Gender-Affirming Care Billing Manual

• Gender-Affirming Care Services Benefit
• Member Eligibility
  • Members Under 21 Years of Age
• Covered Services
  • Behavioral Health
  • Hormone Therapy
  • Gonadotropin-Releasing Hormone Therapy
  • Cross Sex-Hormone Therapy
  • Surgical Procedures
  • Genital Surgeries
  • Breast/Chest Surgeries
  • Facial and Neck Surgeries
  • Other Surgeries
  • Pre- and Post-Operative Services
  • Physical Therapy
• Non-Covered Services
• Billing Information
  • Gender-Specific Procedures
  • Prior Authorization Requests
• Revision Log

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Gender-Affirming Care Services Benefit

Providers must be enrolled as a Health First Colorado provider in order to:

• Treat a Health First Colorado member, and,
• Submit claims for payment to Health First Colorado.

Enrolled providers are eligible to provide gender-affirming care services if:

• The provider is licensed by the Colorado Department of Regulatory Agencies or the licensing agency of the state in which the provider practices,
• The services are within the scope of the provider's practice, and,
• The provider is knowledgeable about gender-diverse identities and expressions and the assessment and treatment of gender dysphoria.

Health First Colorado provides gender-affirming care services benefits to eligible members. Providers should refer to the Code of Colorado Regulations, Program Rules (10 CCR 2505-10 8.735), for specific information when providing these benefits.

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Member Eligibility

Members with a clinical diagnosis of gender dysphoria are eligible for the gender-affirming care services benefit, subject to the service-specific criteria and restrictions detailed in 10 CCR 2505-10 8.735.4. The following requirements apply to all covered gender-affirming care:

• Member has a clinical diagnosis of gender dysphoria,
• Requested service is medically necessary, as defined in section 8.076.1.8,
• Any co-existing physical and behavioral health conditions do not interfere with diagnostic clarity or capacity to consent, and associated risks and benefits have been discussed,
• Member has given informed consent for the service, and,
• Subject to the exceptions in C.R.S. § 13-22-103, if member is under 18 years of age, member's parent(s) or legal guardian has given informed consent for the service.

 

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Members Under 21 Years of Age

Requests for services for members under 21 years of age are evaluated in accordance with the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program criteria detailed in section 8.280.

Covered Services

Behavioral Health

Beginning July 1, 2022, behavioral health services with a primary diagnosis of F64.0-F64.9 will no longer be billed through the outpatient behavioral health fee-for-service benefit for members enrolled in the ACC and assigned to a RAE. Behavioral health providers must contract directly with the RAEs in order to bill for behavioral health services provided for these diagnoses.  

Providers billing professional claims (CMS-1500):

• Please see the State Behavioral Health Services Billing Manual for a list of procedure codes that should be billed to the RAEs when the primary diagnosis is F64.0-F64.9, as well as additional billing information for behavioral health services.

Hospital and Community Clinic providers (Provider types 01 and 86):

• All claims with primary diagnosis F64.0-F64.9 should be submitted fee-for-service.

Psychiatric Hospital (Provider type 02)

• All claims with primary diagnosis F64.0-F64.9 should be submitted to the RAEs.

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) billing institutional claims (UB-04):

• Please see the State Behavioral Health Services Billing Manual for a list of procedure codes that should be billed to the RAEs when the primary diagnosis is F64.0-F64.9, as well as additional billing information for behavioral health services.
• FQHC claims with primary diagnosis F64.0-F64.9 related to physical health should be submitted to the Department of Health Care Policy and Financing using Revenue Code 529.
• RHC claims with primary diagnosis F64.0-F64.9 related to physical health should be submitted to the Department of Health Care Policy and Financing using Revenue Code 521.
• Please see the Federally Qualified Health Center and Rural Health Clinic Billing Manual for billing guidance. 

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Hormone Therapy

Covered hormone therapy services are limited to Gonadotropin-Releasing Hormone Therapy and Gender-Affirming Hormone Therapy.

