the specific point-in-time in which the calculation is made. The sum shall not include:
8.950.2.U. Year-Round Basis - Comprehensive Primary Care provided in a consecutive 52-week period directly by the provider and/or through an established referral relationship with other providers. If an organization is closed for four consecutive weeks or longer in a calendar year on a regularly scheduled basis, it is not considered to directly provide services on a year-round basis.
8.950.3 PROVIDER ELIGIBILITY
8.950.3.A. Providers who provide Comprehensive Primary Care to Medically Indigent Patients and who meet all of the requirements established for the Primary Care Fund as of the date the application form is submitted to the Department shall receive moneys appropriated to the Primary Care Fund. Specifically, the provider shall:
8.950.4 APPLICATION
8.950.4.A. The application form shall be available to providers annually and posted for public access on the Department's website at least 30 calendar days prior to the response due date. 8.950.4.B. At a minimum, the application form shall require responses that:
8.950.4.C. Providers shall complete and provide a response annually. The response shall be made in compliance with all specifications in the application form, including format, data and documentation. Responses to the application form shall be submitted directly to the Department by the required response deadline.
8.950.4.D. All providers who submit a response to the application form shall be notified within 45 days of the response deadline if the provider met or did not meet the requirements to become an Eligible Qualified Provider.
8.950.5 DISBURSEMENT
8.950.5.A. Eligible Qualified Providers are determined on a state fiscal year basis and shall receive only those moneys appropriated to the Primary Care Fund for that same state fiscal year, subject to the tax amount actually collected for that state fiscal year. 8.950.5.B. Payments shall be based on the number of Medically Indigent Patients in each Eligible Qualified Provider’s Unduplicated User/Patient Count in an amount proportionate to the total number of Medically Indigent Patients from all Eligible Qualified Providers’ Unduplicated User/Patient Counts.
8.950.5.C. The schedule for the disbursement of moneys to all Eligible Qualified Providers shall be dependent on actual tax collections allocated to the Primary Care Fund such that:
8.960 COLORADO DENTAL HEALTH CARE PROGRAM FOR LOW-INCOME SENIORS
8.960.1 Definitions
Arrange For or Arranging For means demonstrating established relations with Qualified Providers for any of the Covered Dental Care Services not directly provided by the applicant. Covered Dental Care Services include Diagnostic Imaging, Emergency Services, Endodontic Services, Evaluation, Oral and Maxillofacial Surgery, Palliative Treatment, Periodontal Treatment, Preventive Services, Prophylaxis, Removable Prosthesis, and Restorative Services as listed by alphanumeric procedure code in Appendix A.
C.R.S. means the Colorado Revised Statutes.
Dental Health Professional Shortage Area or Dental HPSA means a geographic area, population group, or facility so designated by the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
Dental Prosthesis means any device or appliance replacing one or more missing teeth and associated structures if required.
Department means the Colorado Department of Health Care Policy and Financing established pursuant to title 25.5, C.R.S. (2014).
Diagnostic Imaging means a visual display of structural or functional patterns for the purpose of diagnostic evaluation.
Economically Disadvantaged means a person whose Income is at or below 250% of the most recently published federal poverty level for a household of that size. Eligible Senior or Client means an adult who is 60 years of age or older, who is Economically Disadvantaged, who is able to demonstrate lawful presence in the country, who is not eligible for dental services under Medicaid or the Old Age Pension Health and Medical Care Program, and who does not have private dental insurance. An Eligible Senior shall be considered lawfully present in the country if they produce a document or waiver in accordance with 1 CCR 204-30 Rule 5 (effective August 30, 2016), which is hereby incorporated by reference. This incorporation of 1 CCR 204-30 Rule 5 excludes later amendments to, or editions of, the referenced material. Pursuant to § 24-4-103 (12.5), C.R.S., the Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, Colorado 80203. Certified copies of incorporated materials are provided at cost upon request. Emergency Services means the need for immediate intervention by a Qualified Provider to stabilize an oral cavity condition.
