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Pharmacist Services Billing Manual

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Provider Qualifications

Providers must be enrolled as a Health First Colorado (Colorado's Medicaid program) provider in order to:

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

Pharmacists must be licensed by the Colorado Department of Regulatory Agencies (DORA) pursuant to Article 280 of Title 12. Pharmacists must deliver all services in accordance with the Colorado Board of Pharmacy Rules at 3 CCR 719-1 and Rule 17 Appendix A, B and C.

All providers must submit a completed provider enrollment to become a Health First Colorado provider. Providers will find enrollment information on the Provider Enrollment web page and the Revalidation web page.

Indian Health Service (IHS) Providers

IHS Facility providers must submit claims for all Pharmacist Services described in this manual using their provider type 61 FQHC enrollment. IHS providers should not use their provider type 62 enrollment for billing these services. Refer to the IHS Billing Manual.

Federally Qualified Health Centers

Federally Qualified Health Centers (FQHCs) will not submit claims for Pharmacist Services described in this manual. Costs for Pharmacist Services described in this manual are an allowed addition to the cost reports for FQHCs. Pharmacists remain a non-billable provider.

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Enrollment

How to Enroll as a Pharmacist

  • Begin at the Provider Web Portal
  • Enroll as:
    • Individual within a Group
    • Provider Type = 75
    • Specialty= 750 Pharmacist
  • SSN is required for individual enrollment and screening
  • NPI (type 1 for an individual)
  • Taxonomy Required
  • Affiliation to at least one pharmacy (PT09 or PT62) or clinic (PT16); providers may affiliate to multiple pharmacies and/or practitioner clinics on one enrollment application (if applicable)

Documents Required with Application

  • Validation of Pharmacist status (DORA license for in state, authorizing authority for out of state)
  • Malpractice Insurance

Additional Information

  • Professional Claims: Pharmacists are the rendering provider on the claim while the affiliated clinic or pharmacy is the billing provider.
  • Pharmacy Claims: Pharmacists may be the prescriber in certain instances.
  • Pharmacists are a limited risk level for screening.
  • Out-of-state enrollments are allowed.
  • Not Required:
    • Application Fee
    • W9
    • Electronic Funds Transfer (EFT)
    • Proof of Lawful Presence
    • Supervising Physician Signature Form
  • Optional:
    • Medicare Enrollment
    • Network Participation (MCO/RAE)

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General Benefit Policies

 

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

8.280.4.E Other EPSDT Benefits

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

  • All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
  • For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
  • The service provides a safe environment or situation for the child.
  • The service is not for the convenience of the caregiver.
  • The service is medically necessary.
  • The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
  • The service is the least costly.

 

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Payment for Covered Services

Services paid for by the dispensing fee, such as counseling on proper pharmaceutical usage, are not separately reimbursed by professional pharmacist claims.

When applicable, payment for Pharmacist Services does include an administration fee (not to be confused with a dispensing fee).

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Medically Necessary

Pharmacist services must be medically necessary to qualify for Health First Colorado reimbursement. Medical necessity (10 CCR 2505-10 8.076.1.8) means a medical assistance program good or service:

  1. Will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability. This may include a course of treatment that includes mere observation or no treatment at all. Is provided in accordance with generally accepted professional standards for health care in the United States,
  2. Is clinically appropriate in terms of type, frequency, extent, site, and duration,
  3. Is not primarily for the economic benefit of the provider or primarily for the convenience of the member, caretaker, or provider,
  4. Is delivered in the most appropriate setting(s) required by the member's condition,
  5. Is not experimental or investigational, and
  6. Is not more costly than other equally effective treatment options.

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Documentation Requirements

In accordance with 8.130.2 providers must document all services provided. All documentation must be kept in the member's records along with a copy of the referral or prescribing provider's order. Documentation must support both the medical necessity of services and the need for the level of skill provided.

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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 menu for general billing information.

