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Lactation Support Services Billing Manual

The lactation support services benefit program is administered by the Colorado Department of Health Care Policy & Financing (the Department). This billing manual provides information regarding coverage, policy and billing requirements. The information in this manual is subject to change as the Department periodically modifies the lactation support services program’s benefits and services. The manual will be updated as new policies are implemented.  
 

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for general information about Health First Colorado (Colorado’s Medicaid program). The General Provider Information Manual provides information about billing Health First Colorado, reimbursement policies, provider participation, eligibility requirements and other useful information. 


Table of Contents

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Program Overview


On December 1, 2024, the Colorado Department of Health Care Policy and Financing (the Department) implemented a lactation support services benefit for Health First Colorado members. This program is based on legislation HB22-1289


Rules and Regulations
The lactation support services benefit program is administered by the Department. Rules governing the program are outlined in the Code of Colorado Regulations 10 C.C.R. 2505-10 8.732.7. Providers are required to comply with all rules and guidance provided by the Department and are encouraged to contact the Department’s policy specialists with any questions at  HCPF_MaternalChildHealth@state.co.us. Updates to policy and guidance will be published in this manual. Providers will be given notice of updates through the Department’s monthly Provider Bulletin

This program gives people access to lactation support services, including training and counseling the breastfeeding (or lactating) member about breastfeeding and human lactation. It provides comprehensive, skilled care and evidence-based information for breastfeeding and human lactation.

To be eligible for the program, a member must meet the following criteria: 

  • Be eligible for Health First Colorado 
  • Be a pregnant, postpartum or pediatric member who is breastfeeding
     

Member Eligibility
Before rendering services, the provider should verify the member's eligibility to ensure that the member is eligible for benefits. Providers should retain documentation of the verified eligibility for billing purposes. In order to be eligible for reimbursement for services provided to Child Health Plan Plus (CHP+) members, all CHP+ providers must have an active contract with a CHP+ Managed Care Organization (MCO). Providers should submit claims to the MCO once a CHP+ member is enrolled into an MCO. Refer to the Child Health Plan Plus (CHP+) web page for further guidance.

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Provider Qualifications and Enrollment


Providers must be enrolled as Health First Colorado providers to: 

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


Visit the Provider Enrollment web page if interested in becoming a Health First Colorado provider. 

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Eligible Rendering Providers


Lactation support services may only be provided by enrolled individual providers with training in advanced lactation support. Providers may not bill for services provided by un-enrolled providers, such as supervised interns or persons undergoing training to become a Certified Lactation Educator (CLE), Certified Lactation Counselor (CLC), or International Board-Certified Lactation Consultant (IBCLC).  

The following enrolled provider types (PT) may provide lactation support services if it is within their scope of practice according to state licensing requirements and laws and the provider has training in advanced lactation support: 

  • International Board-Certified Lactation Consultant (IBCLC) – PT 70 
  • Certified Lactation Counselor (CLC) - PT 71
  • Certified Lactation Educator (CLE) - PT 71
  • Certified Professional Midwife (CPM)/Direct Entry Midwife (DEM) - PT 69
  • Certified Midwife (CM) - PT 80
  • Certified Nurse Midwife (CNM) - PT 22
  • Licensed Physician (MD) – PT 05
  • Licensed Osteopath (DO) - PT 26
  • Licensed Physician Assistant (PA) – PT 39
  • Licensed Advanced Practice Nurse (APN) – PT 41
  • Licensed Registered Nurse (RN) – PT 24 (enrolled as a Non-Physician Practitioner-Individual)

Enrolled Doula providers who meet IBCLC, CLC or CLE qualifications per 10 C.C.R. 2505-10 8.732.9 may provide lactation support without separate PT 70 or 71 enrollment.

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Eligible Billing Providers

Facility Provider Types

The only facility provider type that may bill for lactation support services is:

  • Supply – PT 14

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Supply (PT 14)

When claims are submitted using a supplier as the billing provider, the rendering provider’s National Provider Identifier (NPI) listed on the claim must be the individual provider who rendered the service. The rendering provider does not need to be formally affiliated with the group in order for the claim to be processed.

