- Covered Services
- Pharmacy Administration of Vaccines
- Pharmacist Billing Guidelines
- Non-Covered Services and General Limitations
- Billing Information
- Billing for Members Ages 18 and Under
- Billing for Members Ages 19 and Over
- Vaccine Administration Codes and Reimbursement Rates
- Using Pediatric Immunization Codes 90460 and 90461
- Using Vaccine Administration Codes 90471-90474
- Preventive Medicine Counseling Codes
- Billing Instructions for Specific Providers
- Medicare Crossover Claims (Medicare/Medicaid Claims)
- Immunization Billing Codes
- National Correct Coding Initiative (NCCI) Impacts on Immunization and Evaluation and Management (E&M) Codes
- COVID-19 Vaccines
- Synagis® (palivizumab) Vaccine
- Seasonal Influenza Vaccine
- Colorado Department of Public Health and Environment (CDPHE) Vaccines for Children (VFC) Program
- CMS 1500 Paper Claim Reference Table
- CMS 1500 Immunization Claim Example
- Timely Filing
- Vaccines for Children Program (VCF) Information
- Immunization Manual Revisions Log
This Immunization Benefit Billing Manual provides a summary of benefits and billing guidelines for Health First Colorado (Colorado's Medicaid Program) providers who administer vaccines to adults and children. The Colorado Department of Health Care Policy and Financing (the Department) periodically reviews and modifies the immunization benefits and services. Therefore, the information in this manual is subject to change, and the manual is updated as new policies are implemented.
To access the most recent fee schedule, please refer to the provider Rates and Fee Schedules web page.
The Colorado Health First Colorado immunization benefit works to promote and facilitate the prevention of vaccine-preventable diseases. Colorado Health First Colorado maintains an inter-agency agreement with the Colorado Department of Public Health and Environment (CDPHE) to implement immunization recommendations by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Department of Health and Human Services.
Immunizations for all Health First Colorado members are a benefit when recommended by the ACIP. This includes COVID-19 Vaccines approved through an Emergency Use Authorization (EUA).
Health First Colorado members ages 18 and under are eligible to receive all immunizations available from the federal Vaccines for Children (VFC) Program, at VFC-enrolled provider offices, as well as any other vaccine distributed by the federal government, at no cost, to Health First Colorado providers.
- For more information about the VFC Program, please see the "Vaccines for Children Program" section in Appendix C of this manual.
- Immunizations may be given during an Early Periodic Screening Diagnosis and Treatment (EPSDT) periodic screening visit, an EPSDT inter-periodic visit, or any other medical appointment.
- The CDPHE Immunization Branch administers the VFC Program in Colorado, which provides all ACIP-recommended vaccines to medical providers at no cost to the provider for eligible members.
- Health First Colorado-enrolled providers will also be reimbursed for administering vaccines distributed to eligible providers, by the federal government, at no cost, outside of the VFC program.
- Vaccines for Children vaccines cannot be used for anyone 19 and older.
- The influenza vaccine is covered for members ages 19 and older one time per year.
All ACIP-recommended vaccines are covered for all Health First Colorado Members without cost-sharing.
Members enrolled in a Health First Colorado Managed Care Organization (MCO) must receive immunization services through a provider in the MCO's network. COVID-19 vaccines are an exception to this policy. Reimbursement for COVID-19 vaccine administration must be billed through fee for service. COVID-19 vaccine administrations in a clinic setting and billed on a professional claim are covered directly through fee for service and do not need to be billed to the managed care organization (MCO). Institutional claims that include a COVID-19 vaccine should continue to be submitted to the appropriate MCO.
Vaccines available from the VFC Program are updated annually and listed in this manual.
Refer to the Immunization Schedules for the current ACIP recommended schedules for children, teens and adults.
A VFC product code, as well as an administration code, must always be included on any claims for vaccination.