Endodontic Services means services which are concerned with the morphology, physiology and pathology of the human dental pulp and periradicular tissues, including pulpectomy. Evaluation means an assessment that may include gathering of information through interview, observation, examination, and use of specific tests that allows a dentist to diagnose existing conditions. Federally Qualified Health Center means a federally funded nonprofit health center or clinic that serves medically underserved areas and populations as defined in 42 U.S.C. section 1395x (aa)(4). Income means any cash, payments, wages, in-kind receipt, inheritance, gift, prize, rents, dividends, or interest that are received by an individual or family. Income may be self-declared. Resources are not included in Income.
Max Allowable Fee means the total reimbursement listed by procedure for Covered Dental Care Services under the Colorado Dental Health Care Program for Low-Income Seniors in Appendix A. The Max Allowable Fee is the sum of the Program Payment and the Max Client Co-Pay. Max Client Co-Pay means the maximum amount that a Qualified Provider may collect from an Eligible Senior listed by procedure in Appendix A for Covered Dental Services under the Colorado Dental Health Care Program for Low-Income Seniors.
Medicaid means the Colorado medical assistance program as defined in article 4 of title 25.5, C.R.S. (2014).
Old Age Pension Health and Medical Care Program means the program described at 10 CCR 2505-10, section 8.940 et. seq. and as defined in sections 25.5-2-101 and 26-2-111(2), C.R.S. (2014) Oral and Maxillofacial Surgery means the diagnosis, surgical and adjunctive treatment of diseases, injuries and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial region.
Palliative Treatment for dental pain means emergency treatment to relieve the client of pain; it is not a mechanism for addressing chronic pain.
Periodontal Treatment means the therapeutic plan intended to stop or slow periodontal disease progression.
Preventive Services means services concerned with promoting good oral health and function by preventing or reducing the onset and/or development of oral diseases or deformities and the occurrence of oro-facial injuries.
Program Payment means the maximum amount by procedure listed in Appendix A for Covered Dental Care Services for which a Qualified Grantee may invoice the Department under the Colorado Dental Health Care Program for Low-Income Seniors Prophylaxis means the removal of dental plaque and calculus from teeth, in order to prevent dental caries, gingivitis and periodontitis.
Qualified Grantee means an entity that can demonstrate that it can provide or Arrange For the provision of Covered Dental Care Services and may include but is not limited to:
Qualified Provider means a licensed dentist or dental hygienist in good standing in Colorado or a person who employs a licensed dentist or dental hygienist in good standing in Colorado and who is willing to accept reimbursement for Covered Dental Services. A Qualified Provider may also be a Qualified Grantee if the person meets the qualifications of a Qualified Grantee. Removable Prosthesis means complete or partial Dental Prosthesis, which after an initial fitting by a dentist, can be removed and reinserted by the eligible senior. Restorative Services means services rendered for the purpose of rehabilitation of dentition to functional or aesthetic needs of the client.
Senior Dental Advisory Committee means the advisory committee established pursuant to section 25.5-3- 406, C.R.S. (2014).
8.960.2 Legal Basis
The Colorado Dental Health Care Program for Low-Income Seniors is authorized by state law at part 4 of article 3 of title 25.5, C.R.S. (2014).
8.960.3 Request of Grant Proposals and Grant Award Procedures
8.960.3.A Request for Grant Proposals Grant awards shall be made through an application process. The request for grant proposals form shall be issued by the Department and posted for public access on the Department’s website at https://www.colorado.gov/hcpf/research-data-and-grants at least 30 days prior to the due date. 8.960.3.B Evaluation of Grant Proposals Proposals submitted for the Colorado Dental Health Care Program for Low-Income Seniors will be evaluated by a review panel in accordance with the following criteria developed under the advice of the Senior Dental Advisory Committee.
8.960.3.C Grant Awards The Department’s executive director, or his or her designee, shall make the final grant awards to selected Qualified Grantees for the Colorado Dental Health Care Program for Low-Income Seniors. 8.960.3.D Qualified Grantee Responsibilities A Qualified Grantee that is awarded a grant under the Colorado Dental Health Care Program for Low- Income Seniors is required to:
8.960.3.F Annual Report On or before September 1, 2016, and each September 1 thereafter, each Qualified Grantee receiving funds from the Colorado Dental Health Care Program for Low-Income Seniors shall submit a report to the Department following the state fiscal year contract period. The annual report shall be completed in a format specified by the Department and shall include:
Evaluation used by general dentist or a specialist when evaluating a client comprehensively. Applicable to new clients; established clients with significant health changes or other unusual circumstances; or established clients who have been absent from active treatment for three or more Comprehensive years. It is a thorough evaluation and oral evaluation - D0150 $81.00 $81.00 $0.00 recording of the extraoral and intraoral new or established hard and soft tissues, and an client evaluation and recording of the client's dental and medical history and general health assessment. A periodontal evaluation, oral cancer evaluation, diagnosis and treatment planning should be included. Frequency: 1 per 3 years per client. Cannot be charged on the same date as D0180.