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Group Provider Types

The only group provider types that may bill for lactation support services are:

  • Federally Qualified Health Center (FQHC) – PT 32
  • Rural Health Clinic (RHC) – PT 45
  • Indian Health Services (IHS) – PT 61
  • Clinic – PT 16
  • Non-Physician Practitioner Group – PT 25
  • Lactation/Doula Professional Group – PT 72

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Federally Qualified Health Centers and Rural Health Clinics (PT 32 and 45)

Refer to the Federally Qualified Health Center (FQHC)/Rural Health Clinic (RHC) billing manual for details regarding billing lactation support services in an FQHC/RHC setting. Lactation support services provided by an employee at an FQHC/RHC site are billed as part of the encounter rate for the FQHC/RHC and may result in a payment when delivered by a provider included in the FQHC/RHC visit definition (10 CCR 8.700 & 8.740). Lactation support services are not billed separately on professional claim forms (CMS 1500). Lactation support services provided by an employee at an FQHC/RHC site that are not included in the FQHC/RHC visit definition should be included in the FQHC/RHC cost report.

Lactation support service providers who provide lactation support services at a FQHC or RHC but are not employed by the FQHC/RHC can bill for services separately on a professional claim form (CMS 1500) and use the applicable Place of Service codes. These claims are reimbursed at the Health First Colorado Fee Schedule rate. 

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Indian Health Services (PT 61)

Refer to the Indian Health Services (IHS) billing manual for details regarding billing lactation support services in an outpatient setting. Lactation support services provided at an IHS site are billed per encounter as part of the all-inclusive rate. They are not billed separately on professional claim forms (CMS 1500).  
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Clinics and Non-Physician Practitioner Groups (PT 16 and 25)

When claims are submitted using Clinics and Non-Physician Practitioner Groups as the billing provider, the rendering provider’s National Provider Identifier (NPI) listed on the claim must be the individual provider who rendered the service. The rendering provider must be formally affiliated with the group in order for the claim to be processed.

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Lactation/Doula Professional Groups (PT 72)

When claims are submitted using the Lactation/Doula Professional Group as the billing provider, the rendering provider’s NPI listed on the claim must be the individual provider who rendered the service. The rendering provider must be formally affiliated with the group in order for the claim to be processed.

A Lactation/Doula Professional Group consists of any of the following professionals who are enrolled with the Department as approved providers: 

  • International Board-Certified Lactation Consultant (IBCLC) – PT 70
  • Certified Lactation Counselor – PT 71
  • Certified Lactation Educator – PT 71
  • Doula – PT 79

This billing provider type must have at least one (1) IBCLC or Doula affiliated with the group.

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Individual Billing Providers

Individual providers may choose to be their own billing provider for lactation support services. The following list of providers can have billing status when enrolling with Health First Colorado:

  • International Board-Certified Lactation Consultant (IBCLC) – PT 70
  • Certified Midwife (CM) – PT 80
  • Certified Nurse Midwife (CNM) – PT 22 
  • Licensed Physician (MD) – PT 05
  • Licensed Osteopath (DO) - PT 26
  • Licensed Advanced Practice Nurse (APN) – PT 41

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Supervision Requirements

International Board-Certified Lactation Consultants (IBCLCs) with current certification by the International Board of Lactation Consultant Examiners (IBLCE) may provide lactation support services without supervision.

Certified Lactation Counselors (CLCs) with current certification by the Academy of Lactation Policy and Practice, Inc. (ALPP) and Certified Lactation Educators (CLEs) with current certification by the Childbirth and Postpartum Professional Association (CAPPA) may only provide lactation support services under the general supervision of enrolled:

  • Physicians (MDs) – PT 05/65
  • Osteopaths (DOs) – PT 26
  • Physician Assistants (PAs) – PT 39
  • Advanced Practice Nurses (APNs) - PT 41
  • Certified Nurse Midwives (CNMs) – PT 22
  • International-Board Certified Lactation Consultants (IBCLCs) – PT 70

A Certified Lactation Counselor (CLC)/Certified Lactation Educator (CLE) may render services but does not bill directly. Claims must be submitted through the enrolled group. Claims must identify the CLC/CLE with their NPI number as the rendering provider. 

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Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for general information.

Covered Lactation Support Services


Lactation support services are billed using a single Healthcare Common Procedure Coding System (HCPCS) procedure code (S9443), one (1) of two (2) modifier codes indicating individual (U1) or group settings (U2) and one (1) of eight (8) modifier codes (U3, U4, U5, U6, U7, U8, U9, UA) to indicate the number of minutes spent providing direct contact services to the member.  Add an additional modifier code if services are delivered via telemedicine (FQ, FR, 93, 95), as shown in the tables below. Refer to the current Fee Schedule for rates

Prior authorization requests are not required. There are no amount, duration or scope limitations for the lactation support services benefit. 

Appropriate diagnosis codes must be utilized when billing for lactation support services (e.g., Z39.1: encounter for care and examination of a lactating mother, O92.70: unspecified disorders of lactation). If billing a claim for a breastfeeding child, use a child lactation-related code (e.g., R63.31: pediatric feeding difficulty, P92.5: neonatal feeding difficulties at breast).