There are no prior authorization requirements for any vaccine recommended by the ACIP. Please refer to the Synagis® section of this manual for more information about prior authorization of Synagis®.
Pharmacist Administration of Vaccines
Health First Colorado members may receive the following vaccinations by an enrolled pharmacist at a Health First Colorado-enrolled pharmacy:
|Vaccine||CPT Codes||Age Restrictions|
|In accordance with evolving FDA EUA approval|
|Vaccine Counseling||99401||All ages|
Pharmacist Billing Guidelines
To submit vaccine claims, please use these guidelines:
- The pharmacy's NPI is the billing provider
- The pharmacist's NPI is the rendering provider
- A product code, as well as an administration code, must always be included in any claims for vaccination.
Pharmacists must follow the Board of Pharmacy Rules outlined in 3CCR 719-1, 19.00.00.
For additional information related to provider registration or claim submission, please visit the Quick Guides and Webinars web page.
Non-Covered Services and General Limitations
Health First Colorado will not reimburse providers for the cost of vaccines that are available through the VFC Program or for the cost of vaccines that the provider receives at no cost from the federal government. A product code, as well as an administration code, must always be included on any claims for vaccination.
Immunizations for the sole purpose of international travel are not a benefit for Colorado Health First Colorado members.
School District providers participating in the School Health Services (SHS) Program may not bill for immunizations.
General Billing Information
Refer to the General Provider Information manual for general billing information.
Vaccine Administration Codes and Reimbursement Rates
The following codes should be used for all vaccine administration, including VFC vaccine administration for members 18 years old and younger. Report these codes in addition to the vaccine and toxoid code(s).
|Use the following codes for VFC vaccine administration, to members 18 and under, with face-to-face counseling of the member/family during the vaccine administration:|
|90460||90461 (list separately in addition to 90460, use to indicate multi-component vaccinations)|
|Use the following codes for vaccine administration to members of any age when the administration is not accompanied by any face-to-face counseling, or for administration to members over 18 with or without counseling:|
|90471||+ 90472 (List separately in addition to 90471, 90473)|
|+ 90472||+ 90474 (List separately in addition to 90471, 90473)|
|Use the following codes for vaccine administration to members of the corresponding age when administering COVID-19 vaccines|
Please always refer to the fee schedule in the Provider Services section of the Department's website for the most up-to-date rate information.
Using Pediatric Immunization Codes 90460 and 90461
The following chart identifies the number of components in some of the common pediatric vaccines, and how to report the pediatric immunization administration codes for each vaccine:
|Vaccine||# of Components||Which Administration Codes to Report?|
|DTaP or Tdap||3||90460, 90461, 90461|
|MMR||3||90460, 90461, 90461|
|DTaP-Hib-IPV||5||90460, 90461, 90461, 90461, 90461|
|DTaP-HepB-IPV||5||90460, 90461, 90461, 90461, 90461|
|DTaP-IPV||4||90460, 90461, 90461, 90461|
|MMRV||4||90460, 90461, 90461, 90461|
|DTaP-Hib||4||90460, 90461, 90461, 90461|
Source: American Academy of Pediatrics
To submit claims for immunization services, providers must "roll up/bundle" the total unit count of the immunization administration codes.
- If an immunization administration code is billed for each vaccine that was given during the visit as its own line item, each subsequent line item billed using 90460 after the initial 90460 line item will be denied as a duplicate claim.
The following example demonstrates how to bill for the administration of Hep A, DTaP-HIB-IPV, and MMR vaccines.
Component Calculation and which codes to report (Using Table 1):
|Vaccine||# of Components||Which Codes to Report?|
|DTaP-HIB-IPV||5||90460, 90461, 90461, 90461, 90461|
|MMR||3||90460, 90461, 90461|
How to Bill:
|Line #||CPT Descriptor||CPT Code||Units|
|Line 1||First Vaccine Component||90460||3|
|Line 2||Additional Vaccine Component||90461||6|
|Line 3||Hep A||90633||1|
- CPT code 90460 is billed for three (3) units because it was reported once for each vaccine that was administered.