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Gonadotropin-Releasing Hormone Therapy

Gonadotropin-Releasing Hormone Therapy (GnRH) is a course of reversible pubertal or gonadal suppression therapy used to block the development of secondary sex characteristics in adolescents. GnRH therapy is a covered service for a member who:

• Meets the Member Eligibility criteria listed above,
• Meets the applicable pharmacy criteria at section 8.800, and,
• Has reached Tanner Stage 2

 

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Gender-Affirming Hormone Therapy

Gender-Affirming Hormone Therapy is a course of hormone replacement therapy intended to induce or change secondary sex characteristics.

Gender-Affirming Hormone Therapy is a covered service for a member who:

• Meets the Member Eligibility criteria listed above
• Meets the applicable pharmacy criteria at section 8.800,
• Has been informed of the possible reproductive effects of hormone therapy, including the potential loss of fertility, and the available options to preserve fertility,
• Has reached Tanner Stage 2, and
• If under 18 years of age, demonstrates the emotional and cognitive maturity required to understand the potential impacts of the treatment.

Other Gender-Affirming Hormone Therapy requirements include:

• Prior to beginning gender-affirming hormone therapy, a licensed health care professional who has competencies in the assessment of transgender and gender diverse people must determine that any behavioral health conditions that could negatively impact the outcome of treatment have been assessed and the risks and benefits have been discussed with the member, and
• For the first twelve (12) months of cross-sex hormone therapy member must receive medical assessments at a frequency determined to be clinically appropriate by the prescribing provider.

 

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Surgical Procedures

Gender-Affirming Surgery means a surgery to change primary or secondary sex characteristics to affirm a person's gender identity. This is also known as gender confirmation surgery or sex reassignment surgery.

Covered surgical procedures are benefits to a member who:

• Meets the Member Eligibility criteria listed above,
• Is 18 years of age or older,
• Has completed six (6) continuous months of hormone therapy, unless hormone therapy is not clinically indicated or is inconsistent with the client’s desires, goals, or expressions of individual gender identity,
  • This requirement does not apply to mastectomy surgeries,
  • Twelve (12) continuous months of hormone therapy are required for mammoplasty, unless hormone therapy is not clinically indicated or is inconsistent with the client’s desires, goals, or expressions of gender-identity,
• Understands the potential effect of the gender-affirming surgery on fertility

Requests for surgery for members under 18 years of age will be reviewed by the Department and considered based on medical circumstances and clinical appropriateness of the request.

Rendering surgical providers must retain the following documentation for each member:

• A signed statement from a licensed health care professional who has competencies in the assessment of transgender and gender diverse people, demonstrating that:
  • Surgical procedure criteria have been met (8.735.5.E.1.a-d), and,
  • A post-operative care plan is in place.

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The following are examples of surgeries that may be covered when the criteria above are met. This list is not exhaustive.

Genital Surgeries

• Ovariectomy/oophorectomy
• Salpingo-oophorectomy
• Hysterectomy
• Vaginectomy
• Vulvectomy
• Metoidioplasty
• Phalloplasty
• Erectile prosthesis
• Scrotoplasty
• Testicular prostheses
• Urethroplasty
• Orchiectomy
• Penectomy
• Prostatectomy
• Clitoroplasty
• Vaginoplasty
• Vulvoplasty
• Labiaplasty

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Breast/Chest Surgeries

• Mastectomy
• Mammoplasty
  • Twelve continuous months of hormone therapy are required for mammoplasty, unless hormone therapy is not clinically indicated or is inconsistent with the client’s desires, goals, or expressions of gender-identity.

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Facial and Neck Surgeries

• Blepharoplasty
• Brow Lift
• Forehead Reduction
• Genioplasty
• Mandibular Augmentation
• Osteoplasty
• Rhinoplasty
• Rhytidectomy
• Tracheal Shave

Other Surgeries

Requests for other medically necessary gender-affirming surgeries will be reviewed by the Department and considered based on the medical circumstances and clinical appropriateness of the request.

