Colorado CO
Accountable Care Collaborative (ACC) with 4 Regional Accountable Entities (RAEs) as PCCM+PIHP; physical-health claims paid FFS by HCPF; behavioral-health capitated to RAE; two full-risk MCOs (RMHP PRIME, Denver Health Elevate) operate as carve-outs.
CO Medicaid (Health First Colorado): NOT a traditional MCO state. Uses Accountable Care Collaborative (ACC) Phase II since 2018 — 7 Regional Accountable Entities (RAEs) provide care coordination + BH services in their region (provider-led, not full-risk MCOs in the traditional sense). RAEs cover BH at risk-based capitation; physical health is FFS coordinated by RAE. PA for medical services goes to HCPF FFS via interChange, with RAE consultation for care coordination. BH PA goes to the member's RAE. Pharmacy is state-administered via Magellan as fiscal agent. NOT a WISeR pilot state.
Who administers prior authorization in Colorado
Structural facts on file
Colorado Department of Health Care Policy & Financing (HCPF) maintains a public interoperability page describing its CMS-0057-F implementation. Along with WA, CO is one of two states with public state-Medicaid 0057-F commitment. Most other state Medicaid programs have made no public commitment for Medicaid (CA = regulatory pass-through; ~40 states silent).
Accountable Care Collaborative (ACC) with 4 Regional Accountable Entities (RAEs) as PCCM+PIHP; physical-health claims paid FFS by HCPF; behavioral-health capitated to RAE; two full-risk MCOs (RMHP PRIME, Denver Health Elevate) operate as carve-outs.
Colorado (Health First Colorado / HCPF) expresses FFS prior-authorization in TWO public layers plus a vendor submission portal. (1) ROUTING: Billing Manual Appendix C (Prior Authorization and Review Agencies) and Appendix D (Programs/Services and Authorizing Agencies) are the canonical map of WHICH agent authorizes each service — ColoradoPAR/Acentra (FFS outpatient + out-of-state inpatient + select PADs), DentaQuest (dental), Case Management Agencies (HCBS waivers), Telligen (HCBS-SLS exceptions/LTSS via Qualitrac), TransDev/Intelliride (NEMT), and the 7 RAEs (behavioral health). (2) CRITERIA: the actual medical-necessity criteria, code-specific PA requirements, and questionnaires live in PUBLIC per-benefit HTML billing manuals on hcpf.colorado.gov (e.g. DMEPOS 166KB w/ Questionnaires #1-#19, Outpatient Imaging, PT/OT, Physician-Administered Drugs), backed by 10 CCR 2505-10 regulations. Criteria are NOT behind a login. (3) SUBMISSION: providers submit PARs through Acentra's Atrezzo portal (portal.kepro.com -> atrezzo.acentra.com), login-gated. AUTHORITY: HCPF owns policy/criteria (publishes manuals); Acentra is the FFS UM contractor (review + portal); Gainwell is fiscal agent (interChange MMIS); pharmacy PA is state-administered (Magellan/MedImpact, Appendix P, CoverMyMeds ePA). CO is one of only ~2 states (with WA) publishing a public state-Medicaid CMS-0057-F PA-metrics report: CY2025 = 77.24% standard PARs approved, 22.30% denied, 0.56% approved after appeal, across 13 PA programs (1,746,685 standard requests). DISTINCT from CA (TAR manual + Anchor-MCO), WA (5-step), MA (per-service PDFs): CO's criteria are embedded in long HTML benefit manuals, routing is appendix-driven, and FFS UM is delegated to one vendor (Acentra) while criteria authorship stays at HCPF.
Last award: 2024-09-11. Next due: 2031-Q1. Contracts extended through: None.
status=partial
Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.