- CPT code 90461 is billed for six (6) units because it was reported six (6) times (four (4) times for the DTaP-HIB-IPV vaccine and two (2) times the MMR vaccine).
For further clarification on billing pediatric immunization codes, please refer to the American Academy of Pediatrics (AAP) practice guidelines.
For billing questions, please contact the Provider Services Call Center.
Using Vaccine Administration Codes 90471-90474
The immunization administration codes 90471-90474 need to be billed as one (1) line item, and the vaccine product should be billed as a separate line item. In order for an immunization claim to be reimbursed both an administration code and the vaccine product must be billed. If immunization is the only service rendered, providers may not submit charges for an E&M service.
Adult immunizations are reimbursed at the lower of: billed charges, or the Health First Colorado fee schedule amount for each immunization.
Note: Providers are not to bill CPT codes 90471-90474 for children ages 0-18 for whom counseling was given (see section Using Pediatric Immunization Codes 90460 and 90461" in this manual). CPT Codes 90471-90474 must only be billed for members (ages 19 and older) or members ages 18 and under for whom no counseling was given.
Preventive Medicine Counseling Codes
Health First Colorado covers COVID-19 vaccine counseling visits in which healthcare providers talk to families about the importance of vaccination. Health First Colorado will also reimburse for and cover stand-alone vaccine counseling visits as part of vaccine administration required for all routine vaccines. Providers should bill CPT 99401: for visits in which healthcare providers give counseling about the importance of vaccination. Providers should include modifier CR for all COVID-19 vaccine counseling-only visits.
Providers should not bill for the vaccine counseling code and the vaccine administration code on the same date of service. Vaccine administration codes are inclusive of counseling.
CPT 99401 can be billed at only one visit for each member per day, but there are no quantity limits for the number of times this education is provided to an individual member.
Keep documentation in the member's chart that shows the duration of counseling and a list of the prevention topics covered during counseling.
If there is a separately identifiable Evaluation and Management (E/M) service performed outside of vaccine counseling and immunization administration, a separate E/M visit code may be reported, along with modifier 25.
When using a modifier is appropriate, refer to the CMS National Correct Coding Initiative (NCCI) Policy Manual, Chapter 1, Section E for specific guidance on the proper use of modifiers.
Billing Instructions for Specific Providers
Pharmacists must bill for vaccinations on a professional claim either via batch through a vendor or through the Provider Web Portal, using the pharmacy's NPI as the billing provider, the pharmacist's NPI as the rendering provider and the physician on the standing order as the ordering provider.
- Pharmacies must have a web portal account because the pharmacists do not bill, they are strictly the renderer on the claims.
- If the pharmacy would like to add a Pharmacist as a delegate to their web portal account for the purpose of submitting claims on their behalf, they can.
- Pharmacies can submit Fee-For-Service (FFS) claims via the portal or batch claims via the 837P.
- If the member is enrolled in Denver Health Medicaid Choice or Rocky Mountain Health Plans Prime, providers must submit the claim to the MCO. COVID-19 vaccines are an exception to this policy. Reimbursement for COVID-19 vaccine administration must be billed through fee for service. COVID-19 vaccine administrations in a clinic setting and billed on a professional claim are covered directly through fee for service and do not need to be billed to the managed care organization (MCO). Institutional claims that include a COVID-19 vaccine should still be submitted to the appropriate MCO as usual.
Managed Care Programs
Health First Colorado members enrolled in an MCO must receive immunization services from the MCO, and providers may not bill Colorado Health First Colorado directly for vaccines provided to these members. COVID-19 vaccines are an exception to this policy. Reimbursement for COVID-19 vaccine administration must be billed through fee for service. COVID-19 vaccine administrations in a clinic setting and billed on a professional claim are covered directly through fee for service and do not need to be billed to the managed care organization (MCO). Institutional claims that include a COVID-19 vaccine should still be submitted to the appropriate MCO as usual.