Services for the lactating member and child must be billed on one (1) claim. Both the lactating member and the breastfeeding child must not have claims submitted for the same service and the same date of service. The provider should bill the claim under the eligible member for whom the visit was scheduled, or most closely aligns with the provider’s scope of practice. For example, a pediatrician would bill under the Health First Colorado enrolled breastfeeding child, and an obstetrician would bill under the Health First Colorado enrolled lactating member.

When billing for lactation support services for twins, multiple infants or tandem breastfeeding, providers have two options:

  1. Bill for extended time spent with the lactating member; OR
  2. Bill separately for time spent with each breastfeeding child. Providers will need to ensure to bill for distinct and separate identifiable amounts of time for each pediatric member.

A lactation support provider who renders services to more than one (1) member at a time must bill appropriately using the approved group session modifier U2. The group session must be an instructor-led breastfeeding education group. Not all participants in the group need to be members of Health First Colorado, but a claim for payment may only be submitted for each enrolled Health First Colorado member who received services in the group session. Such claims must be coded using S9443 with the U2 modifier.

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Coding Table for Lactation Support Services 
 

Procedure CodeDescriptionFirst Position Modifersecond position Modifier
S9443

Lactation Support Services

 

 

Telemedicine service delivery is allowed.

U1 = individual session

 

U2 = group session

U3 = 8-22 minutes

U4 = 23-37 minutes

U5 = 38-52 minutes

U6 = 53-67 minutes

U7 = 68-82 minutes

U8 = 83-97 minutes

U9 = 98-112 minutes

UA = 113-127 minutes

Example: A member received a total of 90 minutes of individual in-person lactation support services on a given date of service. The provider should report S9443 with the U1 modifier to indicate individual setting and the U8 modifier to indicate 90 minutes of direct member contact services provided.

Important Notes on S9443

Although the formal definition of HCPCS procedure code S9443 is “Lactation classes, non-physician provider, per session,” the Department instructs providers to use this procedure code under the direction detailed in this billing manual. Key differences are:

  1. This procedure code should be reported for lactation support services by any eligible provider, including physicians, rather than just “non-physicians.” 

 

Modifier Codes for Telemedicine Service Delivery for S9443Description
FQThe service was furnished using audio-only communication technology.
FRThe supervising practitioner was present through two-way audio/video communication technology.
93Synchronous telemedicine service was rendered via telephone or other real-time interactive audio-only telecommunications system.
95Synchronous telemedicine service was rendered via real-time interactive audio and video telecommunications system.

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Determining What Time Counts Towards Timed Codes

Providers report the code for the time spent in direct member treatment. Pre- and post-delivery services are not to be counted in determining the treatment service time. In other words, the time counted as "intra-service care" begins when the lactation provider is directly working with the member to deliver treatment services. Record-keeping documentation and travel time is not reimbursable. Time spent for preparation, report writing, processing of claims, or documentation regarding billing or service provision is not reimbursable.

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National Correct Coding Initiative (NCCI)


When multiple services, including lactation support, are provided during a single visit, providers should not bill for overlapping time spent on different activities. Each billed procedure code must correspond to a distinct and separately identifiable amount of time and work for each service. For example, if during a visit both preventive medicine services and lactation support services are provided, the provider may bill each code only if the time spent on each is separately identifiable and does not overlap.

NCCI Procedure-To-Procedure (PTP) and Medically Unlikely Edits (MUE) may apply to certain combinations of procedure codes. Visit the Centers for Medicare & Medicaid Services (CMS) NCCI web page for a complete list of impacted codes, guidance on bypass modifier uses, and general information.

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Recommendation for Lactation Support Services


Lactation support services are provided as preventative services and require a recommendation by a physician or other licensed practitioner of the healing arts acting within their scope of practice in accordance with 42 CFR 440.130(c)

  • The lactating individual-child dyad requires a recommendation on file from a physician or other licensed practitioner of the healing arts. This recommendation authorizes lactation support services from pregnancy through the duration of breastfeeding. The recommendation can come from the licensed healthcare provider of either the lactating individual or the child.  
  • All claims for lactation support services must have the NPI number of the enrolled provider who recommended the items to be indicated on the claim in the appropriate Ordering, Prescribing and Referring (OPR) field on the claim. The enrolled provider types who may recommend these services are: 
    • Physician – PT 05/65
    • Osteopath – PT 26
    • Physician Assistant – PT 39
    • Advanced Practice Nurse – PT 41
    • Nurse Midwife – PT 22
    • Certified Midwife (CM) – PT 80
    • Certified Professional Midwife (CPM)/Direct Entry Midwife (DEM) - PT 69
    • Non-Physician Practitioner-Individual – PT 24
  • The recommending provider indicated on the claim must be actively enrolled with Health First Colorado (42 CFR 455.410(b)). The claim will be denied if the indicated provider is not actively enrolled. Reference the Ordering, Prescribing, and Referring Claim Project Identifier for further details.
  • If a licensed provider listed in this manual renders a service under their own ordering authority, then that rendering licensed provider's NPI number should be placed in the applicable OPR field on the claim. This does not apply to providers enrolled as IBCLC, CLC and CLEs.

