Physician-Administered Drug (PAD) FAQs | Department of Health Care Policy and Financing

Does the drug administered by the healthcare professional in the office/clinic/hospital setting and billed to Health First Colorado with an NDC have to be a "rebatable" drug?
1. Yes. Manufacturers who wish their drug to be eligible for coverage by Health First Colorado must enter into a rebate agreement with the Secretary of the Department of Health and Human Services (HHS) in exchange for state Medicaid coverage of most of the manufacturer’ drugs.
How do I know if a drug is rebatable?
1. Please refer to the CMS website or the Appendix X - HCPCS/NDC Crosswalk.
The NDC is not rebatable or I am not sure which NDC was used to treat the member, can I pick another NDC paired with the HCPCS on the Crosswalk and bill for it?
1. No. The NDC submitted to Health First Colorado must be the actual NDC number on the package or container from which the medication was administered.
2. It is considered a fraudulent billing practice to bill using an NDC other than the one administered to the member.
Which NDC do we bill for, the one from the package or the vial?
1. The NDC is found on the drug container (i.e. vial, bottle or tube). The NDC submitted to Health First Colorado must be the actual NDC number on the package or vial from which the medication was administered.
2. The NDC submitted on the claim must be in 11-digit format. Information on converting to 11-digit formatting can be found in the PAD Billing Manual, under the Claim Submission Requirements.
3. If the vial is removed from a carton of similar vials, use the NDC on the individual bottle (inner package NDC) and not the NDC from the carton (outer package NDC).
  1. The only exception is if the vial is part of a kit that contains multiple products needed for administration of the PAD. In this case use the NDC on the kit.
Can you confirm the NDC requirement is for outpatient claims only?
1. Yes. This requirement applies to all drug products administered by a healthcare professional in outpatient settings, including the provider’s office, clinic, and hospital.
2. Hospital Specialty Drugs administered in an inpatient setting and billed on an outpatient claim are subject to this requirement.
Do radiopharmaceuticals, contrast media, devices or immunizations require an NDC?
1. Not usually, as these products are not considered part of the PAD benefit and do not require claims to be billed with an NDC.
2. Refer to the Crosswalk for guidance on which HCPCS require a valid NDC to be billed on the claim.
Who do I contact if I have questions about billing with an NDC?
1. Refer to the Appendix X - HCPCS/NDC Crosswalk or call the fiscal agent Provider Services Call Center.
I want to administer a PAD but cannot find the HCPCS and/or the NDC on the Crosswalk. Who do I contact to request a review?
1. Prior to administering the desired PAD, email the following information to HCPF_PAD@state.co.us:
  1. HCPCS code
  2. HCPCS description
  3. NDC in 11-digit format
  4. NDC description
2. Should the HCPCS/NDC combination be added to the Crosswalk, it will be considered a covered benefit.
3. The Department may also respond to your request directly to advise of the coverage determination.
Are Medicare primary claims excluded from the NDC requirement?
1. No. Medicare Part B Crossover claims require valid HCPCS/NDC combinations to be billed on PAD claims.
I am a 340B participating provider. Do I need to submit NDC codes for PAD claims?
1. Yes. The Department requires the submission of this data.
2. Additional billing information may be required i.e. the UD modifier.
  1. Please refer to the 340B Billing Manual.
3. For drugs administered in the inpatient setting and billed on an outpatient hospital claim, 340B inventory cannot be used.
  1. Please refer to the 340B Billing Manual.
  2. Please refer to the Inpatient/Outpatient (IP/OP) Billing Manual.
Can my office receive the PAD from a specialty pharmacy or can the member bring the PAD to the office and I just administer the medication?
1. No. These processes are referred to as "white-bagging" and "brown-bagging", respectively and are not usually allowed under the Health First Colorado PAD policy.
2. Some PADs can be considered a pharmacy benefit in certain situations.
  1. For additional information, please refer to the Pharmacist Services Billing Manual.
3. Effective January 14, 2022, PADs associated with House Bill 21-1275 may not be subject to policy restrictions.
  1. For additional information and all applicable PADs, refer to the Pharmacist Services Billing Manual.
  2. Any applicable criteria can be found on Appendix P.
I did not use the full quantity of drug within the vial. Can I get reimbursed for the amount of drug wasted?
1. No. The Department does not pay for wasted drug from single or multi-use vials, a provider must bill only for the amount of drug administered to the member.
  1. For members having both Health First Colorado and Medicare (dual-eligible), a provider may bill for wasted drug on a second line with the JW modifier on Medicare Part B Crossover claims.
I need help enrolling as a Health First Colorado provider, billing medical claims or need to speak with customer service regarding PAD claims, who do I contact?
1. Please call the fiscal agent Provider Services Call Center for any issues or questions on enrollment, billing PADs, training or the provider portal.
I have questions about prior authorizations or need help submitting a request, who should I contact?
1. For the PAD PA program:
  1. Refer to Appendix Y: Physician Administered Drug Medical Benefit Prior Authorization Procedures and Criteria
  2. Contact the UM Customer Service Line for assistance with or questions regarding all PAD prior authorizations when billing on the CMS 1500 claim form.
    - Visit the Provider Contacts page.
2. For the Hospital Specialty Drug PA program:
  1. Refer to Appendix Z: Hospital Specialty Drugs
  2. Contact Department staff at HCPF_PharmacyPAD@state.co.us
Is there a PAD billing manual I can refer to when building a PAD claim?
1. Yes. The PAD Billing Manual is available and posted for provider reference.
Where can I access additional PAD specific information?
1. The Department has made available the PAD Resources Page, which includes frequently asked questions, prior authorization information, and links to additional resources.
How can I be kept up-to-date with guidance and communication from the Department?
1. Communication is provided by the Department on a regular basis via the Provider News webpage, newsletters, emails, and monthly bulletins; therefore, providers are strongly encouraged to sign up for general and specific Provider News to ensure you stay up-to-date on all issued guidance and receive all communication from the Department.

Updated 02/18/2025