Outpatient, Emergency Room, or Inpatient Hospital
Immunization administration may be billed as part of an outpatient or emergency room visit when the visit is for medical reasons.
Outpatient or emergency room visits cannot be billed for the sole purpose of immunization administration. Administration of immunization at the time of an inpatient stay is included in the APR-DRG.
Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC)
Federally Qualified Health Centers and Rural Health Centers may bill an encounter fee even if the only service provided is administering an immunization by a billable provider, so long as the visit otherwise qualifies as a billable encounter per 10 CCR 2505-10 8.700 (FQHC) and 8.740 (RHC). If immunization is administered in addition to a routine office visit, then an additional encounter fee may not be billed. Effective February 21, 2021, through the end of the Public Health Emergency, FQHCs will be directly reimbursed at the fee schedule rates for administering the COVID-19 vaccines. If the COVID-19 vaccine is provided as part of a regular billable visit, or another service is provided by an FQHC billable provider, FQHCs can receive their encounter rate reimbursement in addition to the fee schedule reimbursement.
Nursing facility residents may receive immunizations if ordered by their physician. The skilled nursing component for immunization administration is included in the facility's rate. The vaccine itself may be billed directly to Colorado Health First Colorado by a Colorado Health First Colorado enrolled pharmacy. The pharmacy must bill the appropriate National Drug Code (NDC) for the individual vaccine dose under the member's Colorado Health First Colorado ID. Nursing facility residents may receive COVID-19 vaccinations from any qualified provider. If a pharmacist, pharmacy intern, or pharmacy technician administers the vaccine to a nursing facility resident, the pharmacy may bill for the vaccine administration under the member's Health First Colorado ID.
A member receiving home health services may receive immunizations if the administration is part of a normally scheduled home health visit. A home health visit for the sole purpose of immunization administration is not a benefit.
The pharmacy bills the vaccine as an individual dose under the member's Colorado Health First Colorado ID. The home health agency may not bill for the vaccine. Pharmacies may bill for reimbursement of COVID-19 vaccine administration. Pharmacies may not bill for the cost of COVID-19 vaccine products if the vaccine products are received from the federal government at no cost.
Alternative Health Care Facilities (ACFs)/Group Homes
Residents of an ACF may receive immunizations from their own physicians. They may also receive vaccines under home health as stated above in the home health guideline.
Health First Colorado does not pay for home health agencies, physicians, or other non-physician practitioners to go to nursing facilities, group homes, or residential treatment centers to administer immunizations (example: flu vaccines) to groups of members. However, COVID-19 vaccines are an exception to this policy. Health First Colorado will pay pharmacists, pharmacy interns, and pharmacy technicians for the administration of COVID-19 vaccines in Long-term Care Facilities through the CDC's Pharmacy Partnership for Long-term Care (LTC) Program or other partnership between an LTC and a pharmacy.
Medicare Crossover Claims (Medicare/Medicaid Claims)
For Medicare crossover claims, Health First Colorado pays the Medicare deductible and coinsurance or Health First Colorado allowable reimbursement minus the Medicare payment, whichever amount is less. If Medicare's payment for immunization services is the same or greater than the Health First Colorado allowable benefit, no additional payment is made.
If Medicare pays 100% of the Medicare allowable, Colorado Health First Colorado makes no additional payment.
Immunization Billing Codes
Please see Appendix B of this manual.
National Correct Coding Initiative (NCCI) Impacts on Immunization and Evaluation & Management (E&M) Codes
Effective April 1, 2014, the Department will no longer reimburse NCCI procedure-to-procedure (PTP) edits when immunization administration procedure codes (CPT 90460-90474) are paired with preventive medicine E&M service procedure codes (CPT 99381-99397).
