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CODE OF COLORADO REGULATIONS 10 CCR 2505-10 8.100 Medical Services Board

225 eligibility will be discontinued. Indicate the date the discontinuation will be effective. j. Failure to provide a correct and timely AP-5615 to the Long-Term Care institution may result in the refusal of the Department to reimburse such Long-Term Care institution care. The AP-5615 form is required in order for a Prior Authorization Request (PAR) to be issued for Long-Term Care institution claim reimbursement. k. General Instructions: i) The AP-5615 form must be verified and a signed AP-5615 form returned to the Long-Term Care institution. ii) The AP-5615 form must be signed and dated by the director of the Eligibility Site or by his/her designee. iii) AP-5615 forms may be initiated by either the Long-Term Care institution or Eligibility Site. If the Eligibility Site is aware of information requiring a change in financial arrangements of a resident, and a new AP-5615 form is not forthcoming from the Long-Term Care institution, the Eligibility Site may initiate the revision to the AP-5615 form. In such case, one copy of the AP- 5615 form showing the changes will be sent to the Long-Term Care institution. l. The Department may deduct excess payments from the Eligibility Site administrative reimbursement as stated in the Colorado Department of Human Services Finance Staff Manual, Volume 5 if the Eligibility Site fails to: i) Perform the duties as detailed in this section; or ii) Adhere to the limitations on a reduced patient payment; as detailed in section 8.100.7.V.4; or iii) Notify the Long-Term Care institution within 5 working days of any changes in resident income, provided the Long-Term Care