The ASC is responsible for obtaining required billing information from the surgeon. ASC providers are required to verify Medicaid eligibility before services are rendered. If eligibility is not verified, payment may be denied.
ICD-9-CM diagnosis: The diagnosis field(s) must be completed with an appropriate ICD-9-CM diagnosis code(s).
Place of service: Complete the Place Of Service (POS) field with a "24" for ASC facility charges.
Note: Electronic billers should consult the software instructions to assure that POS coding is submitted properly.
Rendering provider: Complete with the eight digit Colorado Medical Assistance Program provider number assigned to the operating surgeon.
Referring provider: If the member is enrolled in the Primary Care Physician (PCP) program and the operating surgeon is not the PCP, the PCP's Colorado Medical Assistance Program provider number must be entered in this field. PCP-enrolled members must obtain PCP referral if surgical services are performed by a physician other than the PCP. If the member does not have an assigned PCP, this field may be left blank.
Sterilization procedures: All sterilization claims must have an attached copy of a properly completed MED-178 sterilization consent form. The surgeon is responsible for providing a copy of the MED-178 to the ASC. Claims without a properly completed MED-178 are denied. Refer to the Ambulatory Surgical Centers provider manual for complete billing requirements.
Hysterectomy procedures: Hysterectomy procedures are a benefit of Colorado Medicaid when performed solely for medical reasons. Hysterectomy is not a benefit if the procedure is performed solely for the purpose of sterilization, or if there was more than one purpose for the procedure and it would not have been performed but for the purpose of sterilization. Refer to the Ambulatory Surgical Centers provider manual for complete billing requirements.
Medicare crossover claims: Medicaid pays the Medicare deductible and coinsurance or the Medicaid-allowed benefit minus the Medicare payment, whichever is less. If Medicare’s payment equals or is more than the Medicaid allowed benefit, crossover claims are paid at zero.
Most Medicare crossover claims are transmitted electronically from Medicare to Medicaid. If a Medicare claim does not cross automatically, the provider is responsible for submitting a "hardcopy crossover" claim on the CMS 1500 paper claim form. Refer to the end of the manual for an example of a completed paper crossover claim.
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