Professional Claims

  • Paper claims use field 17.b.
  • Electronic submissions use loop 2420 with qualifier DK (Ordering), DN (Referring) or DQ (Supervising).
  • Claims submitted through the Provider Web Portal use the “Referring Provider” field.

Institutional Claims

  • The Attending Provider field (#76) or the Other ID fields (#78 or #79) for both paper and electronic claims.
  • Providers may refer to their applicable UB-04 billing manuals for guidance on how each field is used.

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Documentation Requirements


The provider must maintain documentation in accordance with 10 CCR 2505-10 8.130.2 that complies with state and federal regulations. The provider must retain records that specifically record the dates and precise times at which direct services provided to a member began and ended, among other general requirements for documentation. These timestamps are critical for validating the number of units of service that are billed.

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Physical Health Managed Care

Lactation support services are not included in Health First Colorado physical health managed care plans. Lactation support services are still covered benefits for members enrolled in those plans as “wrap-around” benefits of the plan.

All claims for lactation support services should be billed to the Department’s Fiscal Agent, Gainwell Technologies, even if the member is attributed to a Health First Colorado physical health managed care plan.

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Outpatient Hospital

Lactation support services provided at an Outpatient Hospital are reported on the institutional claim type and are reimbursed as part of the hospital's EAPG payment.

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Inpatient Hospital and Freestanding Birth Center Services


Professional services provided by a lactation support services provider associated with newborn deliveries and immediate postnatal breastfeeding support care for the lactating individual are part of the hospital’s facility All Patient Refined-Diagnosis Related Group (APR-DRG) payment and the Freestanding Birth Center’s delivery payment. Such circumstances are not eligible for billing through the Lactation Support Services benefit. Place of Service codes 21 (Inpatient Hospital) and 25 (Freestanding Birth Center) are not available for billing use. HCPCS codes for lactation support services cannot be billed for dates on or during the date span of the delivery and inpatient stay.  Refer to the Obstetrical Care Billing Manual.

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Place of Service Coding

Providers may provide lactation support services in a variety of settings, including the member’s home, clinics, provider offices or via telehealth. The visit setting should be indicated on the claim using the Place of Service code. A full list of allowable places of service for lactation support services is indicated below.

Lactation support services can be provided via telemedicine with Place of Service codes 02 or 10. Telehealth services must adhere to the Telemedicine Billing Manual.

Official descriptors of the Place of Service can be found on the Centers for Medicare and Medicaid Services (CMS) website.

The following Place of Service codes are allowed:

Allowed Place of Service CodeDescription (short)
02Telehealth Provided Other than in Patient’s Home
04Homeless Shelter
10Telehealth Provided in Patient’s Home
11Office
12Home
15Mobile Unit
19Off Campus-Outpatient Hospital
20Urgent Care Facility
22On Campus-Outpatient Hospital
49Independent Clinic
50Federally Qualified Health Center
71Public Health Clinic
72Rural Health Clinic

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Contact Information


Contact the Provider Services Call Center with billing inquiries. 

Contact the Department’s Lactation Support Services policy specialist at HCPF_MaternalChildHealth@state.co.us for all other inquiries. 
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CMS 1500 Paper Claim Reference Table

The following paper claim form reference table shows required, optional and conditional fields and detailed field completion instructions for the CMS 1500 professional claim form.

 

CMS Field Number & LabelField is?Instructions
1. Insurance TypeRequiredPlace an "X" in the box marked as Medicaid.
1a. Insured's ID NumberRequiredEnter the member's Health First Colorado seven (7)-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's NameRequiredEnter the member's last name, first name and middle initial.
3. Patient's Date of Birth/SexRequiredEnter the member's birth date using two (2) digits for the month, two (2) digits for the date and two (2) 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 NameConditionalComplete 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 AddressNot Required 
6. Patient's Relationship to InsuredConditionalComplete 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 AddressNot Required 
8. Reserved for NUCC UseNot Required 
9. Other Insured's NameConditionalIf field 11d is marked "YES," enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group NumberConditionalIf 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 NameConditionalIf field 11D is marked "YES" enter the insurance plan or program name.
10a-c. Is patient's condition related to?ConditionalWhen appropriate, place an "X" in the correct box to indicate whether one (1) 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 NumberConditionalComplete 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, SexConditionalComplete if the member is covered by a Medicare health insurance policy.