Medical Benefit Billing

  • Administration fees associated with applicable Pharmacist Services should be billed through the medical benefit.
    • Process claims as normal through the medical benefit 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.
  • Refer to the Immunizations Billing Manual for details on how to bill immunizations through the medical benefit.
  • Refer to the Physician-Administered Drugs (PAD) Billing Manual for details on how to bill injections through the medical benefit.
  • For billing issues, contact the Provider Services Call Center.

Pharmacy Benefit Billing

  • Process claims as normal through the pharmacy point of sale system using the prescriber’s NPI or the enrolled pharmacist's NPI if applicable.
  • Refer to the Pharmacy Billing Manual for details on how to bill the pharmacy point of sale system.
  • For billing issues, contact Magellan at 1-800-424-5725

Duplicative Billing

A pharmacist is eligible to receive reimbursement for medically necessary services authorized in Part 6 of Article 280 of Title 12 that are not duplicative of other pharmacist services or programs reimbursed under the medical assistance program.

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Covered Pharmacist Services

Prescribing OTCs

Effective November 1, 2018, pharmacists may enroll as a provider with the Department and prescribe specified OTC products (the specific products are outlined near the bottom of the page). The drugs:

  • Must be prescribed consistent with the Pharmacist OTC Prescriptive Authority list.
  • Must follow the Board of Pharmacy Rules outlined in 3 CCR 719-1.
  • Must follow the Department's Rules outlined in 10 CCR 2505-10, 8.800.

Posted on the Pharmacy Resources web page.

 

Drug CategoriesAge RestrictionsQuantity/Dosing Limits
Oral Emergency ContraceptiveNone1 package per fill
OTC Nicotine Replacement Therapy (patch, gum, lozenge)NoneGum
Up to 220 units per fill

Lozenge
Up to 288 units per fill

Patch
Up to 30 patches per 30 days
OTC Dextromethorphan (DM) Children's Liquid4 to 11 years oldUp to 150mL per 30 days
OTC Acetaminophen Children's/Infant's (only liquid/chewable)2 to 11 years oldLiquid
Up to 240ml per 30 days

Chewable
Up to 60 tablets per 30 days
OTC Ibuprofen Children's/Infant's (only liquid/chewable)6 months to 11 years oldLiquid
Up to 240ml per 30 days

Chewable
Up to 48 tablets per 30 days
OTC Naloxone (4mg nasal spray)NoneNo quantity/dosing limits

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Immunization List

Effective November 1, 2018, pharmacists may enroll as a provider with the Department and once enrolled can administer specific vaccinations. Pharmacists must:

  • Follow the Board of Pharmacy Rules outlined in 3CCR 719-1, 19.00.00.
  • Render vaccinations consistent with the Pharmacist Vaccination list.

Detailed billing instructions are posted in the Immunizations Billing Manual.

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Injection List

Administering Vivitrol

Effective January 1, 2019, the Department implemented HB 18-1007 which stipulates that if a pharmacy has entered into a collaborative practice agreement with one or more physicians for the purposes of administering Vivitrol, that the pharmacy where the injection is administered shall receive reimbursement when an enrolled pharmacist administers it.

Administering Extended-Release Injectable Medications (LAIs)

In accordance with House Bill 21-1275 and effective January 14, 2022, no place of service prior authorization is required for extended-release injectable medications (LAIs) used for the treatment of mental health or substance use disorders (SUD), when administered by a healthcare professional and billed under the pharmacy benefit. In addition, LAIs may be administered in any setting (pharmacy, clinic, medical office or member home) and billed to the pharmacy or medical benefit as most appropriate and in accordance with all Health First Colorado billing policies.

HCPCS
Q9991
Q9992
J2315
J0401
J1944
J1943
J2680
J1631
J2426
J2426
J2798
J2794
J2358

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Prescribing Medications   

Effective November 15, 2023, Pharmacists may be indicated as a prescribing provider for certain medications which fall outside of Collaborative Practice Agreements and Statewide Protocols.

