CO · guidance
CO HCPF Children's Habilitation Residential Program (CHRP) Waiver Program Billing Manual — Paper Claim Reference Table
PaperClaimReferenceTable
Thefollowingpaperformreferencetablegivesrequiredand/orconditionalfieldsforthepaperCMS1500claimformforCHRPclaims:
CMSFieldNumberandLabel
Fieldis?
Instructions
1.InsuranceType
Required
Placean"X"intheboxmarkedasMedicaid.
1a.Insured'sIDNumber
Required
Enterthemember'sHealthFirstColoradoseven(7)-digitIDnumberasitappearsontheHealthFirstColoradoIdentificationcard.Example:A123456.
2.Patient'sName
Required
Enterthemember'slastname,firstname,andmiddleinitial.
3.Patient'sDateofBirth/Sex
Required
Enterthemember'sbirthdateusingtwo(2)digitsforthemonth,two(2)digitsforthedate,andtwo(2)digitsfortheyear.Example:070114forJuly1,2014.Placean"X"intheappropriateboxtoindicatethesexofthemember.
4.Insured'sName
Notrequired
5.Patient'sAddress
NotRequired
6.ClientRelationshiptoInsured
NotRequired
7.Insured'sAddress
NotRequired
8.ReservedforNUCCUse
NotRequired
9.OtherInsured'sName
NotRequired
9a.OtherInsured'sPolicyorGroupNumber
NotRequired
9b.ReservedforNUCCUse
9c.ReservedforNUCCUse
9d.InsurancePlanorProgramName
NotRequired
10a-c.Ispatient'sconditionrelatedto?
NotRequired
10d.ReservedforLocalUse
11.Insured'sPolicy,GrouporFECANumber
NotRequired
11a.Insured'sDateofBirth,Sex
NotRequired
11b.OtherClaimID
NotRequired
11c.InsurancePlanNameorProgramName
NotRequired
11d.IsthereanotherHealthBenefitPlan?
NotRequired
12.Patient'sorAuthorizedPerson'ssignature
Required
Enter"SignatureonFile","SOF",orlegalsignature.Ifthereisnosignatureonfile,leaveblankorenter"NoSignatureonFile".Enterthedatetheclaimformwassigned.
13.Insured'sorAuthorizedPerson'sSignature
NotRequired
14.DateofCurrentIllnessInjuryorPregnancy
NotRequired
15.OtherDate
NotRequired
16.DatePatientUnabletoWorkinCurrentOccupation
NotRequired
17.NameofReferringPhysician
Conditional
18.HospitalizationDatesRelatedtoCurrentService
NotRequired
19.AdditionalClaimInformation
Conditional
20.OutsideLab?$Charges
NotRequired
21.DiagnosisorNatureofIllnessorInjury
Required
Enteratleastone(1)butnomorethan12diagnosiscodesbasedonthemember'sdiagnosis/condition.EnterapplicableICD-10indicator.HCBSCHRPmayuseR69
22.MedicaidResubmissionCode
Conditional
Listtheoriginalreferencenumberforresubmittedclaims.Whenresubmittingaclaim,entertheappropriatebillfrequencycodeintheleft-handsideofthefield.7-Replacementofpriorclaim8-Void/CancelofpriorclaimThisfieldisnotintendedforusefororiginalclaimsubmissions.
23.PriorAuthorization
NotRequired
HCBSLeaveBlank
24.ClaimLineDetail
Information
Thepaperclaimformallowsentryofuptosix(6)detailedbillinglines.Fields24Athrough24Japplytoeachbilledline.Donotentermorethansix(6)linesofinformationonthepaperclaim.Ifmorethansix(6)linesofinformationareentered,theadditionallineswillnotbeenteredforprocessing.Eachclaimformmustbefullycompleted(totaled).Donotfilecontinuationclaims(e.g.,Page1of2).
24A.DatesofService
Required
Thefieldaccommodatestheentryoftwo(2)dates:a"From"dateofservicesanda"To"dateofservice.Enterthedateofserviceusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:010116forJanuary1,2016.
From
To
01
01
19
or
From
To
01
01
19
01
01
19
Spandatesofservice
From
To
01
01
19
01
31
19
Practitionerclaimsmustbeconsecutivedays.SingleDateofService:Enterthesix(6)-digitdateofserviceinthe"From"field.Completionofthe"Tofieldisnotrequired.Donotspreadthedateentryacrossthetwo(2)fields.Spanbilling:permissibleifthesameservice(sameprocedurecode)isprovidedonconsecutivedates.
24B.PlaceofService
Required
EnterthePlaceofService(POS)codethatdescribesthelocationwhereserviceswererendered.HealthFirstColoradoacceptstheCMSplaceofservicecodes.
03
School
11
Office
12
Home
34
Hospice
Note:UsePOSCode12(Home)forFosterHome,GroupHomeandRespite.UseetherPOS11(Office)orPOS11(Home)whereapplicableforallotherservices.
24C.EMG
NotRequired
24D.Procedures,Services,orSupplies
Required
EntertheHCPCSprocedurecodethatspecificallydescribestheserviceforwhichpaymentisrequested.HCBS
RefertotheCHRPRateScheduleslocatedontheRatesandFeeSchedulewebpage.
