Health First Colorado (Colorado's Medicaid program) covers outpatient imaging and radiology benefits. These services are provided by outpatient hospitals, x-ray facilities, and medical clinics.
Who is eligible for these services?
All enrolled members have these services covered for medically necessary conditions.
Refer to the Outpatient Imaging and Radiology Billing Manual for complete details.
What services are available?
A variety of Current Procedural Terminology (CPT) billing codes are available for billing. These include but are not limited to:
- General radiography (x-rays)
- Positron Emission Tomography (PET)
- Ultrasound
- Radiation therapy
Refer to the Outpatient Imaging and Radiology Billing Manual for complete details.
What services are not covered?
Refer to the Outpatient Imaging and Radiology Billing Manual for complete details.
How do I become an enrolled provider?
As a Health First Colorado provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance - it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.
The enrollment process is online. Visit the Why Become a Provider? web page.
Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.
How are services reimbursed?
Outpatient imaging and radiology services are reimbursed in two ways, depending on how the provider is enrolled.
If the provider is an outpatient hospital, the services will be reimbursed with the Enhanced Ambulatory Patient Groups (EAPG) method. Refer to the Outpatient Hospital Payment Manual for more information.
If the provider is an x-ray facility, clinic, or radiology practice, services are reimbursed according to the current Health First Colorado Fee Schedule. Reimbursement rates will vary by CPT code reported. The fee schedule shows the maximum allowed reimbursement for each CPT code. Submitted claims will be reimbursed according to 'lesser-of' pricing logic. This means that the line item will reimburse either at submitted charges or the fee schedule rate, whichever is lesser.
Providers must first enroll in the program to submit claims. Once they are enrolled, providers may submit claims directly by logging into the Provider Web Portal. Claims may be submitted by billing agencies on behalf of the provider.
Visit the Provider Resources web page for resources on enrollment and billing.
What's the difference between outpatient and other settings?
- Services provided during an inpatient hospital admission are reimbursed as part of the
APR-DRG hospital payment.
- Services provided during an Ambulatory Surgery Center (ASC) visit procedure are included in the ASC bundled payment. Refer to the ASC Billing Manual for details.
Recent News and Updates
- Refer to the Provider Bulletin Index located on the Bulletins web page for all provider bulletins related to outpatient imaging and radiology.
- National Correct Coding Initiative (NCCI) billing edits affect this benefit. Providers should be familiar with the information on the NCCI web page on the Centers for Medicare & Medicaid Services website, including the NCCI Policy Manual found there.
General Policies
- Services must be medically necessary.
- Services must be authorized and supervised by a licensed physician.
- The services are performed to treat and diagnose conditions and illnesses with specific symptoms.
- The services are not routine diagnostic tests performed without apparent relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.
- Radiology services are performed by a provider with equipment certified by the Colorado Department of Public Health and Environment (CDPHE) and enrolled as a Health First Colorado Provider.
Refer to the Outpatient Imaging and Radiology Billing Manual for complete details.
Co-Pays
Providers should always refer to the Provider Web Portal to check a member's co-pay eligibility prior to rendering services. Detailed information can be found at HealthFirstColorado.com.
Effective 7/1/2023, there is a $0 co-pay per visit regardless of the place of service for Health First Colorado members.
Most non-emergent CT, MRI, and PET scans require Prior Authorization regardless of setting. The authorization process begins at the ColoradoPAR web page.
Refer to the Outpatient Imaging and Radiology Billing Manual for complete details. Refer to the Health First Colorado Fee Schedule for a list of codes requiring PAR.
Policy Documents
Outpatient Imaging and Radiology Billing and Policy Manual
This manual is applicable to both CMS1500 (837p) and UB-04 (837i) claim types.
Applicable Rules, Regulations, and Statutes
All Medicaid Rules, Regulations, and Statutes apply to the administration of the Colorado Medical Assistance Program at large, which providers are required to follow. The following are specific to the outpatient imaging and radiology benefit:
- 42 CFR 440.20 - Outpatient hospital services
- 42 CFR 440.30 - X-ray services
- 42 CFR 440.90 - Clinic services
- 10 CCR 2505-10 8.200 - Physician services
- 10 CCR 2505-10 8.300 - Hospital services
- 10 CCR 2505-10 8.660 - Laboratory and x-ray services
Contact Information
- Questions about claims and billing must be directed to Gainwell Technologies. Visit the Provider Contacts web page for a list of resources.
- Questions about policy and coverage may be directed to the program administrator. Contact Sarah Kaslow at Sarah.Kaslow@state.co.us.