Enter the insured's birth date using two (2) digits for the month, two (2) digits for the date and two (2) 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 IDNot Required 
11c. Insurance Plan Name or Program NameNot Required 
11d. Is there another Health Benefit Plan?ConditionalWhen appropriate, place an "X" in the correct box. If marked "YES," complete 9, 9a and 9d.
12. Patient's or Authorized Person's SignatureRequiredEnter "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 SignatureNot Required 
14. Date of Current Illness, Injury or PregnancyConditionalComplete if information is known. Enter the date of illness, injury or pregnancy (date of the last menstrual period) using two (2) digits for the month, two (2) digits for the date and two (2) 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 NotNot Required 
16. Date Patient Unable to Work in Current OccupationNot Required 
17. Name of Referring PhysicianConditional 
17b. NPI of Referring PhysicianRequiredRequired in accordance with Program Rule 8.125.8.A
18. Hospitalization Dates Related to Current ServiceNot Required 
19. Additional Claim InformationConditional 
20. Outside Lab?
$ Charges
ConditionalComplete 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 InjuryRequiredEnter at least one (1) but no more than 12 diagnosis codes based on the member's diagnosis/condition. 
22. Medicaid Resubmission CodeConditionalList 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 with original claim submissions.
23. Prior AuthorizationNot RequiredPrior Authorization
Enter the six (6)-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one (1) approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agent or the fiscal agent.
24. Claim Line DetailInformationThe paper claim form allows entry of up to six (6) detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six (6) lines of information on the paper claim. If more than six (6) 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 ServiceRequired

The field accommodates the entry of two (2) dates: a "From" date of services and a "To" date of service. Enter the date of service using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year. Example: 010119 for January 1, 2019.

FromTo

01

01

24

010124

 
Single Date of Service: Enter the six (6)-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 (2) fields.

Span billing: Not permitted. All dates of service must have their own detailed line item on the claim. 
billing date example

24B. Place of ServiceRequiredReference the billing policy found in this manual for allowed Place of Service codes. 
24C. EMGConditionalEnter a "Y" for YES or leave blank for NO in the bottom unshaded area of the field to indicate the service was rendered for a life-threatening condition or one that requires immediate medical intervention.

24D.Procedures, Services, or Supplies

 

RequiredEnter the HCPCS procedure code that specifically describes the service for which payment is requested: S9443

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. 
24D. ModifierConditionalEnter the appropriate procedure-related modifier that applies to the billed service. Up to four (4) modifiers may be entered when using the paper claim form. Please reference the billing policy detailed in this manual for specific modifier code use. 
24E. Diagnosis PointerRequiredEnter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one (1) diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first and other applicable services should follow.

This field allows for the entry of four (4) characters in the unshaded area.
24F. $ ChargesRequiredEnter 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 (1) 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 (1) 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-pay or commercial insurance payments from the usual and customary charges.
24G. Days or UnitsRequiredEnter the number of services provided for each procedure code.
Enter whole numbers only. Do not enter fractions or decimals.
24H. EPSDT/Family PlanConditionalEPSDT (shaded area)
For Early & 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 (e.g., contraception, sterilization), enter "Y" for YES or "N" for NO in the bottom unshaded area of the field.
24I. ID QualifierNot Required 
24J. Rendering Provider ID #RequiredIn the shaded portion of the field, enter the National Provider Identifier (NPI) or 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 NumberNot Required 
26. Patient's Account NumberOptionalEnter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment?RequiredThe accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total ChargeRequiredEnter 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 PaidConditionalEnter 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 CredentialsRequiredEach 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 (2) digits for the month, two (2) digits for the date and two (2) 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 #
RequiredEnter 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 PT is not able to obtain an NPI, enter the eight (8)-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
RequiredEnter 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 NumberRequired 
33b- Other ID # If the PT is not able to obtain an NPI, enter the eight (8)-digit Health First Colorado provider number of the individual or organization.

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CMS 1500 Lactation Support Service Example

Example of lactation claim on form CMS-1500

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UB-04 Paper Claim Reference Table

Lactation Support Services outpatient hospital paper claims must be submitted on the UB-04 claim form.

The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBC UB-04 Reference Manual.

All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.
The UB-04 Certification document must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.

Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form.
Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.
Bill with a date span (From and To dates of service) only if the service was provided every consecutive day within the span. The From and To dates must be in the same month.

The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to Health First Colorado for nursing facility services.

Form Locator and labelsCompletion formatInstructions
1. Billing Provider Name, Address, Telephone NumberText

Required
Enter the provider or agency name and complete mailing address of the provider who is billing for the services:

  • Street
  • City
  • State
  • Zip Code

Abbreviate the state using standard post office abbreviations. Enter the telephone number.

2. Pay-to Name, Address, City, StateText

Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who is billing for the services:

  • Street
  • City
  • State
  • Zip Code

Abbreviate the state using standard post office abbreviations. Enter the telephone number.

3a. Patient Control NumberUp to 20 characters: Letters, numbers or hyphensOptional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
3b. Medical Record Number17 digitsOptional
Enter the number assigned to the member to assist in retrieval of medical records.
4. Type of Bill3 digits

Required
For PRTF, use TOB 89X.
Enter the three-digit number indicating the specific type of bill. The three-digit code requires one digit each in the following sequences (Type of facility, Bill classification, and Frequency):

Digit 1Type of Facility
1Hospital
2Skilled Nursing
3Home Health Services
4Religious Non-Medical Health Care Institution
6Intermediate Care
7Clinic (Rural Health/FQHC/Dialysis Center)
8Special Facility (Hospice, RTCs)
Digit 2Bill Classification (Except Clinics & Special Facilities):
1Inpatient (Including Medicare Part A)
2Inpatient (Medicare Part B only)
3Outpatient
4Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
5Intermediate Care Level I
6Intermediate Care Level II
7Sub-Acute Inpatient (Revenue Code 019X required with this bill type)
8Swing Beds
9Other
Digit 2Bill Classification (Clinics Only):
1Rural Health/FQHC
2Hospital Based or Independent Renal Dialysis Center
3Freestanding
4Outpatient Rehabilitation Facility (ORF)
5Comprehensive Outpatient Rehabilitation Facilities (CORFs)
6Community Mental Health Center
Digit 2Bill Classification (Special Facilities Only):
1Hospice (Non-Hospital Based)
2Hospice (Hospital Based)
3Ambulatory Surgery Center
4Freestanding Birthing Center
5Critical Access Hospital
6Residential Facility
Digit 3Frequency:
0Non-Payment/Zero Claim
1Admit through discharge claim
2Interim - First claim
3Interim - Continuous claim
4Interim - Last claim
7Replacement of prior claim
8Void of prior claim
5. Federal Tax NumberNoneSubmitted information is not entered into the claim processing system.
6. Statement covers period From/ThroughFrom:6 digits MMDDYY
Through: 6 digits MMDDYY
Required
This form locator must reflect the beginning and ending dates of service. When span billing for multiple dates of service and multiple procedures, complete FL 45 (Service Date). Providers not wishing to span bill following these guidelines, must submit one claim per date of service. "From" and "Through" dates must be the same. All line item entries must represent the same date of service.
8a. Patient IdentifierTextSubmitted information is not entered into the claim processing system.
8b. Patient NameUp to 25 characters, letters & spacesRequired
Enter the member's last name, first name and middle initial.
9a. Patient Address - StreetCharacters Letters & numbersRequired
Enter the member's street/post office box as determined at the time of admission.
9b. Patient Address - CityTextRequired
Enter the member's city as determined at the time of admission
9c. Patient Address - StateTextRequired
Enter the member's state as determined at the time of admission.
9d. Patient Address - ZIPTextRequired
Enter the member's zip code as determined at the time of admission.
9e. Patient Address - Country CodeDigitsOptional
10. Birthdate8 digits (MMDDCCYY)Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDCCYY format). Example: 01012010 for January 1, 2010.
11. Patient Sex1 letterRequired
Enter an M (male) or F (female) to indicate the member's sex.
12. Admission Date6 digitsNot Required
13. Admission Hour6 digitsNot Required
14. Admission Type1 digitNot Required
15. Source of Admission1 digitRequired
16. Discharge Hour2 digitsNot Required
17. Patient Discharge Status2 digits

Required

Dialysis must use code 01.

18-28. Conditions Codes2 digits

Conditional

Complete with as many codes necessary to identify conditions related to this bill.

