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HCPF details Rural Health Clinic reconciliation letters, rate posting, 2026 rates and audit options
Summary
Department staff said reconciliation demand letters were sent in April starting a 30-day appeal window, that 2026 RHC rates were implemented in February, and that the department will post aggregated RHC rates publicly; staff also outlined scope-of-service adjustments and managed-care accuracy audit participation options.
Andrew Avalos, facility rate section manager at the Colorado Department of Health Care Policy & Financing, provided several operational updates for Rural Health Clinics (RHCs) during the April 30 engagement meeting.
Reconciliations and demand letters: Avalos said the department has aggregated 2025 work into 2026 reconciliation work and sent reconciliation demand letters in April, which begin a 30-day appeal window. He said if finalized rates are lower than amounts already paid, the department will set up accounts receivable to recover funds; conversely, if finalized rates are higher than interim payments, the department will issue additional payments based on claims data. "We did send out the reconciliation demand letters in April, which starts the 30 day, appeal window," Avalos said. He told clinics to expect departmental actions around mid-May.
Public posting of rates and 2026 implementation: Avalos said the department plans to publish an aggregated set of RHC rates on the HCPCS website to provide a single, public location for rates that are otherwise available in hospital cost reports and Medicare UPL data. He also said the department implemented 2026 rates in its MMIS system in February using finalized cost-report/HICRIS data and asked providers to email Marcela Kuzmiak or himself if they still see unadjusted claims. "We should be paying the 2026 rates as of right now," he said.
Scope-of-service adjustments and managed-care audits: Avalos described a relatively new scope-of-service rate adjustment process for valid changes in a clinic’s scope that could modify the PPS rate, and he pointed attendees to guidance on the RHC form site. He also summarized the managed care accuracy audit process and said managed-care entities are required to reimburse RHCs at no less than the encounter rate set by the department; he described participation options for clinics that believe payments are incorrect and named Kennedy as a point of contact for the audit process.
Transcription and acronym notes: the transcript references an acronym "BIPA" and several internal system names (HCPCS, HICRIS, MMIS); the meeting did not define "BIPA" on the record, and the transcript includes a few apparent transcription errors (for example, the words "raise" and "ray" appear in places where meaning is unclear). The article reports the department’s descriptions as stated and notes undefined acronyms and unclear transcriptions where present.
Marcela Kuzmiak, the new FQHC/RHC rates analyst announced by the department, was not in attendance; Avalos provided contact details and encouraged clinics to reach out with questions.