Claims where pharmacists are indicated as the prescribing provider must meet the following criteria: 

  1. The member is 12 years of age or older.
  2. The drug being prescribed is not a controlled substance.
  3. The condition does not require a new diagnosis, is minor and generally self-limiting or has a Clinical Laboratory Improvement Amendments (CLIA)-waived test which the pharmacist administers and uses to guide clinical decision-making. 

Or

  1. The prescription falls within prescriptive authority as outlined under Department of Regulatory Agencies (DORA) Rules incorporated in 3 CCR 719-1 17.00.00

Or

  1. The prescription is for a medication which has Emergency Use Authorization (EUA) issued by the US Food and Drug Administration (FDA) that supersedes state law and allows a pharmacist to prescribe said medication.

Enrolled pharmacists submitting pharmacy claims for criteria 1, 2 and 3 will receive denial code 6Z/50602 – “Provider Not Elig To Perform Serv/Dispense Product” and must call Magellan in order to complete a prior authorization for the claim.

Evaluation and Management Services While Prescribing Medications

Effective November 15, 2023, evaluation and management services rendered to members while prescribing a medication outside of Collaborative Practice or a Statewide Protocol are reimbursable. 

The Following table contains requirements for evaluation and management services that fall under and outside of a Collaborative Practice Agreement (CPA) or a Statewide Protocol (SWP). Some requirements overlap while others are distinct:

Outside of CPA or SWPUnder CPA or SWP
The pharmacy dispensing fee already includes medication counseling. Pharmacy providers billing the pharmacy benefit to dispense the medication being prescribed should not separately bill the medical benefit for medication counseling or use it lengthen time spent performing evaluation and management services.Medication counseling services performed under the prescriptive authority granted by SWP or CPA are considered distinct from the pharmacy dispensing fee in all cases and may be billed separately to the medical benefit.
If applicable pharmacists must adhere to all terms set within the FDA’s EUA for the prescription of PaxlovidTM. This guidance supersedes previous guidance included in the September 2022 Provider Bulletin (B2200482).If applicable pharmacists must adhere to all practice requirements set within the applicable SWP.

 

Shared Requirements
Claims are billed on a Centers for Medicare & Medicaid Services (CMS)-1500 professional claim, not a pharmacy claim.
Providers must ensure the requirements of a code are fully met before it is used to describe a procedure.
Provider documentation must support the choice of code used and accurately reflect the time spent prescribing, if applicable.

 

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Diagnostic Testing

Claims must be billed on a Centers for Medicare & Medicaid Services (CMS) 1500 professional claim. The affiliated pharmacy or clinic’s National Provider Identification (NPI) should be used as the billing provider and the pharmacist’s NPI as the rendering provider. The pharmacist’s NPI may also be used as the ordering provider if the same provider is ordering and rendering the test.

Affiliated pharmacies and clinics may only bill for tests performed by their affiliated pharmacists. Tests ordered by pharmacists but performed by laboratories or hospital outpatient laboratories must be billed by the performing laboratory. Each pharmacy and clinic must have any applicable Clinical Laboratory Improvement Amendments (CLIA) certifications for any tests provided.

For more information on testing policies, as well as CLIA waived testing requirements, refer to the Laboratory Services Billing Manual.

Clinical Laboratory Improvement Amendments (CLIA) Waived Diagnostic Tests

Effective December 20, 2023, Pharmacists may be indicated as rendering providers for the following CLIA waived diagnostic testing codes when performed outside of Collaborative Practice Agreements and Statewide Protocols:

81002, 81003, 87804, 87807, 87809, 87880

COVID-19 Diagnostic Testing

Effective May 1, 2020, and in accordance with the Public Readiness and Emergency Preparedness Act for Medical Countermeasures Against COVID-19 (PREP Act), COVID-19 Diagnostic Testing conducted by pharmacists is a covered benefit. All testing must be in compliance with applicable Clinical Laboratory Improvement Amendment (CLIA) certification requirements and regulations, as well as all requirements set forth in 3 CCR 719-1 30.00.00.