Condition Codes
06 ESRD member - First 18 months entitlement

Renal dialysis settings
71 Full care unit
72 Self care unit
73 Self care training
74 Home care
75 Home care - 100 percent reimbursement

29. Accident State2 digitsOptional
31-34. Occurrence Code/Date2 digits & 6 digits

Conditional
Complete both the code and date of occurrence.
Enter the appropriate code and the date on which it occurred. Enter the date using MMDDYY format.
Occurrence Codes:

1Accident/Medical Coverage
2Auto Accident - No Fault Liability
3Accident/Tort Liability
4Accident/Employment Related
5Other Accident/No Medical Coverage or Liability Coverage
6Crime Victim
20Date Guarantee of Payment Began
24*Date Insurance Denied
25*Date Benefits Terminated by Primary Payer
26Date Skilled Nursing Facility Bed Available
27Date of Hospice Certification or Re-certification
40Scheduled Date of Admission (RTD)
50Medicare Pay Date
51Medicare Denial Date
53No longer used
55Insurance Pay Date
A3Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer A indicated in FL 50
B3Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer B indicated in FL 50
C3Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer C indicated in FL 50
*Other Payer occurrence codes 24 and 25 must be used when applicable. The claim must be submitted with the third-party information.

 

35-36. Occurrence Span Code From/ ThroughDigitsLeave blank
38. Responsible Party Name/AddressNoneLeave blank
39-41. Value Codes and Amounts2 characters and up to 9 digits

Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
Most Common Codes:
 

01Semiprivate rate (Accommodation Rate)
06Medicare blood deductible
14No fault including auto/other
15Worker's Compensation
31Member Liability Amount*
32Multiple Member Ambulance Transport
37Pints of Blood Furnished
38Blood Deductible Pints
40New Coverage Not Implemented by HMO
45Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).
49Hematocrit Reading - EPO Related
58Arterial Blood Gas (PO2/PA2)
68EPO-Drug
80Covered Days
81Non-Covered Days
Enter the deductible amount applied by indicated payer:
Deductible Payer A
B1 Deductible Payer B
C1 Deductible Payer C
Enter the amount applied to member's co-insurance by indicated payer:
A2 Coinsurance Payer A
B2 Coinsurance Payer B
C2 Coinsurance Payer C
Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C
42. Revenue Code4 digits

Required

Enter the revenue code which identifies the specific service provided. List revenue codes in ascending order. These codes are listed in Appendix Q, under the Appendices drop-down section on the Billing Manuals web page, for valid dialysis revenue codes.

A revenue code must appear only once per date of service.* If more than one of the same service is provided on the same day, combine the units and charges on one line accordingly.

Complete with as many codes necessary to identify conditions related to this bill.

43. Revenue code DescriptionText

Required
Enter the revenue code description or abbreviated description.
When reporting an NDC:

  • Enter the NDC qualifier of "N4" in the first two positions on the left side of the field, immediately followed by the 11-digit NDC numeric code
  • Enter one space for separation.
  • Enter the NDC unit of measure qualifier (examples include):
    • F2 - International Unit
    • GR - Gram
    • ML - Milliliter
    • UN - Units
  • Enter one period for separation
  • Enter the quantity (number of NDC units).

Example:

42 REV.CD.43 DESCRIPTION
0636N467066000501 ME.016
44. HCPCS/Rates/ HIPPS Rate Codes5 digits

Conditional

Enter only the HCPCS code for each detail line. Use approved modifiers listed in this section for hospital based transportation services.

Complete for laboratory, radiology, physical therapy, occupational therapy and hospital based transportation. When billing HCPCS codes, the appropriate revenue code must also be billed.

Services Requiring HCPCS
Anatomical Laboratory: Bill with TC modifier
Hospital Based Transportation
Outpatient Laboratory: Use only HCPCS 80000s - 89000s.
Outpatient Radiology Services

Enter HCPCS and revenue codes for each radiology line. The only valid modifier for OP radiology is TC. Refer to the annual HCPCS bulletin for instructions in the Provider Services Bulletins section of the website.

With the exception of outpatient lab and hospital-based transportation, outpatient radiology services can be billed with other outpatient services.

HCPCS codes must be identified for the following revenue codes:

  • 030X Laboratory
  • 032X Radiology - Diagnostic
  • 033X Radiology - Therapeutic
  • 034X Nuclear Medicine
  • 035X CT Scan
  • 040X Other Imaging Services
  • 042X Physical Therapy
  • 043X Occupational Therapy
  • 054X Ambulance
  • 061X MRI and MRA

HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.

45. Service Date6 digits

For span bills only
Enter the date of service using MMDDYY format for each detail line completed.

Each date of service must fall within the date span entered in the "Statement Covers Period" field (FL 6).

46. Service Units3 digits

Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit).

For span bills, the units of service reflect only those visits, miles or treatments provided on dates of service in FL 45.

47. Total Charges9 digits

Required

Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total on line 23 is required for all charges.

