Medical Provider

Hospital

• Hospital

  • Inpatient Hospital Facility Fees Rule 18-6(I)

    • Provider restrictions Rule 18-6(I)(1)

    • Bills for Service Rule 18-6(I)(2)

      • Use of UB-04 Rule 18-6(I)(2)(a)

      • Determining MS-DRG Rule 18-6(I)(2)(b)

      • Maximum Length of Stay (LOS) Rule 18-6(I)(2)(c)

      • Acute care facility and its rehab facility Rule 18-6(I)(2)(d)

    • Reimbursement, Inpatient Rule 18-6(I)(3)

      • 80% billed charges, inpatient Rule 18-6(I)(3)(b)

      • 100% billed charges, inpatient Rule 18-6(I)(3)(a)

      • Children’s hospital 100%, inpatient Rule 18-6(I)(3)(a)(1)

      • Veterans’ Administration 100%, inpatient Rule 18-6(I)(3)(a)(2)

      • State psychiatric hospital 100%, inpatient Rule 18-6(I)(3)(a)(3)

      • Medicare certified critical Access 80% Rule 18-6(I)(3)(b)(1)

      • Medicare certified long-term care Rule 18-6(I)(3)(b)(2)

      • CDPHE licensed Rehabilitation Rule 18-6(I)(3)(b)(3)

      • CDPHE licensed, private psychiatric Rule 18-6(I)(3)(b)(4)

      • All other facilities, inpatient Rule 18-6(I)(3)(c)

        • Basic equation, inpatient Rule 18-6(I)(3)(c)(1)

        • Supply et al., inpatient Rule 18-6(I)(3)(c)(2)

        • Trauma Center Activation Rule 18-6(I)(3)(c)(3)

      • Determining outliers Rule 18-6(I)(3)(d)

        • “Hospital Cost,” inpatient Rule 18-6(I)(3)(d)(1)

        • Cost to charge ratio, inpatient Rule 18-6(I)(3)(d)(2)

        • Base “difference,” inpatient Rule 18-6(I)(3)(d)(3)

        • Outlier reimbursement, inpatient Rule 18-6(I)(3)(d)(4)

        • Inpatient with ERD Rule 18-6(I)(3)(e)(1)

        • Inpatient with Trauma Center Rule 18-6(I)(3)(e)(2)

      • Transfers Rule 18-6(I)(3)(f)

      • Compliance with Rule 16-6(B) & Final Payment Rule 18-6(I)(3)(g)

  • Outpatient, scheduled  Rule 18-6(J)

    • Provider restrictions, outpatient Rule 18-6(J)(1)

      • Prior authorization, outpatient Rule 18-6(J)(1)(a)

      • Separate facility restrictions, outpatient Rule 18-6(J)(1)(b)

        • Hospital affiliated, outpatient Rule 18-6(J)(1)(b)(1)

        • Ambulatory Surgery Center (ASC) Rule 18-6(J)(1)(b)(2)

    • Bills for Service, outpatient Rule 18-6(J)(2)

      • UB-04. outpatient Rule 18-6(J)(2)(a)

      • Professional charges, outpatient Rule 18-6(J)(2)(b)

      • Surgical RVP codes, outpatient Rule 18-6(J)(2)(c)

    • Reimbursement, outpatient Rule 18-6(J)(3)

      • Children’s hospital 100%, outpatient Rule 18-6(J)(3)(a)(1)

      • Veterans’ Administration 100%, outpatient Rule 18-6(J)(3)(a)(2)

      • State psychiatric hospital 100%, outpatient Rule 18-6(J)(3)(a)(3)

      • Critical Access Hospital, outpatient Rule 18-6(J)(3)(b)

      • Additional reimbursement, outpatient Rule 18-6(J)(3)(c)(5)

      • Other facilities, outpatient reimbursement Rule 18-6(J)(3)(c)

      • Reimbursement, outpatient facility Rule 18-6(J)(3)(c)(1-5)

      • Convalescence Rule 18-6(J)(3)(c)(4)

      • Diagnostics, pre-operative, outpatient Rule 18-6(J)(3)(c)(3)

      • X-rays, pre-operative, outpatient Rule 18-6(J)(3)(c)(3)

      • Ambulance service, outpatient  Rule 18-6(J)(3)(c)(5)

      • Blood supplies, outpatient Rule 18-6(J)(3)(c)(5)

      • Observation Room, outpatient Rule 18-6(J)(3)(c)(4)

      • Supply et al., outpatient, Rule 18-6(J)(3)(c)(2)

      • Implants, outpatient Rule 18-6(J)(3)(c)(2)

      • Primary & multiple procedures, outpatient Rule 18-6(J)(3)(c)(1)

      • Diagnostic testing, outpatient Rule 18-6(J)(3)(c)(3)

      • Laboratory, outpatient Rule 18-6(J)(3)(c)(3)

      • Observation Room, outpatient Rule 18-6(J)(3)(c)(4)

    • Prior authorization, outpatient Rule 18-6(J)(1)(a)

    • APC Values include, outpatient Rule 18-6(J)(3)(c)

      • Nursing, outpatient Rule 18-6(J)(3)(c)