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Collaborative Pharmacy Practice 

Effective January 14, 2022, Health First Colorado will reimburse pharmacists that are enrolled with the Department for medically necessary services as defined in 3 CCR 719-1 17.00.00 that are not duplicative of covered Pharmacy benefits. Pharmacists must fully meet all requirements outlined in each appendix, to receive reimbursement for services outlined in 3 CCR 719-1 Appendix A, B, C and E.

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Collaborative Pharmacy Practice Services Under Supervision

Licensed pharmacists may provide covered services, in accordance with the scope of practice for pharmacists as described by the Colorado Department of Regulatory Agencies rules, without a physician order. Pharmacy Interns, per Department rule 10 CCR 2505-10 8.200.2.D.1. are a non-physician provider that may provide covered goods and services only under the Direct Supervision of an enrolled provider who has the authority to supervise those services, according to the Colorado Department of Regulatory Agencies rules. If Colorado Department of Regulatory Agencies rules do not designate who has the authority to supervise, the non-physician provider must provide services under the Direct Supervision of an enrolled physician.

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Comprehensive Medication Management (CMM) 

Medication management, when rendered as part of a collaborative pharmacy practice agreement, as outlined in 3 CCR 719-1 17.00.00, is a covered benefit. 

At this time, a universal code does not exist to describe the entirety of services that comprise CMM as a standard of care and not every part of CMM currently constitutes a billable service. Therefore, providers must ensure they are fully meeting the requirements of a procedure code before using it to bill for a service.

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Procedure Code List

Pharmacists may be indicated as rendering providers for the following procedure codes. Reference the current Fee Schedule for current reimbursement rates.

  • This table serves only as a reference guide and not a guarantee of payment or coverage. Definitive coverage of a specific procedure code is found on the Fee Schedule.
  • Providers should reference official AMA CPT and CMS HCPCS resources for full descriptions of procedure codes and instruction for correct coding.
  • NCCI MUE edits stipulate maximum daily units for each code. NCCI PTP edits disallow certain combinations of procedure codes. Refer to the NCCI web page for further information.
  • ClaimsXTN edits apply to these services. Refer to the ClaimsXten web page for details.
  • Some codes are allowed for telemedicine delivery. Refer to the Telemedicine Services web page for more detail.
  • Certain procedure codes were temporarily carved out from the physical health managed care plans, Denver Health and Rocky Mountain Health Plans. Providers should submit claims fee-for-service for these MCO-enrolled members until the carveout period ends.
Procedure CodeNotes
86328 
86701MCO Carveout Until 6-30-2022
86769 
87389MCO Carveout Until 6-30-2022
87635 
87806MCO Carveout Until 6-30-2022
90471 
90472 
90473 
90474 
96372MCO Carveout Until 6-30-2022
99202MCO Carveout Until 6-30-2022
99203MCO Carveout Until 6-30-2022
99204MCO Carveout Until 6-30-2022
99205MCO Carveout Until 6-30-2022
99211MCO Carveout Until 6-30-2022
99212MCO Carveout Until 6-30-2022
99213MCO Carveout Until 6-30-2022
99214MCO Carveout Until 6-30-2022
99215MCO Carveout Until 6-30-2022
99401MCO Carveout Until 6-30-2022
99402MCO Carveout Until 6-30-2022
99403MCO Carveout Until 6-30-2022
99404MCO Carveout Until 6-30-2022
99406MCO Carveout Until 6-30-2022
99407MCO Carveout Until 6-30-2022
99408MCO Carveout Until 6-30-2022
99409MCO Carveout Until 6-30-2022
99411MCO Carveout Until 6-30-2022
99412MCO Carveout Until 6-30-2022
99441MCO Carveout Until 6-30-2022
99442MCO Carveout Until 6-30-2022
99443MCO Carveout Until 6-30-2022
99473 
99474 
G0108MCO Carveout Until 6-30-2022
G0109MCO Carveout Until 6-30-2022
G0433MCO Carveout Until 6-30-2022
G2023 
G2024 
U0001 
U0002 
U0003 
U0004 
U0005 
81002Refer to the Laboratory Services Billing Manual for further guidance on CLIA waived testing.
81003Refer to the Laboratory Services Billing Manual for further guidance on CLIA waived testing.
87804Refer to the Laboratory Services Billing Manual for further guidance on CLIA waived testing.
87807Refer to the Laboratory Services Billing Manual for further guidance on CLIA waived testing.
87809Refer to the Laboratory Services Billing Manual for further guidance on CLIA waived testing.
87880Refer to the Laboratory Services Billing Manual for further guidance on CLIA waived testing.
93784 
93786 
93788 
93790 
95249 
95250 
95251 

