8 Colo. Code Regs. § 1405-1-5.108

Current through Register Vol. 47, No. 20, October 25, 2024

Section 8 CCR 1405-1-5.108 - CERTIFIED EARLY INTERVENTION SERVICE BROKERS

This rule is promulgated pursuant to section 26.5-3-408, C.R.S.

A. Designation of Roles and Responsibilities

1. One entity per designated service area shall be designated in writing by the Department as the Certified Early Intervention Service Broker for that region and shall provide early intervention services and service coordination to any eligible child who resides in that region.

2. A Community Centered Board or other interested agency shall submit a Department approved application for designation as a Certified Early Intervention Service Broker.

3. Designation as a Certified Early Intervention Service Broker shall be based on the following criteria:

a. Agency background and expertise in early intervention services;

b. Agency policies and procedures that ensure accurate data entry as required by the Department;

c. Demonstrated ability to conform with generally accepted accounting and contracting practices; and,

d. Assurance to comply with state and federal laws and regulations regarding early intervention services as described in Rules 5.100, et. seq.

4. Failure to maintain ongoing compliance with the above criteria may result in revocation of designation as a Certified Early Intervention Service Broker.

5. If the Department determines that a Community Centered Board or other entity does not meet the criteria to be designated as a Certified Early Intervention Service Broker or is de-designated as the Certified Early Intervention Service Broker, the Community Centered Board or other entity may dispute the decision in accordance with provisions of section 24-4-105, C.R.S.

6. If a Community Centered Board is unwilling to be the Certified Early Intervention Service Broker for its service area, or the Community Centered Board does not meet the criteria established in Rule 5.108, then applications from other entities shall be solicited and accepted and another entity shall be designated as the Certified Early Intervention Service Broker.

7. The Department may act as the Early Intervention Service Broker until such time as a Certified Early Intervention Service Broker can be found.

8. Upon designation, a Certified Early Intervention Service Broker shall:

a. Ensure payment for early intervention services is rendered pursuant to an Individualized Family Service Plan;

b. Ensure that the funding hierarchy in Rule 5.107(C)(1), is followed;

c. Ensure that federal funds for early intervention services are utilized as payor of last resort;

d. Use procedures and forms as defined by the Department to document the provision or purchase of early intervention services;

e. Negotiate, within state and federally-defined parameters and Rule 5.107, for payment of early intervention services;

f. With written parental consent, notify the appropriate public or private health insurance plan within ten (10) working days that a covered infant or toddler has been determined eligible for early intervention services. At a minimum, the notification shall include:

(1) The child's name;

(2) The child's date of birth;

(3) The name of the public or private health insurance carrier;

(4) The policy/group number and subscriber number or Social Security Number;

(5) The name of the primary policy holder;

(6) The customer service telephone number for the insurance carrier;

(7) The initial Individualized Family Service Plan date; and

(8) The contact person and telephone number for the Early Intervention Service Broker.

g. Establish a registry of qualified early intervention service providers who have active records in the Early Intervention Provider Database from which early intervention services for eligible infants and toddlers in the designated service area shall be purchased;

h. Accept and process insurance claims in accordance with state and federal law for those families with health insurance coverage for early intervention services;

i. Ensure that all required demographic and billing information is entered into the early intervention statewide data system for each child who is eligible for early intervention services, as defined in Rule 5.111(D);

j. Participate in ongoing reviews of the use of the funding hierarchy; and

k. Provide the Department with accurate data for reporting purposes for the legislature or other funding sources.

9. Certified Early Intervention Service Brokers may provide early intervention services directly or may subcontract the provision of services to other qualified providers.

10. Invoices or insurance claims for early intervention services shall be submitted based on the available funding source for each eligible child and the reimbursement rate for the appropriate federal, state, local, or private funding sources, including public health insurance and benefits, and private health insurance.

11. Reimbursement rates for Early Intervention Service Broker functions shall be established with input from Certified Early Intervention Service Brokers.

12. Use of a Certified Early Intervention Service Broker for billing non-qualifying plans on behalf of a contractor shall be voluntary. Qualified early intervention service providers may directly bill the appropriate program of a public health insurance plan or benefits, or a participating private health insurance carrier, for services rendered, in accordance with section 10-16-104 (1.3), C.R.S.

B. Purchase of Service Rates

1. The Certified Early Intervention Service Broker shall adopt and implement sufficient policies and procedures to ensure:

a. The qualified provider or employee meets minimum provider qualifications as set forth in Rule 5.115;

b. Services are delivered in accordance with Rule 5.114 and as identified in the Individualized Family Service Plan; and

c. The qualified provider maintains sufficient documentation to support the claims submitted.

