Medicaid Rules in Colorado

The Colorado Foundation of Medical Care (CDMC) is a review organization for the Colorado Medicaid Program. They provide prior authorization reviews according to the Colorado Department of Health Care Policy and Financing (CDHCPF) rules. They have serviced Colorado since 1974. Some reviews, however, must be approved by the Affiliated Colorado Services (ACS). Among these organizations, certain procedures are excluded from the Medicaid program. If you must seek medical care outside of the state, certain rules will also apply.

Prior Authorization Requests (PAR)

• CFMC reviews requests for surgeries and medical devices that include power wheelchairs and respiratory equipment. Any request for prosthetics or physical therapy must be approved by CFMC also. Before being able to use at-home health services or being admitted to an out-of-state hospital, CFMC must first approve it.

  Requests for manual wheelchairs or repair of equipment must be submitted through ACS. They process all claims and send out notification of approval or denial of claims to clients. CFMC has 10 business days to approve or deny a claim. Once the decision is made, the decision is passed on to ACS and they have an additional 10 business days to contact the client.

Excluded Coverage

• CDHCPF has excluded some items from the Medicaid program. It is important to be aware of these rules before seeking medical attention. Any service that helps the patient's comfort but not the actual diagnosis or treatment is excluded from the plan. This does not include inoculations or immunizations. Any service that is paid for by another government entity, including the Veterans' Administration Program, is also excluded. If a patient received an injury due to civil disobedience, the medical attention needed will not be covered. If a client seeks medical attention at a hospital designed for serving only special categories, such as prisoners, the Medicaid program will decline payment. One other consideration is any medical procedure not offered in the U.S., including Puerto Rico, the Virgin Islands, Guam and American Samoa will be excluded from coverage.

Out-of-State

• Any individual covered by the Colorado Medicaid Program can receive the same benefits outside of the state as long as they are still a resident of Colorado. However, conditions do apply. In case of a medical emergency, no prior authorization is needed. However, documentation of the emergency must be provided along with the claim. If the individual's health is determined by a doctor to be endangered by waiting to return to Colorado for treatment, out-of-state medical attention can be obtained. Notification to a consultant of the Colorado Medicaid Program must be notified before treatment is rendered. If a certain state has the means to treat the patient where the state of Colorado cannot, then with prior approval, the patient can seek the needed medical attention out-of-state.