If a significant separately identifiable E&M service (e.g. new or established member office or other outpatient services [99201-99215], office or other outpatient consultation [99241-99245], emergency department service [99281-99285], preventive medicine service [99381-99429] is performed), the appropriate E&M service code should be reported in addition to the vaccine and toxoid administration codes.
Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of 0" indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. A modifier indicator of 1" indicates that NCCI PTP-associated modifiers may be used to bypass an edit under appropriate circumstances. A modifier indicator of 9" indicates that the edit has been deleted, and the modifier indicator is not relevant. The Correct Coding Modifier Indicator can be found in the files containing Health First Colorado NCCI PTP edits on the CMS website.
A modifier should not be added to an HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. If the E&M service is significant and separately identifiable and performed on the same day, the E&M code should be billed with the vaccine and toxoid administration codes using PTP associated modifier '25'. Modifier '25' is only valid when appended to the E&M codes. Do not append to the immunization administration procedure codes 90460-90474.
COVID-19 vaccines are used to prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral infections and the disease they cause, Coronavirus disease (COVID-19). All FDA-approved COVID-19 vaccines are a covered benefit for all Health First Colorado Members, without cost-sharing and without prior authorization. This includes COVID-19 vaccines approved under an Emergency Use Authorization (EUA). As long as providers receive the vaccine product from the federal government, at no cost, Health First Colorado will only reimburse for vaccine administration. A product code, as well as an administration code, must always be included in any claims for vaccination.
Synagis® (palivizumab) Vaccine
Synagis® (Palivizumab) is used to prevent serious lower respiratory tract disease caused by Respiratory Syncytial Virus (RSV) in certain high-risk pediatric members. The Department uses coverage criteria based on the American Academy of Pediatrics (AAP) 2014 and the Colorado Chapter of the AAP recommendations for RSV prophylactic therapy. Synagis® (Palivizumab) is not provided by the VFC program.
Limitations on Synagis®
Synagis® is administered by intramuscular injections, at 15 mg per kg of body weight, once a month during expected periods of RSV frequency in the community. Providers should be aware that the Colorado RSV season typically has a later onset, starting closer to December, and should schedule their Synagis® doses accordingly. Synagis® administration must be prior authorized.
The 2021-2022 Synagis® season began August 17, 2021. For more information, please see the August 2021 Synagis® and Influenza Vaccines provider bulletin on the Provider Bulletin web page.
Billing for Synagis®
- The Department will provide pricing information during each Synagis® season.
- Providers may not ask members to obtain Synagis® from a pharmacy and bring it to the practitioner's office for administration.
- Synagis® given in a doctor's office, hospital, or dialysis unit is to be billed directly by those facilities as a medical benefit. Prior Authorization Requests for Synagis® billed as a medical benefit shall be submitted to the Fee For Service UM Vendor, Kepro via their online PAR portal, Atrezzo.
- Synagis® may only be a pharmacy benefit if the medication is administered in the member's home or long-term care facility.
Note: A separate Synagis® PAR process exists for the CHP+ State Managed Care Network members. Any questions regarding this process should be directed to Colorado Access at 303-751-9005 or 800-511-5010, or US Bioservices at 303-706-0053.
Seasonal Influenza Vaccine
Seasonal influenza vaccine is a benefit for children and adults and is recommended for individuals who are six (6) months of age or older. Influenza vaccine is available through the VFC Program for providers enrolled in the program to administer to Health First Colorado enrolled children/adolescents (aged 18 and under). (See Appendix B).
For more Health First Colorado information on the seasonal influenza vaccine for both children and adults, please see the August 2021 Synagis® and Influenza Vaccines Provider Bulletin on the Provider Bulletin web page.
Colorado Department of Public Health and Environment (CDPHE) Vaccines for Children (VFC) Program
The VFC Program, administered by CDPHE, partners with Health First Colorado to provide free vaccines for providers to administer to Health First Colorado-enrolled children.
