Pharmacist Services Billing Manual

• Provider Qualifications
• Enrollment
• General Benefit Policies
  • Early & Periodic Screening, Diagnostic and Treatment (EPSDT)
  • Payment for Covered Services
  • Medically Necessary
  • Documentation Requirements
• Billing Information
• Covered Pharmacist Services
  • Prescribing Over-the Counter Medications (OTCs)
  • Immunization List
  • Injections List
  • Prescribing Medications
  • Diagnostics Testing
  • Collaborative Pharmacy Practice
  • Collaborative Pharmacy Practices Under Supervision
  • Comprehensive Medication Management
• Procedure Code List
  • Eligible Place of Service Codes
  • Procedure Code Modifier
• Billing Edits
• CMS 1500 Claim Reference Table
• Timely Filing
• Revision Log

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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 Injection List section and 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 Prime Therapeutics 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 Over-the-Counter Medications (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.

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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.

Injection Billing Instructions

When billing these injections (considered Physician-Administered Drugs [PADs]) to the medical benefit, valid HCPCS/NDC combinations are required to be included on the claim. Refer to the Department’s HCPCS/NDC Crosswalk (Appendix X) for valid and reimbursable HCPCS/NDC combinations.

Billing Instructions for 340B Covered Entities

All claims and encounters for administering these injections, if purchased through the 340B program, should include the “UD” modifier on the CMS 1500 claim form. Refer to the 340B Policy and Procedures Manual for more information on billing these injections if part of the 340B program.
 

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Prescribing Medications   

Effective November 15, 2023, Pharmacists may be indicated as a prescribing provider for certain non-OTC 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

4. The prescription falls within prescriptive authority as outlined under Department of Regulatory Agencies (DORA) Rules incorporated in 3 CCR 719-1 17.00.00. For a list of available medications refer to the Collaborative Pharmacy Practice section of this billing manual.

Or

5. 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. Effective 07/26/2022 and retroactive to 07/06/2022 Paxlovid is covered with a written prescription by a pharmacist.
6. The prescription is for one of the following opioid antagonists:
   1. Naloxone product formulations FDA-approved for use for the emergency treatment of opioid overdose (effective 05/12/22; retroactive to 01/14/22) 
   2. Opvee (nalmefene) intranasal spray

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 Prime Therapeutics 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 non-OTC 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:

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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.

The following medications are available for coverage with a written prescription by an enrolled pharmacist rendering services under Collaborative Practice:

• Oral contraceptives 
• Topical patch contraceptives 
• Vaginal ring contraceptives (effective 11/30/22) 
• Depo medroxyprogesterone contraceptive injection (effective 11/30/22) 
• Oral HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) medications 
• Smoking cessation medications (Chantix, varenicline, generic Zyban) 
• Nicotine replacement therapy products (Nicotrol) 
• Statins (effective 11/30/22)
 

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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. 
• 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.

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.

• 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.

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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

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