Table updated December 2023

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Eligible Place of Service Codes 

The following place of service codes are allowed for most codes under the “Other Covered Pharmacist Services” table. This list is not exhaustive and not a guarantee of payment.

Place of Service (POS) CodeDescription
01Pharmacy
02Telemedicine, other than in patient’s home (only applicable to certain procedure codes, see details below)
10Telemedicine, in patient’s home (only applicable to certain procedure codes, see details below)
11Office 
19Off Campus-Outpatient Hospital
20Urgent Care Facility
22On Campus-Outpatient Hospital

 

  • Telemedicine place of service (POS) codes 02 and 10 are available for specific procedure codes. Refer to the Telemedicine Billing Manual for further details.
  • Allowable place of service codes can vary depending on each CPT or HCPCS code as well as the affiliated billing provider type code associated with the claim.

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Procedure Code Modifiers

Modifier FP

When billing for family planning services, such as for contraception provision, always include the family planning (FP) modifier next to the appropriate procedure code on claims. Family planning services and supplies are identified and provided only when the intent of the service is to prevent, delay or plan for a pregnancy. Family planning services can include, but are not limited to: examinations, treatment, all FDA-approved contraceptives/methods of birth control and family planning counseling. 

Modifier FP+32

Effective July 1, 2022, members eligible for expanded family panning benefits require modifier FP and 32 on services that are defined as family planning related. For more information on these requirements as well as member eligibility, refer to the Family Planning Benefit Expansion for Special Populations Billing Manual.   

Modifier 33

The Department recognizes Modifier 33 when appended to a preventive service(s), as mandated under the terms of the Patient Protection and Affordable Care Act (PPACA) comprehensive healthcare reform law, and defined in accordance with the U.S. Preventive Services Task Force (USPSTF) A and B rating in effect at the time of service.

Use of Modifier 33 will bypass co-pay requirements and is appropriate with a CPT or HCPCS Code(s) that is a diagnostic/therapeutic service that is being performed as a preventative health service that is not for the treatment of illness or injury. For separately reported services specifically identified as preventive, the modifier should not be used. Providers may append Modifier 33 to an Evaluation & Management (E&M) visit only if the primary purpose of the E&M visit is the delivery of a USPSTF grade A or B service, and not if it is simply a component part of a different billed service. 

Billing Edits

The provider's adherence to the application of policies in this manual is monitored through either post-payment review of claims by the Department or computer audits or edits of claims. When computer audits or edits fail to function properly, the application of policies in this manual remain in effect. Therefore, all claims shall be subject to review by the Department.

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CMS 1500 Claim Reference Table

The following form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 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-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 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 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. Client Relationship to InsuredConditionalComplete if the member is covered by a commercial health care 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 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 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 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 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 NotNot Required 
16. Date Patient Unable to Work in Current OccupationNot Required 
17. NPI of Referring Physician or other sourceNot Required 
18. Hospitalization Dates Related to Current ServiceConditionalComplete 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: 070118 for July 1, 2018. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.
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 but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
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 for original claim submissions.
23. Prior AuthorizationConditionalCLIA
When applicable, enter the word "CLIA" followed by the number.

