Two Medicaid payment paths
Most Health First Colorado members are billed through Gainwell's interChange. Members in Elevate Medicaid Choice or RMHP PRIME? Those claims go to the plan instead.
Colorado cardiology billing
Cardiology medical billing services in Colorado
Monday, it's a Health First Colorado claim. Tuesday, Medicare through Novitas. By Friday, a commercial plan wants prior auth for a nuclear study. Same practice, three rulebooks, and we work all of them.
Health First Colorado
Claims sent to the right plan
Novitas Medicare
Jurisdiction H rules
Coding by the line
Every modifier checked
365 days
Minimum Medicaid filing window
Jurisdiction H
Novitas handles Colorado Medicare
4 RAEs
Plus 2 managed care plans
5 years
Longest gap between Medicaid revalidations
Colorado payer rules
Where Colorado cardiology claims get stuck
Look, one patient visit can hit more than one Colorado payer system. Cath lab, echo, nuclear. Each system has its own filing window and its own enrollment rules, and small gaps turn into denials.
ColoradoPAR imaging approvals
Acentra Health reviews requests for most non-emergent CT and MRI and for every PET or SPECT scan. Retroactive approval isn't available, so it has to exist before the scan.
Filing windows that run out quietly
Medicaid allows at least 365 days from the date of service. Still waiting on a prior auth? The clock keeps running anyway.
Enrollment on every claim
Every provider on a Medicaid claim has to be enrolled and revalidated at least every five years. One lapsed rendering physician is enough to stall the whole thing.
Commercial authorization lists
Each carrier keeps its own. UnitedHealthcare, for one, wants approval for outpatient nuclear cardiology. Lists get revised on the carrier's schedule, not the practice's.
Prompt-pay rules and aged balances
Colorado gives carriers 30 days to pay a clean electronic claim, 45 for anything else. Self-funded employer plans sit outside that rule, which probably surprises more offices than it should.
What we handle
Everything between the front desk and the final payment
We take on every stage of the claim cycle. Coverage checks, coding, submission, posting, denials, payer enrollment. A practice can hand us all of it or just the piece that hurts most.
Benefit and coverage checks
We determine if interChange or a managed care plan pays after verifying the active plan, network status, and any secondary coverage.
Review of procedure coding
Our coders match CPT and ICD-10-CM codes, modifiers, units, and location of service to what the physician actually documented.
Charge entry
Charges come straight from the signed report. Professionals are professionals.
Scrubbing claims prior to submission
Edits verify provider IDs, authorisation numbers, modifier pairs, and diagnosis links before sending anything.
Electronic submission
Claims are transmitted through a clearinghouse, the Health First Colorado Provider Web Portal or a payer portal. Whatever that strategy calls for.
Payment posting
ERAs and EOBs are posted line by line. Write-offs, patient balances and underpayments are recognized, not hidden.
Denial handling
Every refusal is tracked to the reason code then amended or appealed. It is in the front end so it doesn't repeat.
A/R follow up
Oldest balances go first. Payer calls, status checks, updated claims, appeals, whatever it takes to get the claim moving.
Credentialing & Enrollment
We keep rendering and billing providers active by tracking Medicaid revalidation, Medicare enrollment and commercial credentialing.
Procedures we bill
Procedures and tests inside our billing scope
Office visits to cath lab cases. Each procedure family has its own CPT codes and its own payer quirks, and we code them that way.
Office and hospital E/M visits
12-lead ECG and its interpretation
Transthoracic echo-cardiography
Echocardiography, esophageal
Pharmacologic stress testing and exercise
Stress echocardiography
Myocardial perfusion imaging using SPECT
Heart PET scan
CT coronary angiogram
MRI of the heart
Patch and Holter Monitors
Telemetry and event tracking
Loop recorders, implantable
Pacemaker implantation and examination
ICD implantation and follow-up
Electrophysiology study
Catheter ablation
Left & Right Heart Catheterization
PCI + stenting
Peripheral vascular procedures
TAVR
Transcatheter mitral and tricuspid repair
Cardiac rehab
Remote physiologic data
Note box:
Authorization rules shift with the plan and the place of service. In Health First Colorado,
PET and SPECT scans always need ColoradoPAR approval. Emergency outpatient imaging is the exception.
Practice types
Practice types we bill for across Colorado
General cardiology doesn't bill like electrophysiology. Different code families, different documentation habits, different authorization triggers. So we apply rules per service line.
General cardiology
Clinic visits, ECGs, in-office echo and stress testing, lengthy tail of follow-up for hypertension, heart failure, and rhythm patients.
Interventional cardiology
Cath and PCI claims live or die on vascular modifiers (LD, LC, RC), add-on codes and how multi-vessel stents get reported.
Electrophysiology
EP studies, ablations, device implantation. Comprehensive codes absorb component codes. Reporting a component separately is an invitation for a refusal.
Noninvasive cardiology
Echo, stress, nuclear, monitoring. It all depends on who owns the equipment, and if it bills worldwide, professional or technical.
Cardiac imaging
Cardiac CT, MRI and PET are required to have prior authorization and clinical notes to show medical need.
Structural heart
2 doctors reporting TAVR under modifier 62. The imaging surrounding both transcatheter mitral repair and the imaging around both add additional moving elements.
How a claim moves
How a claim moves through our desk, step by step
Eleven steps, in order, and each one feeds the next. And then a denial reason spotted at step 9 sends us back to tighten how we check coverage and authorizations at steps 2 and 4.