Participation in the VFC Program is strongly encouraged by the Department. Providers, including but not limited to: private practitioners, managed care providers, local public health agencies, Rural Health Centers (RHCs), hospital outpatient clinics, school-based health centers, and Federally Qualified Health Centers (FQHCs), who wish to participate in the immunization program must enroll with CDPHE. Providers can get information on the CDPHE VFC program at the program website or by calling 303-692-2650.
CMS 1500 Paper Claim Reference Table
The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.
|CMS Field Number & Label||Field is?||Instructions|
|1. Insurance Type||Required||Place an "X" in the box marked as Medicaid.|
|1a. Insured's ID Number||Required||Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.|
|2. Patient's Name||Required||Enter the member's last name, first name, and middle initial.|
|3. Patient's Date of Birth/Sex||Required||Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.
Place an "X" in the appropriate box to indicate the sex of the member.
|4. Insured's Name||Conditional||Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
|5. Patient's Address||Not Required|
|6. Patient's Relationship to Insured||Conditional||Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.|
|7. Insured's Address||Not Required|
|8. Reserved for NUCC Use||Not Required|
|9. Other Insured's Name||Conditional||If field 11d is marked "YES", enter the insured's last name, first name and middle initial.|
|9a. Other Insured's Policy or Group Number||Conditional||If field 11d is marked "YES", enter the policy or group number.|
|9b. Reserved for NUCC Use|
|9c. Reserved for NUCC Use|
|9d. Insurance Plan or Program Name||Conditional||If field 11D is marked "YES", enter the insurance plan or program name.|
|10a-c. Is patient's condition related to?||Conditional||When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.|
|10d. Reserved for Local Use|
|11. Insured's Policy, Group or FECA Number||Conditional||Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
|11a. Insured's Date of Birth, Sex||Conditional||Complete if the member is covered by a Medicare health insurance policy.
Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.
Place an "X" in the appropriate box to indicate the sex of the insured.
|11b. Other Claim ID||Not Required|
|11c. Insurance Plan Name or Program Name||Not Required|
|11d. Is there another Health Benefit Plan?||Conditional||When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.|
|12. Patient's or Authorized Person's signature||Required||Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".
Enter the date the claim form was signed.
|13. Insured's or Authorized Person's Signature||Not Required|
|14. Date of Current Illness Injury or Pregnancy||Conditional||Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.
Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
|15. Other Date Not||Not Required|
|16. Date Patient Unable to Work in Current Occupation||Not Required|
|17. Name of Referring Physician||Conditional|
|17b. NPI of Referring Physician||Required||Required in accordance with Program Rule 8.125.8.A|
|18. Hospitalization Dates Related to Current Service||Conditional||Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.|
|19. Additional Claim Information||Conditional|
|20. Outside Lab?
|Conditional||Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.
Practitioners may not request payment for services performed by an independent or hospital laboratory.
|21. Diagnosis or Nature of Illness or Injury||Required||Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.
Enter applicable ICD-10 indicator.
|22. Medicaid Resubmission Code||Conditional||List the original reference number for resubmitted claims.
When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
|23. Prior Authorization||Not Required|
|24. Claim Line Detail||Information||The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.
Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.
Each claim form must be fully completed (totaled).
Do not file continuation claims (e.g., Page 1 of 2).
|24A. Dates of Service||Required||The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.
Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
N4 - National Drug Codes
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth and Areas of Oral Cavity
|24B. Place of Service||Required||
Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
01 - Pharmacy
|24C. EMG||Conditional||Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.
If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.
|24D. Procedures, Services, or Supplies||Required||Enter the procedure code that specifically describes the service for which payment is requested.|
|24D.||Required||Enter the HCPCS procedure code that specifically describes the service for which payment is requested.
All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.
HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).
Only approved codes from the current CPT or HCPCS publications will be accepted.
For originating provider use procedure code Q3014.