Prior Authorization
Enter the six-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one 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 detailed billing lines. Fields 24A through 24J apply to each billed line.
24A. Dates of ServiceRequired

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.

FromTo
010119   

or

FromTo
010119010119

Span dates of service

FromTo
010119013119


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.

Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity

National Drug Code (NDC)RequiredAn NDC is required if a physician administered drug is billed. In the shaded area of box 24A, enter “N4" (which is the qualifier that indicates an NDC is being used), followed by the 11-digit NDC (include all leading zeros, the NDC must be 11 digits), followed by the two-letter abbreviation for the unit of measurement (see chart below) and the number of units (up to five digits, a decimal and three digits after the decimal). Do not leave any blank spaces between these elements.

Abbreviations for Units of Measurement
GR…………………………………Gram
ML……………………………...Milliliter
UN…………………………….…Unit(s)
24B. Place of ServiceRequiredEnter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
See manual's section on eligible place of service code
24C. EMGConditionalEnter 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-pay requirements.
24D. Procedures, Services, or SuppliesRequiredEnter 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.
24D. ModifierConditionalEnter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.
See manual's section on required billing modifiers
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 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. $ 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 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-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

Anesthesia Services
Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period.

Anesthesia time begins when the anesthetist begins member preparation for induction in the operating room or an equivalent area and ends when the anesthetist is no longer in constant attendance. No additional benefit or additional units are added for emergency conditions or the member's physical status.

The fiscal agent converts reported anesthesia time into fifteen minute units. Any fractional unit of service is rounded up to the next fifteen-minute increment.

Codes that define units as inclusive numbers
Some services such as allergy testing define units by the number of services as an inclusive number, not as additional services.
24H. EPSDT/Family PlanConditional

EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:

AVAvailable- Not Used
S2Under Treatment
STNew Service Requested
NUNot Used

Family Planning (unshaded area)
If the service is Family Planning, enter "Y" for YES or "N" for NO in the bottom unshaded portion of the field.

24I. ID QualifierNot Required 
24J. Rendering Provider ID #RequiredIn the shaded portion of the field, enter the NPI of the Health First Colorado provider 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 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 #
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
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 #
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 Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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Timely Filing

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

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Pharmacist Services Revision Log

Revision DateAdditions/ChangesMade by
1/1/2022Manual createdHCPF
1/19/2022Code 90653 was removed from a duplicative table, code Q0220 added, immunizations section reformatted to direct to appropriate billing manual, Monoclonal Antibody Injections table updated to reflect new EUA effective dates. HCPF
3/10/2022Enrollment language changed to include PT 16, Sublocade HCPCS codes updated, Fluphenazine HCPCS code corrected, sections added on place of service codes and comprehensive medication management. HCPF
5/3/2022Updated Monoclonal Antibody Injections section, corrected minor editing errorsHCPF
8/17/2022Updated language clarity, added CPT codes 99473 and 99474, included guidance on PaxlovidHCPF
10/14/2022Removed Phone Number References and changed Gainwell Technologies mentions to a hyperlink of Provider Services Call CenterHCPF
12/15/2022Clarified general billing guidance with new section and clarifications to policy language, added COVID-19 Diagnostic Testing guidance.HCPF
2/23/2023Updated Monoclonal Antibody Injections section, adding end date for EUA for M0220 and M0221.HCPF
3/23/2023Added Procedure Code Modifiers section, updated Injection List table, removed COVID-19 Monoclonal Antibody Injections section.HCPF
4/3/2023Updated AWS URL linksHCPF
9/12/2023Updated OTC chart and Collaborative Pharmacy Practice RequirementsHCPF
12/1/2023Added Prescribing Medications Section, Removed and Updated Prescription of Paxlovid SectionHCPF
12/20/2023Added Diagnostic Testing Section which now includes Covid-19 Testing; Updated Procedure Code List with new codes. 

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