## 1. How CO requires PA Colorado Medicaid, known as Health First Colorado (HCPF), mandates prior authorization (PA) for various services and drugs through a structured process involving specific criteria and documentation requirements. The state's PA system is detailed in public billing manuals and supported by an online portal called ColoradoPAR/Acentra. For example, the CO Billing Manual specifies that certain medical devices such as Transcutaneous or Neuromuscular Electrical Nerve Stimulators (TENS or NMES), Lymphedema Pumps and Compressors, and Continuous Passive Motion (CPM) Devices require prior authorization. The documentation needed includes a statement of medical necessity but does not specify step-therapy protocols. Physical and occupational therapy services also necessitate PA, requiring a written order from a physician, PA, NP, or IFSP for Early Intervention. Providers must verify available units before submission and provide initial evaluations, re-evaluations, visit/encounter notes, discharge summaries, and CPT codes as documentation. Audiology services require prior authorization through ColoradoPAR, though specific criteria and thresholds are not detailed in the provided documents. Similarly, certain prescription drugs need approval via the Prescription Drug Card System (PDCS). ## 2. How CO publishes and reports PA Colorado Medicaid publishes its PA requirements primarily through public billing manuals, which detail the services that require prior authorization along with necessary documentation. The state's billing manuals are segmented into different sections addressing various medical categories such as outpatient imaging, physical therapy, occupational therapy, physician-administered drugs, and mental health services. For instance, the CO Billing Manual includes specific sections like "Outpatient Imaging" and "Physical Therapy/OT," which outline the criteria for PA. These manuals serve as canonical references for providers to understand what services require prior authorization and how to submit requests. ColoradoPAR/Acentra is a centralized portal used by providers to submit prior authorization requests. While the state has a partial centralized PA portal, it does not fully integrate all PA processes into one system. The portal supports the submission of PA requests but may not cover all service categories comprehensively. The Colorado Department of Health Care Policy & Financing (HCPF) maintains an interoperability page that outlines the state's commitment to CMS-0057-F compliance and provides updates on its progress. However, specific metrics or reports related to PA activities are not detailed in the provided documents. ## 3. CO's CMS-0057-F and PA-reform compliance posture Colorado is one of two states with a public state-Medicaid commitment to CMS-0057-F interoperability rules, alongside Washington State. The Colorado Department of Health Care Policy & Financing (HCPF) maintains an interoperability page that describes the state's readiness for these regulations. The CMS-0057-F Final Rule mandates changes to Medicaid prior authorization processes to improve efficiency and reduce administrative burden on providers. In Colorado, audiology services require prior authorization through ColoradoPAR/Acentra starting January 17, 2024, in compliance with the new rules. The state's commitment is evident from its public stance and ongoing efforts to integrate these changes. However, specific details about how other service categories will be affected by CMS-0057-F are not provided in the given documents. The state's compliance posture suggests a proactive approach but lacks comprehensive information on implementation timelines for all services. ## 4. How CO runs its own program Colorado Medicaid operates under an Accountable Care Collaborative (ACC) model, which includes four Regional Accountable Entities (RAEs). Physical health claims are paid through fee-for-service (FFS) by HCPF, while behavioral health services are capitated to the RAEs. The state has two full-risk Managed Care Organizations (MCOs): RMHP PRIME and Denver Health Elevate. These MCOs operate as carve-outs for certain services, meaning they manage specific aspects of Medicaid coverage separately from the main FFS program. Carve-ins and carve-outs play a significant role in Colorado's Medicaid structure: - **Pharmacy Carve-in**: The pharmacy benefits are carved into the state's FFS system. - **Behavioral Health Carve-in**: Behavioral health services are carved into RAEs, which manage these services through capitated contracts. - **Long-Term Services and Supports (LTSS) Carve-in**: LTSS services are carved into the state's FFS program. The foster care MCO program is unspecified in the provided documents, indicating a lack of detailed information about this particular carve-out. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Structured Billing Manuals**: The use of public billing manuals to detail PA requirements for various services. - **Centralized Portal**: Partial implementation of a centralized portal (ColoradoPAR/Acentra) for PA submissions. - **Compliance Commitment**: Public commitment to CMS-0057-F interoperability rules, with specific actions taken for audiology services. ### What's Missing/Uncertain: - **Specific Criteria and Thresholds**: Many service categories lack detailed criteria and thresholds for prior authorization. For example, CT scans for acute rhinosinusitis are not covered but no specific reasons or documentation requirements are provided. - **Step-Therapy Protocols**: Step-therapy protocols are not specified for most services requiring PA. - **Foster Care MCO Program Details**: The specifics of the foster care MCO program are unclear, leaving gaps in understanding how this carve-out operates. - **Comprehensive Metrics and Reporting**: While there is a commitment to CMS-0057-F compliance, detailed metrics or reports on PA activities are not provided. - **Effective/Revised Dates**: Many documents do not specify effective or revised dates for the PA criteria, making it difficult to track changes over time. These gaps highlight areas where additional information would be beneficial for a more comprehensive understanding of Colorado's Medicaid prior authorization system.