Evaluation for clients presenting signs & symptoms of periodontal disease & clients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and Comprehensive recording of the client’s dental and periodontal D0180 $88.00 $88.00 $0.00 medical history and general health evaluation - new or assessment. It may include the established client evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation. Frequency: 1 per 3 years per client. Cannot be charged on the same date as D0150.
Radiographic survey of whole mouth, usually consisting of 14-22 periapical & posterior bitewing images intended to display the crowns & roots of all teeth, periapical areas of alveolar bone. Panoramic radiographic image & bitewing radiographic images taken on the same date of service shall not be billed as a D0210. Payment for Intraoral - complete additional periapical radiographs within series of 60 days of a full month series or a D0210 $125.00 $125.00 $0.00 radiographic panoramic film is not covered unless images there is evidence of trauma.
Frequency: 1 per 5 years per client.
Any combination of x-rays taken on the same date of service that equals or exceeds the max allowable fee for D0210 must be billed and reimbursed as D0210. Should not be charged in addition to panoramic film D0330.
Either D0330 or D0210 per 5 year period.
D0220 one (1) per day per client.
Report additional radiographs as D0230. Any combination of D0220, Intraoral - D0230, D0270, D0272, D0273, or periapical first D0220 $25.00 $25.00 $0.00 D0274 taken on the same date of radiographic image service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. D0210 will only be reimbursed every 5 years.
D0230 must be utilized for additional films taken beyond D0220. Any combination of D0220, D0230, D0270, Intraoral - D0272, D0273, or D0274 taken on the periapical each D0230 $23.00 $23.00 $0.00 same date of service that exceeds the additional max allowed fee for D0210 is radiographic image reimbursed at the same fee as D0210.
D0210 will only be reimbursed every 5 years.
Frequency: 1 in a 12 month period.
Report more than 1 radiographic image as: D0272 two (2); D0273 three (3); D0274 four (4). Any combination Bitewing - single D0270 $26.00 $26.00 $0.00 of D0220, D0230, D0270, D0272, radiographic image D0273, or D0274 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.
Frequency: 1 time in a 12 month period. Any combination of D0220, Bitewings - two D0230, D0270, D0272, D0273, or radiographic D0272 $42.00 $42.00 $0.00 D0274 taken on the same date of images service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.
Frequency: 1 time in a 12 month period. Any combination of D0220, Bitewings - three D0230, D0270, D0272, D0273, or radiographic D0273 $52.00 $52.00 $0.00 D0274 taken on the same date of images service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.
Frequency: 1 time in a 12 month period. Any combination of D0220, Bitewings - four D0230, D0270, D0272, D0273, or radiographic D0274 $60.00 $60.00 $0.00 D0274 taken on the same date of images service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210.
Frequency: 1 per 5 years per client.
Panoramic Cannot be charged in addition to full D0330 $63.00 $63.00 $0.00 radiographic image mouth series D0210. Either D0330 or D0210 per 5 years.
D1110 may be billed with D4341 and D4342 one time during initial periodontal therapy for prophylaxis of areas of the mouth not receiving nonsurgical periodontal therapy. When this Prophylaxis - adult D1110 $88.00 $88.00 $0.00 option is used, individual should still be placed on D4910 for maintenance of periodontal disease. D1110 can only be charged once, not per quadrant, and represents areas of the mouth not included in the D4341 or D4342 being reimbursed.
May be alternated w/D4910 for maintenance of periodontally- involved individuals.
Cannot be used as 1 month re-evaluation following nonsurgical periodontal therapy.
