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Claims

Claims Process

All contracted providers are required to submit claims electronically to Trizetto Provider Solutions, the internal Rocky Mountain PACE clearinghouse system. To submit claims manually, visit: https://www.trizettoprovider.com/rocky-mountain-pace and reference Payer ID #93142, RMPACE.

As of August 1, 2021, timely filing requirements are 120 days from the end of the month in which the services are provided. Corrected claims and appeals must be submitted within 60 days from the date of the original explanation of payment (EOP).

If you have any questions regarding the process, please contact the RMHCS Claims Department at 719-314-2327 X869 or via email at PACEClaims@rmhcare.org.

Claims Registration and Submission

If you do not have the software for submission, follow this easy registration process:

  • Visit the website listed above.
  • Fill out the form, then submit. Trizetto Marketing will be notified.
  • NO CHARGE contract will be sent to you, the provider. Please sign the contract.
  • Trizetto Sales will set up an individual site.
  • Trizetto Implementation will notify you that the site is set up and ready to use. They will also provide instructions for the portal.
  • From there, you may begin entering and sending claims.

Corrected Claims and Appeals

Corrected Claims:

The corrected claims process begins when the provider receives an explanation of payment (EOP) from Rocky Mountain Health Care Services/RMPACE detailing the claims processing results. A corrected claim should only be submitted for a claim that has already been paid, was applied to the participant’s liability portion, was denied or original submission of information needs to be corrected (underpayment/overpayment, wrong coding, missing data, etc.). There may also be times when a provider has submitted a claim and before the claim has been processed for payment, the provider found a mistake on the claim submitted and can resubmit the claim with the correct information. In this case, the provider must notify RMHCS PACE immediately.

On UB-04’s, box 4 “Type of Bill” and box 64 for “Document Control Number” are to reference a corrected/voided claim. On CMS 1500’s, box 22 specifies if the claim(s) are resubmissions.

Corrected claim must be electronically filed, entered into the Trizetto clearinghouse or mailed directly to Rocky Mountain PACE.

Appeals:

RMHCS offers an appeal process to providers who believe they have been paid incorrectly. We will provide a full and fair review of any disputed denied claims and/or payment discrepancies. A provider has sixty (60) days from the date they receive the payment determination or denied claim to request an appeal.

Examples of an acceptable reason for appeals; timely filing, incorrect payment or denial or payment, participant eligibility, incorrect coding or further documentation is needed. The provider must fill out the appropriate paperwork and send with a letter of appeal notice.

Appeals may be mailed to: Rocky Mountain PACE, ATTN: Claims Department, 2502 E Pikes Peak Ave, Suite 100, Colorado Springs, CO 80909, or by encrypted email to PACEClaims@rmhcare.org.

To download the appeal form, Click Here.

FAQs

Q: How can I check participant eligibility and member ID information?
A: Please contact our Claims Department at 719-314-2327 X869 or by encrypted email to PACEClaims@rmhcare.org

Q: Do I need a pre-authorization?
A: Yes, all services require a preauthorization.

Q: I submitted a claim but I have not received a payment or denial, who do I contact to ensure the claim(s) was submitted to RMPACE Payer ID#93142?
A: Please contact our Claims Department at 719-314-2327 X869 or by encrypted email to PACEClaims@rmhcare.org. We are NOT affiliated with Rocky Mountain Health Plans OR Rocky Mountain Options.

Q: How do I get a copy of the EOP (explanation of payment)?
A: EOP’s are sent to the provider with payment. Providers may request a copy of the EOP by contacting the PACE Claims Department.

Q: Is RMPACE-Rocky Mountain Health Care Services the same as Rocky Mountain Health Plan(s) OR Rocky Mountain Options.
A: NO, we are not affiliated with Rocky Mountain Health Plan(s) OR Rocky Mountain Options. RMPACE is a completely separate entity.

Q: Do RMPACE participants have any co-pays or deductibles?
A: NO, PACE falls under CMS guidelines and in accordance with 42CFR 420, providers will hold harmless RMPACE participants for all claims, costs, and expenses. Participants are not to be balanced billed.

Q: What does a RMPACE Insurance Card look like?
A:

Forms for Claims Submission

External Forms

For the CMS 1500 Form, Click Here.

For the UB-04, Click Here.

For the ADA Dental Form and Instructions, Click Here.

 

RMHCS Forms

Below, you’ll find all forms you need to submit claims.

Learn More about our Pace Program