Pre- and Post-Operative Services

Pre- and Post-Operative services are covered when related to a covered surgical procedure and medically necessary, as defined in 10 CCR 2505-10 8.076.1.8.

Pre-surgical permanent hair removal/ electrolysis to treat surgical sites is a covered benefit.

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Physical Therapy

Outpatient physical therapy is a covered benefit. Please refer to the Outpatient PT/OT web page for details.

Documentation
Rendering surgical providers must retain the following documentation for each member:

• A signed statement from a licensed health care professional who has competencies in the assessment of transgender and gender diverse people, demonstrating that:
  • Surgical procedure criteria have been met (8.735.5.E.1.a-d), and,
  • A post-operative care plan is in place.

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Non-Covered Services

The following services are not covered under the gender-affirming care benefit:

• Reversal of covered surgical procedures
• Any items or services excluded from coverage under 10 CCR 2505-10 8.011.1

 

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General Billing Information

Refer to the General Provider Information manual for general billing information.

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Gender-Specific Procedures

Many procedures that are restricted to a member's assigned sex at birth will still be medically necessary after legally changing their gender. If a gender-specific procedure conflicts with the member's identified gender in the Colorado Benefits Management System (CBMS), please follow the billing guidance below:

• CMS-1500/837P Claims: Enter the KX modifier on the appropriate line items.
• UB-04/837I Claims: Providers should enter condition code 45 to indicate a procedure is medically necessary despite a gender conflict.

 

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Prior Authorization Requests

All prior authorization requests must provide documentation demonstrating that the applicable requirements in 10 CCR 2505-10 8.735.4 have been met. Prior authorization requests for hormone therapy services must be submitted in accordance with the requirements in 10 CCR 2505-10 8.800.7.

For all covered services, general requirements for prior authorization requests include:

• Member has a clinical diagnosis of gender dysphoria,
• Requested service is medically necessary, as defined in section 8.076.1.8,
• Any co-existing physical and behavioral health conditions do not interfere with diagnostic clarity or capacity to consent, and associated risks and benefits have been discussed,
• Member has given informed consent for the service, and,
• Subject to the exceptions in C.R.S. § 13-22-103, if member is under 18 years of age, member's parent(s) or legal guardian has given informed consent for the service.

For hormone therapy services, in addition to the above general requirements, the member's health care provider shall provide any information requested by the Fiscal Agent including, but not limited to:

• Member name, Health First Colorado identification number, and birth date,
• Name of the drug(s) requested,
• Strength and quantity of drug(s) requested, and,
• Prescriber's name and medical license number, Drug Enforcement Administration number, or National Provider Identifier

 

For surgical procedures, in addition to the above general requirements, prior authorization requests must provide documentation demonstrating that the member:

• Is 18 years of age or older,
• Has completed six (6) continuous months of hormone therapy, unless hormone therapy is not clinically indicated or is inconsistent with the client’s desires, goals, or expressions of individual gender identity,
  • This requirement does not apply to mastectomy surgeries,
  • Twelve continuous months of hormone therapy are required for mammoplasty, unless hormone therapy is not clinically indicated or is inconsistent with the client’s desires, goals, or expressions of gender-identity,
• Understands the potential effect of the gender-affirming surgery on fertility

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Gender-Affirming Care Revision Log

Revision Date	Addition/Changes	Made by
2/7/2019	Creation of Transgender Services manual	HPE
01/06/20	Converted to web page	HCPF
04/06/2020	Updated mastectomy criteria	HCPF
4/4/2022	Added behavioral health section and gender-affirming care language	HCPF
6/29/2022	Updated billing instructions for gender-specific procedures	HCPF
11/7/2022	Clarified behavioral health billing guidance	HCPF
8/30/2023	Updated member eligibility, hormone therapy, and surgery criteria, added covered facial and neck surgeries, updated documentation and prior authorization requirements.	HCPF

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