Topical fluoride application is to be used in conjunction with prophylaxis or Topical application preventive appointment. Should be D1206 $52.00 $52.00 $0.00 of fluoride varnish applied to whole mouth. Frequency: up to four (4) times per 12 calendar months. Cannot be used with D1208.
Any fluoride application, including swishing, trays or paint on variety, to be used in conjunction with Topical application prophylaxis or preventive appointment. of fluoride - D1208 $52.00 $52.00 $0.00 Frequency: one (1) time per 12 excluding varnish calendar months. Cannot be used with D1206. D1206 varnish should be utilized in lieu of D1208 whenever possible.
Includes tooth preparation, all adhesives, liners, polishing, and Amalgam - one bases. Adjustments are included.
surface, primary or D2140 $107.00 $97.00 $10.00 Frequency: 36 months for the same permanent restoration. See Explanation of Restorations.
surfaces, primary D2150 $138.00 $128.00 $10.00 Frequency: 36 months for the same or permanent restoration. See Explanation of Restorations.
surfaces, primary D2160 $167.00 $157.00 $10.00 Frequency: 36 months for the same or permanent restoration. See Explanation of Restorations.
composite - one D2330 $115.00 $105.00 $10.00 Adjustments are included. See surface, anterior Explanation of Restorations.
composite - two D2331 $146.00 $136.00 $10.00 Adjustments are included. Frequency: surfaces, anterior 36 months for the same restoration.
composite - three D2332 $179.00 $169.00 $10.00 Adjustments are included. Frequency: surfaces, anterior 36 months for the same restoration.
Resin-based Includes tooth preparation, all composite - four or adhesives, liners, etching, and bases. more surfaces or D2335 $212.00 $202.00 $10.00 Adjustments are included. Frequency: involving incisal 36 months for the same restoration.
angle (anterior) See Explanation of Restorations.
composite - one D2391 $134.00 $124.00 $10.00 Adjustments are included. Frequency: surface, posterior 36 months for the same restoration.
composite -two D2392 $176.00 $166.00 $10.00 Adjustments are included. Frequency: surfaces, posterior 36 months for the same restoration. See Explanation of Restorations.
composite - three D2393 $218.00 $208.00 $10.00 Adjustments are included. Frequency: surfaces, posterior 36 months for the same restoration. See Explanation of Restorations.
composite - four or D2394 $268.00 $258.00 $10.00 Adjustments are included. Frequency: more surfaces, 36 months for the same restoration.
posterior See Explanation of Restorations.
Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, Crown - 3/4 cast D2752, D2781, D2782, D2783, D2790, predominantly base D2781 $780.00 $730.00 $50.00 D2791, D2792, or D2794. Second metal molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.
Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, Crown - 3/4 cast D2782 $780.00 $730.00 $50.00 D2791, D2792, or D2794. Second noble metal molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.
Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, Crown - 3/4 D2783 $780.00 $730.00 $50.00 D2791, D2792, or D2794. Second porcelain/ceramic molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.
Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, Crown - full cast D2790 $780.00 $730.00 $50.00 D2791, D2792, or D2794. Second high noble metal molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.
Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, Crown - full cast D2752, D2781, D2782, D2783, D2790, predominantly base D2791 $780.00 $730.00 $50.00 D2791, D2792, or D2794. Second metal molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.
Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, Crown - full cast D2792 $780.00 $730.00 $50.00 D2791, D2792, or D2794. Second noble metal molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.
Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, Crown - titanium D2794 $780.00 $730.00 $50.00 D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion.
Re-cement or re- bond inlay, onlay, Not allowed within 6 months of veneer or partial D2910 $87.00 $77.00 $10.00 placement.
coverage restoration Re-cement or re- Not allowed within 6 months of D2920 $89.00 $79.00 $10.00 bond crown placement.
Cast post and core D2952 $332.00 $307.00 $25.00 Refers to building up of anatomical in addition to crown crown when restorative crown will be placed. Not payable on the same tooth and same day as D2951.
Complete root canal therapy; Includes all appointments necessary to Endodontic complete treatment; also includes therapy, molar intra-operative radiographs. Does not D3330 $786.31 $736.31 $50.00 (excluding final include diagnostic evaluation and restoration) necessary radiographs/diagnostic images. Teeth covered: 2, 3, 14, 15, 18, 19, 30, and 31.
Involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. For clients with periodontal disease and is therapeutic, not prophylactic. D4341 and D1110 can be reported on same service date when D1110 is utilized for areas of the mouth that are not affected by periodontal disease. D1110 can only be charged once, not per quadrant; A diagnosis of periodontitis with clinical attachment loss (CAL) included.
Diagnosis and classification of the Periodontal scaling periodontology case type must be in & root planing - four accordance with documentation as D4341 $177.00 $167.00 $10.00 or more teeth per currently established by the American quadrant Academy of Periodontology. Current periodontal charting must be present in client chart documenting active periodontal disease. Frequency:
1 time per quadrant per 36 month interval.
No more than 2 quadrants may be considered in a single visit in a non-hospital setting.
Documentation of other treatment provided at same time will be requested.
Any follow-up and re- evaluation are included in the initial reimbursement.
Involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. For clients with periodontal disease and is therapeutic, not prophylactic. D4342 and D1110 can be reported on same service date when date when D1110 is utilized for areas of the mouth that are not affected by periodontal disease.
D1110 can only be charged once, not per quadrant; A diagnosis of Periodontal scaling periodontitis with clinical attachment & root planing - one loss (CAL) included. Current D4342 $128.00 $128.00 $0.00 to three teeth per periodontal charting must be present quadrant in client chart documenting active periodontal disease. Frequency:
1 time per quadrant per 36 month interval.
No more than 2 quadrants may be considered in a single visit in a non-hospital setting..
Documentation of other treatment provided at same time will be requested.
Any follow-up and re- evaluation are included in the initial reimbursement.
Procedure following periodontal therapy D4341 or D4342. This procedure includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, Periodontal site specific scaling and root planing maintenance D4910 $136.00 $136.00 $0.00 where indicated and polishing the procedures teeth. Frequency:
Up to four times per fiscal year per client.
Cannot be charged within the first three months following active periodontal treatment.
Reimbursement made upon delivery of a complete maxillary denture to the client. D5110 or D5120 cannot be used to report an immediate denture, D5130 or D5140. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A complete denture is made after teeth have been removed and the gum and Complete denture - bone tissues have healed - or to D5110 $793.00 $713.00 $80.00 maxillary replace an existing denture. Complete dentures are provided once adequate healing has taken place following extractions. This can vary greatly depending upon client, oral health, overall health, and other confounding factors. Frequency: Program will only pay for one per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of a complete mandibular denture to the client. D5110 or D5120 cannot be used to report an immediate denture, D5130, D5140. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A complete denture is made after teeth have been removed and the gum and Complete denture - bone tissues have healed - or to D5120 $793.00 $713.00 $80.00 mandibular replace an existing denture. Complete dentures are provided once adequate healing has taken place following extractions. This can vary greatly depending upon client, oral health, overall health, and other confounding factors. Frequency: Program will only pay for one per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of an immediate maxillary denture to the client. Routine follow-up adjustments/soft tissue condition relines within 6 months are to be anticipated and are included in the initial reimbursement. An immediate denture is made prior to teeth being Immediate denture extracted and is inserted same day of D5130 $793.00 $713.00 $80.00 – maxillary extraction of remaining natural teeth.
Frequency: D5130 can be reimbursed only once per lifetime per client.
Complete denture, D5110, may be considered 5 years after immediate denture was reimbursed.
Documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of an immediate mandibular denture to the client. Routine follow-up adjustments/soft tissue condition relines within 6 months are to be anticipated and are included in the initial reimbursement. An immediate denture is made prior to teeth being Immediate denture extracted and is inserted same day of D5140 $793.00 $713.00 $80.00 – mandibular extraction of remaining natural teeth.
Frequency: D5140 can be reimbursed only once per lifetime per client.
Complete dentures, D5120, may be considered 5 years after immediate denture was reimbursed – documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of a complete partial maxillary denture to the client. D5211 and D5212 are considered definitive treatments.
Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial resin base denture can be made right after Maxillary partial having teeth extracted (healing from denture - resin only a few teeth is not as extensive as base (including any healing from multiple). A partial resin D5211 $700.00 $640.00 $60.00 conventional base denture can also be made before clasps, rests and having teeth extracted if the teeth teeth) being removed are in the front or necessary healing will be minimal.