2. The process and methodology the Certified Early Intervention Service Broker implements to determine the rates to be paid to the qualified contracted provider or for services provided directly by the Certified Early Intervention Service Broker employed providers shall be based on the usual and customary practices of the local community, be documented in the policies and procedures of the Certified Early Intervention Service Broker, and shall be made available to the Department upon request.

3. The Certified Early Intervention Service Broker is the provider of record for all services for which it contracts through qualified providers.

4. The Certified Early Intervention Service Broker's purchase of service rates shall comply with the following:

a. Rates shall be consistent with efficiency, economy, and quality of care;

b. The policy and methods used in setting payment rates shall be in writing and consistently applied to all qualified providers, including the Certified Early Intervention Service Broker employed providers; and

c. Documentation of payment rates shall be maintained and kept on file with the Department.

5. A qualified provider shall be given sufficient information concerning the service obligations to assist them in developing cost effective and efficient rate proposals.

6. The Certified Early Intervention Service Broker shall maintain written documentation for an audit trail on how rates were established and paid, and provider expenses to support payments.

7. When a Certified Early Intervention Service Broker proposes to charge fees to a contracted service agency for managing the billing process for early intervention direct services, the following shall be complied with:

a. The Certified Early Intervention Service Broker shall provide the qualified provider with a written description for each service provided and the amount of the proposed fee for each service;

b. The proposed fee to a qualified provider cannot be established to pay for services otherwise reimbursed, as determined by the Department;

c. Any proposed fee by a Certified Early Intervention Service Broker related to managing the billing process shall meet the following criteria:

(1) The fee shall relate to the cost of processing billings and other administrative functions defined in the contract between the Certified Early Intervention Service Broker and the contracted service provider; and

(2) The fee shall not be dependent upon the collection of payment.

d. The Certified Early Intervention Service Broker shall provide the qualified contracted provider with statements for services delivered;

e. The Certified Early Intervention Service Broker shall establish procedures and time frames that provide the opportunity for a qualified contracted provider to protest the proposed fee charges to the Certified Early Intervention Service Broker, and for a timely written response within ten (10) days of receipt;

f. The Certified Early Intervention Service Broker shall inform the qualified contracted provider of the opportunities to dispute the decision to the Department, as defined in Rule 5.108(C); and

g. The Certified Early Intervention Service Broker shall submit a copy of all disputes and subsequent proceedings to the Department within ten (10) days of completion of the proceedings.

C. The following shall apply in the event of a contractual dispute between a qualified contracted provider and a Certified Early Intervention Service Broker:

1. The dispute shall be submitted in writing by the contracted early intervention provider to the Certified Early Intervention Service Broker and shall:

a. State the specific grounds for the dispute and the relief requested; and

b. Provide all available exhibits, evidence, arguments and documents believed to substantiate the dispute.

2. The Certified Early Intervention Service Broker may request, within fifteen (15) working days following the date of the written dispute, additional information deemed necessary to resolve the matters of the dispute.

3. Within fifteen (15) working days following the receipt of written documentation and additional requested information, if applicable, the Certified Early Intervention Service Broker shall respond to the dispute by issuing a written decision, which shall include:

a. The reason(s) for the decision; and

b. The right of the provider to seek departmental review of the decision.

4. If a contracted early intervention provider disagrees with the decision of the Certified Early Intervention Service Broker, within ten (10) working days of the decision, the provider may request that the Executive Director of the Department or designee review the decision.

a. Upon a request for review, the protesting party shall submit all relevant documents related to the dispute;

b. The Executive Director or designee shall review the dispute and determine if the issue in dispute is within the jurisdiction of the Department to resolve or if court action is necessary;

c. If the Executive Director or designee determines that Department review is appropriate, the Certified Early Intervention Service Broker shall respond to the submitted information within ten (10) working days.;

d. The Department shall have the right to additional information it deems necessary and may request oral argument from the parties involved in the dispute; and

e. The Executive Director or designee shall render a final binding decision within fifteen (15) working days of receiving all relevant information. The determination shall set forth a course of action for resolution of the contract dispute.

8 CCR 1405-1-5.108

46 CR 01, January 10, 2023, effective 1/1/2023

46 CR 06, March 25, 2023, effective 4/14/2023

47 CR 13, July 10, 2024, effective 7/30/2024