1. Home
  2. For Our Providers
  3. Provider Services
  4. Billing Manuals
  5. Pharmacist Services Billing Manual

Pharmacist Services Billing Manual

Return to Billing Manuals Web Page

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 Revalidation & Enrollment 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. Please 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.

Back to Top

Enrollment

How to Enroll as a Pharmacist

  • Begin at the Provider 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)

Back to Top

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.

 

Back to Top

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).

Back to Top

Medically Necessity

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.

Back to Top

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.

Back to Top

Billing Information

Refer to the General Provider Information manual 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 Immunization Billing Manual for details on how to bill immunizations through the medical benefit.
  • Refer to the Physician-Administered Drug Billing Manual for details on how to bill injections through the medical benefit.
  • For billing issues, contact 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 (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.

Back to Top

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 web page.

 

Drug Categories Age Restrictions Quantity/Dosing Limits
Oral Emergency Contraceptive None 1 package per fill
OTC Nicotine Replacement Therapy (patch, gum, lozenge) None Gum
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 Liquid 4 to 11 years old Up to 150mL per 30 days
OTC Acetaminophen Children's/Infant's (only liquid/chewable) 2 to 11 years old Liquid
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 old Liquid
Up to 240ml per 30 days

Chewable
Up to 48 tablets per 30 days

Back to Top

Pharmacist Administered Immunizations

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 Immunization Billing Manual.

Back to Top

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.

Pharmacist Injections HCPCS Age Restrictions
Sublocade (buprenorphine extended-release) Q9991  
Q9992  
 
Vivitrol (naltrexone extended-release) J2315 18+
(removed effective 9/06/2021)
Abilify Maintena (aripiprazole extended-release) J0401  
Aristada (aripiprazole lauroxil extended-release) J1944  
Aristada Initio (aripiprazole lauroxil extended-release) J1943  
Fluphenazine Decanoate J2680  
Haloperidol Decanoate J1631  
Invega Sustena (paliperidone palmitate extended-release) J2426  
Invega Trinza (paliperidone palmitate extended-release) J2426  
Perseris (risperidone extended-release) J2798  
Risperdal Consta (risperidone long acting) J2794  
Zyprexa Relprevv (olanzapine pamoate extended-release) J2358  

Back to Top

COVID-19 Monoclonal Antibody Injections

Effective October 22, 2021, in accordance with the Centers for Medicaid and Medicare Services’ (CMS) guidance, Health First Colorado covers certain monoclonal antibody treatments by pharmacists without member cost sharing when used as authorized or approved by the Food and Drug Administration (FDA). Additional information regarding these therapies and EUAs can be found on the FDA Emergency Use Authorization web page.

The following table may be used as a procedure code reference during the applicable Emergency Use Authorization (EUA).

Procedure Code Descriptor Administration Codes EUA
Q0240 Injection, casirivimab and imdevimab, 600 mg M0240
M0241
M0243
M0244		 July 30, 2021 – January 24, 2022
Q0243 Injection, casirivimab and imdevimab, 2400 mg M0240
M0241
M0243
M0244		 July 30, 2021 – January 24, 2022
Q0244 Injection, casirivimab and imdevimab, 1200 mg M0240
M0241
M0243
M0244		 July 30, 2021 – January 24, 2022
Q0220 Injection, tixagevimab and cilgavimab,  300 mg

M0220

M0221

 December 08, 2021 - January 26, 2023
Q0221 Injection, tixagevimab and cilgavimab, 600 mg M0220
M0221		 February 24, 2022 - January 26, 2023

Pharmacists may administer these monoclonal antibody therapies only in settings where they have both of the following:

  • Immediate access to medications to treat a severe infusion reaction, such as anaphylaxis; and
  • The ability to activate the emergency medical system (EMS).