Several impressions and "try-in"
appointments may be necessary and are included in the cost. Frequency:
Program will only pay for one resin maxillary per every 3 years - documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of a complete partial mandibular denture to the client. D5211 and D5212 are considered definitive treatment.
Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial resin base denture can be made right after having Mandibular partial teeth extracted (healing from only a denture - resin few teeth is not as extensive as base (including any healing from multiple). A partial resin D5212 $778.00 $718.00 $60.00 conventional base denture can also be made before clasps, rests and having teeth extracted if the teeth teeth) being removed are in the front or necessary healing will be minimal.
Several impressions and "try-in"
appointments may be necessary and are included in the cost. Frequency:
Program will only pay for one resin mandibular per every 3 years - documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of a complete partial maxillary denture to the client. D5213 and D5214 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial Maxillary partial reimbursement. A partial cast metal denture – cast base can also be made right after metal framework having teeth extracted (healing from with resin denture only a few teeth is not as extensive D5213 $778.00 $718.00 $60.00 bases (including as healing from multiple). A partial any conventional cast metal base denture can be clasps, rests and made before having teeth extracted teeth) if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost. Frequency: Program will only pay for one maxillary per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of a complete partial mandibular denture to the client. D5213 and D5214 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial Mandibular partial reimbursement. A partial cast metal denture – cast base can be made right after having metal framework teeth extracted (healing from only a with resin denture few teeth is not as extensive as D5214 $778.00 $718.00 $60.00 bases (including healing from multiple). A partial cast any conventional metal base denture can also be clasps, rests and made before having teeth extracted teeth) if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and “try-in” appointments may be necessary and are included in the cost. Frequency: Program will only pay for one mandibular per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of an immediate partial maxillary denture to the client. D5221 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in Immediate the initial reimbursement. An maxillary partial immediate partial resin base denture denture – resin can be made before having teeth base (including any D5221 $509.00 $449.00 $60.00 extracted if the teeth being removed conventional are in the front or necessary healing clasps, rests and will be minimal. Several impressions teeth)
and "try-in" appointments may be necessary and are included in the cost. Frequency: A maxillary partial denture may be considered 3 years after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained.
Reimbursement made upon delivery of an immediate partial mandibular denture to the client. D5222 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months is to be anticipated and are Immediate included in the initial reimbursement.
mandibular partial An immediate partial resin base denture – resin denture can be made before having base (including any D5222 $509.00 $449.00 $60.00 teeth extracted if the teeth being conventional removed are in the front or necessary clasps, rests and healing will be minimal. Several teeth)
Frequency: A mandibular partial denture may be considered 5 years after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained.
Repair broken complete denture D5510 $87.00 $77.00 $20.00 Repair broken complete denture base. base Replace missing or broken teeth - Replacement/repair of missing or D5520 $73.00 $63.00 $10.00 complete denture broken teeth.
(each tooth)
Repair resin Repair of upper/lower partial denture D5610 $95.00 $85.00 $10.00 denture base base.
Repair or replace Repair of broken clasp on partial D5630 $123.00 $113.00 $10.00 broken clasp denture base – per tooth.
Replace broken D5640 $80.00 $70.00 $10.00 Repair/replacement of missing tooth. teeth-per tooth Adding tooth to partial denture base.
Add tooth to Documentation may be requested existing partial D5650 $109.00 $99.00 $10.00 when charged on partial delivered in denture last 12 months.
Rebasing the denture base material due to alveolar ridge resorption.
Frequency: one (1) time per 12 Rebase complete months. Completed at laboratory.
D5711 $322.00 $297.00 $25.00 mandibular denture Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period.
Rebasing the partial denture base material due to alveolar ridge resorption. Frequency: one (1) time Rebase maxillary per 12 months. Completed at D5720 $304.00 $279.00 $25.00 partial denture laboratory. Cannot be charged on denture provided in the last 6 months.
Cannot be charged in addition to a reline in a 12 month period.
Rebasing the partial denture base material due to alveolar ridge resorption. Frequency: one (1) time Rebase mandibular per 12 months. Completed at D5721 $304.00 $279.00 $25.00 partial denture laboratory. Cannot be charged on denture provided in the last 6 months.