For distant provider use procedure code + modifier GT.
|24D. Modifier||Not Required|
|24E. Diagnosis Pointer||Required||Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.
At least one diagnosis code reference letter must be entered.
When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.
This field allows for the entry of 4 characters in the unshaded area.
|24F. $ Charges||Required||Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.
The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.
Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.
Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
|24G. Days or Units||Required||Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.
|24H. EPSDT/Family Plan||Conditional||EPSDT (shaded area)
For Early and Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV - Available- Not Used
S2 - Under Treatment
ST - New Service Requested
NU - Not Used
Family Planning (unshaded area)
If the service is Family Planning, enter "Y" for YES or "N" for NO in the bottom, unshaded area of the field.
|24I. ID Qualifier||Not Required|
|24J. Rendering Provider ID #||Required||In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.|
|25. Federal Tax ID Number||Not Required|
|26. Patient's Account Number||Optional||Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).|
|27. Accept Assignment?||Required||The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.|
|28. Total Charge||Required||Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.|
|29. Amount Paid||Conditional||Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.
Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
|30. Rsvd for NUCC Use|
|31. Signature of Physician or Supplier Including Degrees or Credentials||Required||Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.
Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider's name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
"Signature on file" notation is not acceptable in place of an authorized signature.
|32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
|Required||Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
|33. Billing Provider
Info & Ph #
|Required||Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
|33a- NPI Number||Required|
|33b- Other ID #||If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.|
CMS 1500 Immunization Claim Example
For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.
Appendix A - Immunization Schedules
- Recommended Immunization schedule for persons aged 0 through 18 years.
- Recommended Immunization schedule for adults aged 19 and older.
Appendix B - Vaccines for Children (VFC) Program
Immunization Manual Revisions Log
|Revision Date||Addition/Changes||Made by|
|12/1/2016||Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive.||HPE (now DXC)|
|12/27/2016||Updates based on Colorado iC Stage II Provider Billing Manuals Comment Log v0_2.xlsx.||HPE (now DXC)|
|1/10/2017||Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx||HPE (now DXC)|
|1/19/2017||Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx||HPE (now DXC)|
|1/26/2017||Updates based on Department 1/20/2017 approval email||HPE (now DXC)|
|5/22/2017||Updates based on Fiscal Agent name change from HPE to DXC||DXC|
|2/12/2018||Removed NDC supplemental qualifier - not relevant for immunization providers||DXC|
|6/22/2018||Updated general billing and timely filing||HCPF|
|10/15/2018||Added pharmacy-specific billing information||HCPF|
|12/21/2018||Clarification to signature requirements||HCPF|
|3/18/2019||Clarification to signature requirements||HCPF|
|1/9/2020||Converted to web page||HCPF|
|7/22/2020||Added pharmacy-specific flu vaccine billing information||HCPF|
|9/10/2020||Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table||HCPF|
|12/10/2020||Added 2 codes to pharmacy-specific flu vaccine billing information and added information about COVID-19 vaccines||HCPF|
|1/14/2021||MCO, Nursing Facility and ACF policy edits. Co-pay policy clarification||HCPF|
|2/3/2021||Clarification of FQHC/RHC reimbursement policy for immunizations and added flu code||HCPF|
|2/23/2021||Removed IHS references, clarify need for both product and administration codes, addition of 91303 and 0031A to pharmacy-specific billing information||HCPF|
|6/7/2021||MCO billing clarification for COVID-19 vaccines||HCPF|
|8/16/2021||Added COVID-19 booster codes and update 2021 Synagis info||HCPF|
|9/14/2021||Added 90865 to Pharmacy flu codes||HCPF|
|11/2/2021||Added COVID-19 vaccine codes||HCPF|
|1/12/2022||Added COVID-19 vaccine codes||HCPF|
|1/12/2022||Added Vaccine Counseling||HCPF|
|2/8/2022||Modify Vaccine Counseling||HCPF|
|2/8/2022||Add 90671 to Pharmacy Section||HCPF|