      • Technician and related services, outpatient Rule 18-6(J)(3)(c)

      • Facility use, outpatient Rule 18-6(J)(3)(c)

      • Equipment, surgical, outpatient Rule 18-6(J)(3)(c)

      • Fluoroscopy, outpatient Rule 18-6(J)(3)(c)

      • X-rays during surgery, outpatient Rule 18-6(J)(3)(c)

      • Radiology during surgery, outpatient Rule 18-6(J)(3)(c)

      • Administrative costs, outpatient Rule 18-6(J)(3)(c)

      • Housekeeping costs, outpatient Rule 18-6(J)(3)(c)

      • Anesthesia, trained observer outpatient Rule 18-6(J)(3)(c)

      • Discontinued surgeries Rule 18-6(J)(3)(d)

      • Multiple providers, single OR Rule 18-6(J)(3)(e)

      • No line-by-line comparison of charges Rule 18-6(J)(3)(f)

  • Outpatient Clinic Rule 18-6(K)

    • Bills for Service, outpatient clinic Rule 18-6(K)(1)

      • Modifiers, use on UB-94, Clinic Rule 18-6(K)(1)

    • Reimbursement, Clinic Rule 18-6(K)(2)

      • 80% billed charges, clinic Rule 18-6(K)(2)(b)

      • 100% billed charges, clinic Rule 18-6(K)(2)(a)

      • Children’s hospital 100%, clinic Rule 18-6(K)(2)(a)(1)

      • Veterans’ Administration 100%, Clinic Rule 18-6(K)(2)(a)(2)

      • State psychiatric hospital 100%, clinic Rule 18-6(K)(2)(a)(3)

      • Primary Rural Health Facility Clinic Rule 18-6(K)(2)(b)

      • All other clinic facilities Rule 18-6(K)(2)(c)

      • Clinic fees, none Rule 18-6(K)(2)(c)(1)

      • Diagnostic testing, clinic fee, none Rule 18-6(K)(2)(c)(2)

      • "Supply et al." Rule 18-6(K)(2)(c)(3)

      • Pharmaceuticals Rule 18-6(K)(2)(d)

  • Outpatient Urgent Care Facility Rule 18-6(L)

  • Urgent Care Facility, outpatient Rule 18-6(L)

    • Provider restrictions, Urgent care Rule 18-6(L)(1)

    • Prior authorization, urgent care Rule 18-6(L)(1)(a)

    • Urgent Care Facility qualifications Rule 18-6(L)(1)(b)

    • Follow-up care, no facility fees, urgent care Rule 18-6(L)(1)(c)

    • Employer designated provider restrictions Rule 18-6(L)(1)(d)

    • Bills for Service, Urgent Care Facility Rule 18-6(L)(2)

    • CMS for facility fee, urgent care Rule 18-6(L)(2)(a)

    • S9088, Urgent care facility fee Rule 18-6(L)(2)(b)

    • Reimbursement, Urgent Care Rule 18-6(L)(3)

      • Maximum allowance, Urgent Care Fee Rule 18-6(L)(3)(a)

      • Supply et al., urgent care facility Rule 18-6(L)(3)(b)

      • Diagnostic testing, urgent care facility Rule 18-6(L)(3)(c)

      • Laboratory service, urgent care facility Rule 18-6(L)(3)(c)

      • Therapeutic Services, urgent care facility Rule 18-6(L)(3)(c)

      • Observation Room, Urgent Care facility Rule 18-6(L)(3)(d)

      • No line-by-line comparison for payment Rule 18-6(L)(3)(e)

      • Drug supply Rule 18-6(L)(4)

  • Outpatient – Emergency Room Rule 18-6(M)

    • Provider Restrictions, Emergency Room Rule 18-6(M)(1)

    • Bills for Service, Emergency Room Rule 18-6(M)(2)

      • UB-94 Rule 18-6(M)(2)(a)

      • Documentation, Emergency Room Rule 18-6(M)(2)(b)

  • Reimbursement, Emergency Room Rule 18-6(M)(3)

    • 80% billed charges, ER Rule 18-6(M)(3)(b)

    • 100% billed charges, ER Rule 18-6(M)(3)(a)

    • Children’s hospital 100%, ER Rule 18-6(M)(3)(a)(1)

    • Veterans’ Administration 100%, ER Rule 18-6(M)(3)(a)(2)

    • State psychiatric hospital 100%, ER Rule 18-6(M)(3)(a)(3)

    • Critical Access Hospital, ER, Rule 18-6(M)(3)(b)

    • Level Care determination, ER Rule 18-6(M)(3)(c)

    • Level of Care Points Rule 18-6(M)(3)(d)

    • No line-by-line comparison for lesser value Rule 18-6(M)(3)(e)

    • No reimbursement, ER if admitted Rule 18-6(M)(3)(f)

    • Trauma Center, ER Rule 18-6(M)(3)(g)

    • No fees trauma alert, ER Rule 18-6(M)(3)(g)

    • Trauma center in addition to ER Rule 18-6(M)(3)(g)(1)

    • Trauma center activation vs. alert Rule 18-6(M)(3)(g)(2)

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