Cannot be charged in addition to a reline in a 12 month period.
Chair side reline that resurfaces without processing denture base.
Reline complete Frequency: One (1) time per 12 maxillary denture D5730 $182.00 $172.00 $10.00 months. Cannot be charged on (chairside) denture provided in the last 6 months.
Reline complete Frequency: One (1) time per 12 mandibular denture D5731 $182.00 $172.00 $10.00 months. Cannot be charged on (chairside) denture provided in the last 6 months.
Cannot be charged in addition to a rebase in a 12 month period.
Laboratory reline that resurfaces with processing denture base. Frequency:
Reline complete one (1) time per 12 months. Cannot be maxillary denture D5750 $243.00 $218.00 $25.00 charged on denture provided in the (laboratory) last 6 months. Cannot be charged in addition to a rebase in a 12 month period.
Reline complete one (1) time per 12 months. Cannot be mandibular denture D5751 $243.00 $218.00 $25.00 charged on denture provided in the (laboratory) last 6 months. Cannot be charged in addition to a rebase in a 12 month period.
Reline maxillary Frequency: one (1) time per 12 partial denture D5760 $239.00 $214.00 $25.00 months. Cannot be charged on (laboratory) denture provided in the last 6 months.
Reline mandibular Frequency: one (1) time per 12 partial denture D5761 $239.00 $214.00 $25.00 months. Cannot be charged on (laboratory) denture provided in the last 6 months.
root (elevation D7140 $82.00 $72.00 $10.00 Treatment notes must include and/or forceps documentation that an extraction was removal)
Surgical removal of erupted tooth Includes removal of bone, and/or requiring removal sectioning of erupted tooth, smoothing of bone and/or of socket bone and closure as sectioning of tooth, D7210 $135.00 $125.00 $10.00 necessary. Treatment notes must and including include documentation that a surgical elevation of extraction was done per tooth.
mucoperiosteal flap if indicated Includes removal of bone, and/or sectioning of residual tooth roots, smoothing of socket bone and closure as necessary. Treatment notes must Surgical removal of include documentation that a surgical residual tooth roots D7250 $143.00 $133.00 $10.00 extraction was done per tooth. Can (cutting procedure)
Alveoloplasty in conjunction with Substantially reshaping the bone after extractions - four or an extraction procedure, much more D7310 $150.00 $140.00 $10.00 more teeth or tooth than minor smoothing of the bone.
spaces, per Reported per quadrant.
quadrant Alveoloplasty in conjunction with Substantially reshaping the bone after extractions - one to an extraction procedure, much more D7311 $138.00 $128.00 $10.00 three teeth or tooth than minor smoothing of the bone.
spaces, per Reported per quadrant.
quadrant Alveoloplasty not in conjunction with Substantially reshaping the bone after extractions - four or an extraction procedure, correcting D7320 $150.00 $140.00 $10.00 more teeth or tooth anatomical irregularities. Reported per spaces, per quadrant.
quadrant Alveoloplasty not in conjunction with Substantially reshaping the bone after extractions - one to an extraction procedure, correcting D7321 $138.00 $128.00 $10.00 three teeth or tooth anatomical irregularities. Reported per spaces, per quadrant.
quadrant Removal of torus To remove a malformation of bone for D7472 $308.00 $298.00 $10.00 palatinus proper prosthesis fabrication.
Removal of torus To remove a malformation of bone for D7473 $300.00 $290.00 $10.00 mandibularis proper prosthesis fabrication.
Incision & drainage Incision through mucosa, including of abscess - D7510 $193.00 $183.00 $10.00 periodontal origins.
intraoral soft tissue Emergency treatment to alleviate pain/discomfort. This code cannot be used for filing claims or writing or calling in a prescription to the Palliative pharmacy or to address situations that (emergency)
procedure Report per visit, no procedure.
Anterior 3 Placed, without interruption, on three of the five surface classifications – e.g., Lingual–Mesial–Labial.
Posterior 3 Placed, without interruption, on three of the five surface classifications – e.g., Lingual-Occlusal-Distal.
_________________________________________________________________________ EDITOR’S NOTES 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 03/04/2007, 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 All Versions list on the rule's current version page. To view versions effective on or after 03/04/2007, 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]