24D.Modifier
Required
Entertheappropriateprocedure-relatedmodifierthatappliestothebilledservice.Uptofour(4)modifiersmaybeenteredwhenusingthepaperclaimform.HCBS
RefertotheCHRPRateScheduleslocatedontheRatesandFeeSchedulewebpage.
24E.DiagnosisPointer
Required
Enterthediagnosiscodereferenceletter(A-L)thatrelatesthedateofserviceandtheproceduresperformedtotheprimarydiagnosis.Atleastone(1)diagnosiscodereferencelettermustbeentered.Whenmultipleservicesareperformed,theprimaryreferenceletterforeachserviceshouldbelistedfirst,otherapplicableservicesshouldfollow.Thisfieldallowsfortheentryoffour(4)charactersintheunshadedarea.
24F.$Charges
Required
Entertheusualandcustomarychargefortheservicerepresentedbytheprocedurecodeonthedetailline.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.SomeCPTprocedurecodesaregroupedwithotherrelatedCPTprocedurecodes.Whenmorethanone(1)procedurefromthesamegroupisbilled,specialmultiplepricingrulesapply.Thebaseprocedureistheprocedurewiththehighestallowableamount.ThebasecodeisusedtodeterminetheallowableamountsforadditionalCPTsurgicalprocedureswhenmorethanone(1)procedurefromthesamegroupingisperformed.Submittedchargescannotbemorethanchargesmadetonon-HealthFirstColoradocoveredindividualsforthesameservice.DonotdeductHealthFirstColoradoco-payorcommercialinsurancepaymentsfromtheusualandcustomarycharges.
24G.DaysorUnits
Required
Enterthenumberofservicesprovidedforeachprocedurecode.Enterwholenumbersonly-donotenterfractionsordecimals.
24G.DaysorUnits
GeneralInstructions
Aunitrepresentsthenumberoftimesthedescribedprocedureorservicewasrendered.ExceptasinstructedinthismanualorinHealthFirstColoradobulletins,thebilledunitmustcorrespondtoprocedurecodedescriptions.Thefollowingexamplesshowtherelationshipbetweentheproceduredescriptionandtheentryofunits.HomeandCommunity-BasedServicesCombineunitsofservicesforasingleprocedurecodeforthebilledtimeperiodonone(1)detailline.Datesofservicedonothavetobereportedseparately.Example:If40unitsofpersonalcareserviceswereprovidedonvariousdaysthroughoutthemonthofJanuary,billthepersonalcareprocedurecodewithaFromDateof01/03/XXandaToDateof01/31/XXand40units.
24H.EPSDT/FamilyPlan
NotRequired
24I.IDQualifier
NotRequired
24J.RenderingProviderID#
Required
Intheshadedportionofthefield,entertheNPIoftheHealthFirstColoradoprovidernumberassignedtotheindividualwhoactuallyperformedorrenderedthebilledservice.Thisnumbercannotbeassignedtoagrouporclinic.
25.FederalTaxIDNumber
NotRequired
26.Patient'sAccountNumber
Optional
Enterinformationthatidentifiesthememberorclaimintheprovider'sbillingsystem.SubmittedinformationappearsontheRemittanceAdvice(RA).
27.AcceptAssignment?
Required
Theacceptassignmentindicatesthattheprovideragreestoacceptassignmentunderthetermsofthepayer'sprogram.
28.TotalCharge
Required
Enterthesumofallchargeslistedinfield24F.Donotusecommaswhenreportingdollaramounts.Enter00inthecentsareaiftheamountisawholenumber.
29.AmountPaid
NotRequired
30.RsvdforNUCCUse
31.SignatureofPhysicianorSupplierIncludingDegreesorCredentials
Required
Eachclaimmustbearthesignatureoftheenrolledproviderorthesignatureofaregisteredauthorizedagent.Eachclaimmusthavethedatetheenrolledproviderorregisteredauthorizedagentsignedtheclaimform.Enterthedatetheclaimwassignedusingtwo(2)digitsforthemonth,two(2)digitsforthedateandtwo(2)digitsfortheyear.Example:070116forJuly1,2016.
32.32-ServiceFacilityLocationInformation32a-NPINumber32b-OtherID#
Conditional
Enterthename,addressandZIPcodeoftheindividualorbusinesswherethememberwasseenorservicewasperformedinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCodeIftheProviderTypeisnotabletoobtainanNPI,entertheeight(8)-digitHealthFirstColoradoprovidernumberoftheindividualororganization.
33.BillingProviderInfo&Ph#
Required
Enterthenameoftheindividualororganizationthatwillreceivepaymentforthebilledservicesinthefollowingformat:1stLineName2ndLineAddress3rdLineCity,StateandZIPCode
33a-NPINumber
Required
33b-OtherID#
IftheProviderTypeisnotabletoobtainanNPI,entertheeight(8)-digitHealthFirstColoradoprovidernumberoftheindividualororganization.
BacktoTop
BacktoTop
Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
241c4219d49c7f56f35d5c0cf967a04847f4c20312657b3eb8d59fdf35b58a5d
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.