Intake and Registration
Patient demographics, insurance cards, referring provider (verified at scheduling)
Coverage Verification
Confirm active plan, payer type, and secondary coverage prior to each visit
Plan Routing
Members of Medicaid are matched with interChange/Elevate/RMHP PRIME to ensure the claim goes to the correct payer
Authorization Tracking
Colorado PAR and commercial authorizations are requested in advance of the imaging, device and cath lab procedures.
Coding and Charge Entry
Diagnostic reports are coded and charged with applicable modifiers and component split.
Claim Scrubbing
Edits catch modifier discrepancies, diagnosis pointer errors, and missing authorizations
Submission
Electronically transmitted to payer/clearinghouse/provider web portal
Payment Posting
Remittances are reviewed line-by-line to ensure payment was made at contracted rate.
Denial Review
Categorized by type and sent to correction, appeal, or write off requiring management approval.
A/R Follow-up
Pledged claims are worked by payer and date until paid or closed.
Reporting
Denial, A/R, collection reports by payer and procedure
Why practices outsource
Why Colorado cardiology groups stop doing their own billing
Honestly, cardiology billing never lets up. Authorizations, corrections, payer calls, repeat. A separate team soaks up that work, and clinic staff get back to patients.
Medical assistants and nurses quit chasing authorization numbers and remittance details between patients.
Health First Colorado, Novitas, and commercial claims all play by different rules. One team keeps up with every set.
Imaging, ablation, and device dates get checked against approval status in advance. Not after the denial.
Every cardiologist documents a little differently. One coding standard keeps modifiers and units uniform across the group.
Open claims have an identified biller and a future step on the schedule. Nothing hangs around for a tranquil afternoon.
Revalidation deadlines and new-physician enrollments are monitored so a gap doesn't stall claims.
Where we work
Cardiology billing from the Front Range to the Western Slope
Front Range groups, mountain-town clinics, rural practices out on the eastern plains. They all bill the same payers. Staffing and referral patterns, though, are another story.
Denver
Aurora
Colorado Springs
Fort Collins
Boulder
Littleton
Longmont
Loveland
Pueblo
Grand Junction
Durango
Steamboat Springs
Why specialty matters
Why cardiology billing isn't like other medical billing
Here’s the deal with cardiology. One cath lab visit may generate a diagnostic angiogram, an intervention, imaging advice, and a facility claim. Everyone does their own modifications. Not often does primary care have that much riding on one interaction.
Vessel modifiers on cath and PCI lines
Global, professional, and technical splits
Bundling edits between EP and ablation codes
Prior approval for PET, SPECT, and device dates
Novitas local coverage rules for Medicare
Medicaid enrollment checks on each provider
FAQs
Questions Colorado cardiology practices ask
Straight answers on filing windows, ColoradoPAR, Medicare, enrollment, and getting denied claims paid.
1. What does Cardialogy Billing handle for a Colorado cardiology practice?
Coverage checks, coding review, charge entry, submission, payment posting, denial work, A/R follow-up, and provider enrollment. Everything, basically. Some practices hand us the whole cycle. Others just want help with authorizations or the aging report, and that works too.
2. How long does a practice have to file a Health First Colorado claim?
At least 365 days from the date of service. Past that, the claim has to be resubmitted every 60 days with the earlier ICN referenced, or it falls out of timely filing. Medicare primary and slow to pay? There's another 120 days from the Medicare payment or denial. Commercial insurance claims get no extension beyond 365.
3. How do RAEs and managed care plans affect where a Medicaid claim goes?
Most physical health claims go to interChange. Members enrolled in Elevate Medicaid Choice or RMHP PRIME are different, since their claims go to the plan. The four RAEs (Rocky Mountain Health Plans, Northeast Health Partners, Colorado Community Health Alliance, and Colorado Access) handle care coordination and behavioral health. For most cardiology services, they aren't the payer.
4. How does Medicaid enrollment work for cardiologists?
The group, every rendering physician, and any attending provider must be enrolled through the Provider Web Portal. Each revalidates at least every five years. Miss one, and a claim can deny because a single provider listed on it has lapsed.
5. Can rejected or delayed cardiology claims be recovered?
Often, yes. We sort denials by cause codes, then correct, resubmit, or appeal inside the payer’s time frame. Aging claims get worked in order from oldest to newest. Some can’t be saved. For example, a PET scan done without a ColoradoPAR approval is a lost claim as Acentra doesn’t do any retroactive requests.
6. Does Cardialogy Billing work with hospital-owned cardiology clinics?
Yes. We can work with both hospital groups. Hospital-employed groups bill professional claims on the CMS-1500 and the hospital bills facility claims on the UB-04. We build the set up around the split.
7. Do commercial plans in Colorado have to pay within a set time?
Yes, state-regulated health plans have to pay, deny or settle a clean claim within 30 days from the date of submission if it was filed electronically and within 45 days if it was filed in paper format. Self-funded employer plans are exempt from this, and their plans and policies dictate terms.
8. Which cardiology tests require a ColoradoPAR approval?
For Health First Colorado members (Colorado's Medicaid program), most non-emergent CT and MRI studies and all PET and SPECT scans require prior approval. Acentra Health reviews the requests and the approval must be granted before the test is done. Emergency outpatient imaging is exempt. A prior approval does not guarantee payment.
9. Who processes Medicare claims in Colorado?
Novitas Solutions, the Medicare Administrative Contractor for Jurisdiction H. That jurisdiction covers Arkansas, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, and Colorado. Novitas's policies and coverage apply to Colorado cardiology claims.
Send us a denial report and see what turns up
A quick look at a recent denial report or aging summary usually shows where authorization, coding, or enrollment gaps are holding payments back.