48. Non-covered ChargesUp to 9 digits

Conditional

Enter incurred charges that are not payable by Health First Colorado.

Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges.) Each column requires a grand total on line 23.

Non-covered charges cannot be billed for outpatient hospital laboratory or hospital based transportation services.

50. Payer Name1 letter and text

Required

Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.

Source Payment Codes
BWorkmen's Compensation
CMedicare
DHealth First Colorado
EOther Federal Program
FInsurance Company
GBlue Cross, including Federal Employee Program
IOther
Line APrimary Payer
Line BSecondary Payer
Line CTertiary Payer
51. Health Plan ID10 digitsRequired
Enter the NPI number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
52. Release of InformationN/ASubmitted information is not entered into the claim processing system.
53. Assignment of BenefitsN/ASubmitted information is not entered into the claim processing system.
54. Prior PaymentsUp to 9 digitsConditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
55. Estimated Amount DueUp to 9 digitsConditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
56. National Provider Identifier (NPI)10 digitsRequired
Enter the billing provider's 10-digit National Provider Identifier (NPI).
57. Other Provider ID Optional
Submitted information is not entered into the claim processing system.
58. Insured's NameUp to 30 charactersRequired
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name and middle initial.
60. Insured's Unique IDUp to 20 charactersRequired
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
61. Insurance Group Name14 letters

Conditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.

62. Insurance Group Number17 digits

Conditional
Complete when there is third party coverage.

Enter the identification number, control number or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.

63. Treatment Authorization CodeUp to 18 charactersConditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
64. Document Control NumberNoneConditional
65. Employer NameTextConditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
66. Diagnosis Version Qualifier Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0ICD-10-CM (DOS 10/1/15 and after)
67. Principal Diagnosis CodeUp to 6 digitsNot required
67A.-67Q. - Other Diagnosis6 digitsOptional
Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.
69. Admitting Diagnosis Code6 digitsNot required
70. Patient Reason Diagnosis Submitted information is not entered into the claim processing system.
71. PPS Code Submitted information is not entered into the claim processing system.
72. External Cause of Injury code (E-Code)6 digitsOptional
Enter the diagnosis code for the external cause of an injury, poisoning or adverse effect. This code must begin with an "E".
74. Principal Procedure Code/Date7 characters and 6 digits

Conditional

Enter the ICD-10-CM procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Enter the date using MMDDYY format. Apply the following criteria to determine the principal procedure:

The principal procedure is not performed for diagnostic or exploratory purposes. This code is related to definitive treatment, and

The principal procedure is most related to the primary diagnosis.

74A. Other Procedure Code/Date7 characters and 6 digits

Conditional

Complete when there are additional significant procedure codes.

Enter the procedure codes identifying all significant procedures other than the principal procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principal diagnosis. Enter the date using MMDDYY format.

76. Attending NPI - RequiredNPI - 10 digitsHealth First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10-digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL - Enter "1D" for Health First Colorado
Enter the attending physician's last and first name.
This form locator must be completed for all services.
77. Operating NPI Not required
Submitted information is not entered into the claim processing system.
78-79. Other IDNPI - 10 digits

Conditional

Complete when attending physician is not the PCP or to identify additional physicians.

Ordering, Prescribing or Referring NPI - when applicable

NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility or PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted.

The attending physician's last and first name are optional.

80. RemarksTextEnter specific additional information necessary to process the claim or fulfill reporting requirements.
81. Code - QUAL/CODE/VALUE (a-d)Qualifier: 2 digits
Taxonomy Code: 10 digits

Optional

Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.

Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system.

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UB-04 Lactation Support Service Example

Example of lactation claim on form UB-04

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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Lactation Support Specialist Billing Manual Revision Log

Revision Date

Addition/Changes

Made by

11/12/2024Creation of ManualHCPF
02/03/2025Added information for lactation support services provided by a dually-qualified Doula; added fee schedule information; updated billing information for twins (multiple infants); added information for determining what time counts towards 15-minute time codes; added information about National Correct Coding Initiative (NCCI); updated OPR policy information.HCPF
04/30/2025Updated billing information for lactation support services. Updated CMS 1500 lactation support services claim example.HCPF
05/20/2025Added Supply PT 14 to eligible billing providers; updated diagnosis code information; updated billing guidance for submitting claims under lactating member or breastfeeding child; added information for outpatient hospital; added UB-04 paper claim reference table; added UB-04 lactation support services example.HCPF
07/16/2025Updated the Ordering, Prescribing, and Referring (OPR) provider types who may recommend Lactation Support Services.HCPF

 

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