Outpatient Imaging and Radiology

Health First Colorado 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.

Reference the billing and policy manual for complete details.

What services are available?

A variety of 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

Reference the billing and policy manual for complete details.

What services are not covered?

Reference the billing and policy manual for complete details.

How do I become an enrolled provider?

As a Health First Colorado (Colorado\'s Medicaid Program) 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. See Why Become a Provider?

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 their services will be reimbursed with the EAPG method.

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.

Resources for enrollment and billing may be found at Provider Resources.

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 and policy manual for details.

Recent News and Updates

  • Check the Provider Bulletin index 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 found on the Medicaid.gov NCCI 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.

Co-pays

Co-pays for outpatient imaging and radiology services will vary by setting and will depend on whether other services are performed in conjunction with the imaging. 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.

  • There is a $1 co-pay per visit if the service is performed at an x-ray facility.
  • There is a $2 co-pay per visit if the service is performed at a medical clinic/office.
  • There is a $4 co-pay per visit if the service is performed at an outpatient hospital.
"General Benefit Limitations"]

Most non-emergent CT, MRI, and PET scans require Prior Authorization regardless of setting. The authorization process begins at the ColoradoPAR web page.

Reference the billing and policy manual for complete details. Reference 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. A list of resources is available on the Provider Contact web page.
  • Questions about policy and coverage may be directed to the program administrator. Contact Justen Adams at Justen.Adams@state.co.us