CO · guidance
CO HCPF General Provider Information Manual — Administration
Administration
TheSocialSecurityActprovidesentitlementtomedicalservicesforindividualswhomeeteligibilityrequirements.TitleXVIIIgovernstheMedicareProgram,andTitleXIXestablishestheStateOptionMedicalAssistanceProgram,alsoknownasHealthFirstColorado.TheColoradoMedicalAssistanceActprovidesthelegalauthorityfortheHealthFirstColoradoprogram.
TheHealthFirstColoradoprogramisastateandfederalpartnershipfundedbytheStateofColoradoandfederalmatchingdollars.StatefundsareappropriatedthroughtheColoradoLegislature.Federalfundingisdependentuponcompliancewithfederalguidelines.
Bystatute,HealthFirstColoradopaysforcoveredhealthcarebenefitsforeligiblemembersafterallotherhealthcareresourceshavebeenexhausted.TheHealthFirstColoradoprogramisanentitlementprogram,whichmeansthatanypersonwhomeetstheeligibilitycriteriaisentitledtoreceiveanymedicallynecessaryservicecoveredbytheprogram.Coveredbenefitsincludemostmedicalservicesandlimitedrelatedsupportservicesrequiredinthediagnosisandtreatmentofdisease,disability,infirmityorimpairment.Ingeneral,HealthFirstColoradobenefitsarecomprehensiveandprovidecareinmostmedicaldisciplines.RefertotheBenefitsandBenefitDeliveryProgramssectionfordetailedbenefitinformation.
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TheDepartment:
Establishesthepolicies,rulesandregulationsthatgovernHealthFirstColorado.
AdministersHealthFirstColoradotoassurecompliancewithstateandfederalrules,guidelinesandregulations.
AdministersaModifiedMedicalProgramprovidinglimitedmedicalbenefitsforneedycitizensaged60andolderwhoarenoteligibleforHealthFirstColoradocoverage.BenefitsfortheseindividualsaresimilarbutnotidenticaltoHealthFirstColoradocoverage.
AdministersothermedicalassistanceprogramssuchasChildHealthPlanPlus(CHP+)andtheColoradoIndigentCareProgram(CICP).
EstablishesHealthFirstColoradopolicy.
Determinesbenefitandreimbursementlevelsforallmedicalassistanceprogramsaccordingtostateandfederallegislativeintent.
Directsandmonitorstheactivitiesofthefiscalagent.
Reviewsandmonitorsprogramutilization.
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TheCountyDepartmentsofHuman/SocialServices:
DetermineHealthFirstColoradomembereligibility.
IssueMedicalIdentificationCards(MICCard)toeligiblemembers.
AdviseHealthFirstColoradomembersofHealthFirstColoradobenefits.
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TheFiscalAgent(FA):
EnrollsHealthFirstColoradoproviders.
Provideseducationandbillingassistancetoenrolledproviders.
Receives,controlsandprocessesHealthFirstColoradoclaimsaccordingtoDepartmentpolicy.
Respondstoproviderinquiries.
PreparestheDepartment'srequiredfinancialandutilizationreports.
PreparesanddistributesRemittanceAdvice(RA).
Adjustsclaimsasrequired.
AcceptsandprocessesReconsiderationrequests.
ProducestheHealthFirstColoradoProviderManualsincooperationwiththeDepartment.
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Providersareresponsiblefor:
Maintainingtheircopiesofthemanualinacurrent,updatedmanner(providermanualupdatesandrevisionsaremadetomanualspostedtotheBillingManualswebpage.UpdatenotificationsarepublishedintheProviderBulletins).
Keepingproviderenrollmentinformationcurrentwiththefiscalagent.
Submittingclaimscorrectlytothefiscalagent.
FollowingtheproceduresandguidelinesforprogramparticipationestablishedbytheDepartment.
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Membersareresponsiblefor:
Understandingtheirrights.
FollowingtheMemberHandbook.
Cooperatingwithandbeingrespectfultoothermembers,providersandtheirstaff.
ChoosingaproviderfromwithintheirplannetworkorcontactingtheDepartmentiftheywanttoseeanotherprovider.
PayingforservicesthatarenotcoveredbyHealthFirstColorado.
TellingtheirproviderandHealthFirstColoradoiftheyhaveotherinsuranceorfamilyoraddresschanges.
Askingquestionswhentheydonotunderstandorwanttolearnmore.
Tellingtheirprovider,theinformationneededtorendercare,suchastheirsymptoms.
Takingmedicationsasprescribedortellingtheirprovideraboutsideeffectsorifthemedicationsarenothelping.
Invitingpeoplewhowillbehelpfulandsupportivetobeincludedintheirtreatment.
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Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
f1f621aab7656982d6f0ffa5daa22f4450e8f6937527781a4ee0a38d2990567a
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