Back to Top

Prescription of Paxlovid   

On July 6, 2022, the Food and Drug Administration (FDA) modified the Emergency Use Authorization (EUA) for Paxlovid to allow pharmacists to prescribe under limited circumstances. Consistent with this guidance, Health First Colorado will reimburse pharmacists for the prescription of Paxlovid with the following limitations:

  • All pharmacists authorized to prescribe Paxlovid must adhere to all the terms set in the FDA’s updated EUA.
  • The pharmacy dispensing fee already includes counseling meaning that providers should not separately bill the Department services that are included in the counseling process.
  • Providers must ensure they are fully meeting the requirements of a code before using it to describe a procedure.
  • Medical procedures must be billed on a Centers for Medicare & Medicaid Services (CMS) 1500 professional claim, not a pharmacy claim.
  • Provider documentation must support the choice of code used and accurately reflect the time spent prescribing, if applicable.

See Provider Bulletin B2200482 for more details.

Back to Top

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.

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.
For more information on testing policies refer to the Laboratory Services billing manual.

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. 

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.

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 website 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 Code Notes
86328  
86701 MCO Carveout Until 6-30-2022
86769  
87389 MCO Carveout Until 6-30-2022
87635  
87806 MCO Carveout Until 6-30-2022
90471  
90472  
90473  
90474  
96372 MCO Carveout Until 6-30-2022
99202 MCO Carveout Until 6-30-2022
99203 MCO Carveout Until 6-30-2022
99204 MCO Carveout Until 6-30-2022
99205 MCO Carveout Until 6-30-2022
99211 MCO Carveout Until 6-30-2022
99212 MCO Carveout Until 6-30-2022
99213 MCO Carveout Until 6-30-2022
99214 MCO Carveout Until 6-30-2022
99215 MCO Carveout Until 6-30-2022
99401 MCO Carveout Until 6-30-2022
99402 MCO Carveout Until 6-30-2022
99403 MCO Carveout Until 6-30-2022
99404 MCO Carveout Until 6-30-2022
99406 MCO Carveout Until 6-30-2022
99407 MCO Carveout Until 6-30-2022
99408 MCO Carveout Until 6-30-2022
99409 MCO Carveout Until 6-30-2022
99411 MCO Carveout Until 6-30-2022
99412 MCO Carveout Until 6-30-2022
99441 MCO Carveout Until 6-30-2022
99442 MCO Carveout Until 6-30-2022
99443 MCO Carveout Until 6-30-2022
G0108 MCO Carveout Until 6-30-2022
G0109 MCO Carveout Until 6-30-2022
G0433 MCO Carveout Until 6-30-2022
G2023  
G2024  
U0001  
U0002  
U0003  
U0004  
U0005  
99473  
99474  
Table updated August 2022

Back to Top

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

 

  • Telemedicine place of service (POS) codes 02 and 10 are available for specific procedure codes. See the Telemedicine Provider 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.

Back to Top
 

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.

Back to Top

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 & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Client Relationship to Insured Conditional Complete 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 Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Conditional Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. NPI of Referring Physician or other source Not Required  
18. Hospitalization Dates Related to Current Service Conditional Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year. Example: 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 Information Conditional  
20. Outside Lab?
$ Charges		 Conditional Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional CLIA
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 Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From To
01 01 19         
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19

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) Required An 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 Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
See manual's section on eligible place of service code
24C. EMG Conditional Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-pay requirements.
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Conditional Enter 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 Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

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

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co-pay or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals

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 Plan Conditional EPSDT (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, enter "Y" for YES or "N" for NO in the bottom unshaded portion of the field.
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider's name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
"Signature on file" notation is not acceptable in place of an authorized signature.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #		 Required Enter the name 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 #		 Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

Back to Top

Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.

Back to Top

Pharmacist Services Revision Log

Revision Date Additions/Changes Made by
1/1/2022 Manual created HCPF
1/19/2022 Code 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
3/10/2022 Enrollment 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
5/3/2022 Updated Monoclonal Antibody Injections section, corrected minor editing errors HCPF
8/17/2022 Updated language clarity, added CPT codes 99473 and 99474, included guidance on Paxlovid HCPF
10/14/2022 Removed Phone Number References and changed Gainwell Technologies mentions to a hyperlink of Provider Services Call Center HCPF
12/15/2022 Clarified general billing guidance with new section and clarifications to policy language, added COVID-19 Diagnostic Testing guidance. HCPF
2/23/2023 Updated Monoclonal Antibody Injections section, adding end date for EUA for M0220 and M0221. HCPF

Back to Top