CO · guidance

CO HCPF Pediatric Personal Care Benefit Billing Manual — Prior Authorization Requests (PARs)

PriorAuthorizationRequests(PARs)

activein force · 2026-07-26 – presentas-observed

TheColoradoPARProgramisHealthFirstColorado’sUtilizationManagement(UM)Program.Athird-partyvendorreviewsPriorAuthorizationRequests(PARs)toensureservicesrequestedmeetmedicalnecessityguidelinesandarewithinHealthFirstColorado’spolicies.

TheColoradoPARProgram’sthird-partyvendorprocesseselectronicPARsthroughanonlinePARportal.TheonlinePARportalisaweb-basedHIPAA-compliantPARsystemthatoffersproviders24/7accesstotheinformationandfunctionsprovidersneed.Clinicaldocumentationwillbeacceptedinthefollowingformats:doc,docx,xls,xlsx,ppt,pdf,jpg,gif,bmp,tiff,tif,andjpeg.

VisittheColoradoPARwebpageforinformationandinstructionsonhowtosubmitPARselectronicallythroughtheonlinePARportal.Foradditionalassistanceorsupport,contacttheColoradoPARproviderhelplineat888-801-9355.PARstatusmaybeverifiedintheonlinePARportalorbycontactingtheColoradoPARproviderhelpline.TheapprovedPARidentificationnumbermustbesubmittedwiththeclaimtoreceivepayment.

Claimsforpriorauthorizedservicesmustbesubmittedwithin365daysofthedateofservice.Servicesrenderedpriortotheauthorizeddatewillbedeniedreimbursement.

ApprovalofthePARdoesnotguaranteepaymentbyHealthFirstColorado.ThememberandthePCprovidershallmeetallapplicableeligibilityrequirementsatthetimeservicesarerenderedandservicesshallbedeliveredinaccordancewithallapplicableservicelimitations.HealthFirstColoradoisthepayeroflastresortandthepresenceofanapprovedorpartiallyapprovedPARdoesnotreleasetheagencyfromtherequirementtobillMedicareorotherthird-partyinsurancepriortobillingHealthFirstColorado.

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AnyprovidersubmittingaPARmustbeenrolledintheHealthFirstColoradoProgram.ProvidersmustalsoverifyeligibilityatthetimeserviceisrenderedandincludethenecessaryinformationwiththePAR.

AllPCservicesrequirepriorauthorizationbyHealthFirstColorado'sthird-partyvendorusingtheapprovedpriorauthorizationrequestonlineportal.

ThePCATcanbecompletedbyaClassAorBagency

PCservicesmustbeorderedinwritingbythemember'sprescribingprovideraspartofawrittenPlanofCare

Theprescribingprovider'sorderandsignedPlanofCaremustbesubmittedwiththePCATaspartofthePAR

Itistheagency'sresponsibilitytoprovidesufficientdocumentationtosupportthemedicalnecessityfortherequestedservices.

Thememberisnotexpectedtoneedafullyearofservices

Themember'seligibilityisnotexpectedtospantheentireyearor,

AsotherwisespecifiedbyHealthFirstColorado.

PARsmustbesubmittedtoHealthFirstColorado'sthird-partyvendorinaccordancewith10CCR2505-10§8.058.

APARwillbependedbyHealthFirstColorado'sthird-partyvendorifalloftherequiredinformationisnotprovidedinthePAR,oradditionalinformationisrequiredbythethird-partyvendortocompletethereview.Ifthethird-partyvendordoesnotreceivetherequireddocumentationwithinfour(4)businessdays,thePARwillbedeniedforlackofinformation.

WhenaPARincludesarequestforreimbursementfortwo(2)staffmembersatthesametime(excludingsupervisoryvisits)toperformtwo-persontransfersoranotherPCtask,documentationsupportingtheneedfortwo(2)peopleandthereasonadaptiveequipmentcannotbeusedmustbeincluded.

AllotherinformationdeterminednecessarybyHealthFirstColorado'sthird-partyvendortomakeadecisiononthemedicalnecessityandappropriatenessoftheproposedtreatmentplanmustbeincluded.

TheagencyisrequiredtosubmitaPARrevision,whichmustincluderevisionstoalldocumentation,includingthePlanofCare,if/whenthememberexperiencesachangeinconditionnecessitatingachangeintheamount,duration,orfrequencyofamember'sPCservices.

WhenamemberreceivingPCservicesthroughHealthFirstColoradoreceivesadditionalPCservicesthroughaHomeandCommunity-BasedServices(HCBS)waiver,theHCBSwaiverprogramisconsideredthepayeroflastresort.

ThePARwillbereviewedbymedicalexpertsinchildren'shealthwhoworkfortheHealthFirstColoradoprogram'sthird-partyvendor.NursesanddoctorswilldecideiftherequestforpersonalcaremeetstherulesformedicalnecessityandforthePersonalCareBenefit.

AnapprovedPARisvalidforuptoone(1)year.Afterone(1)year,aPersonalCareprovidermustsubmitanewPARforanotheryearofPCservices.

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PriortodenyingorpartiallydenyingaPAR,theMD,DOorAPNthatrequestedthePARwillbecontactedtodiscussthePARoverthephoneinaprocesscalledaPeer-To-Peerreview.IfthePeer-To-PeerreviewstillresultsinadeniedorpartiallydeniedPAR,thePersonalCareprovidermayworkwiththeMD,DOorAPNonthesetwo(2)options:

PARReconsideration:APARReconsiderationissimilartoasecondopinionandmustberequestedbythePersonalCareprovider.AMD,DOorAPNwhoisdifferentfromtheonewhomadetheinitialPARdenialwillre-reviewthePARalongwiththenewinformationandmakeafinalPARdecision.AdditionaldocumentsnotsubmittedwiththeoriginalrequestmaybesubmittedduringtheReconsiderationprocess.

PARResubmission:SubmitanewPARthatincludesadditionalmedicalinformationneededforthePARreview.

TheproviderwillbenotifiedofthefinalPARdeterminationviatheonlinePARportal.TheproviderandmemberwillreceivethefinalPARdeterminationletterfromtheDepartment’sfiscalagent.IfthePARisdenied,theproviderwillalsoreceiveadetailedexplanationofwhythePARwasdenied.AmemberwhoreceivesadenialnotificationletterhastheoptiontosubmitawrittenrequestforanappealtotheOfficeofAdministrativeCourts.

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: 31172fa082787626856f2d04069a205d644b0b43f3b647a12c36491aa4f26d8b

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