← Back to list
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600539 - 06/2026)
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Health First Colorado reduces fee-for-service provider rates by 2.0% for dates of service on or after July 1, 2026, with exemptions for pharmacy, RHCs, FQHCs, Pediatric Behavioral Therapy, select NICU and maternity services, and family planning. Spravato (J0013, G2082, G2083) and Qivigy (J1577) are added to the physician-administered drugs that require prior authorization effective July 1, 2026. Pediatric Behavioral Therapy claims for CPT 97151 are limited to one unit per 365 days, and the ordering or referring practitioner NPI is required starting July 1, 2026. Neurological and psychological testing codes 96130, 96131, 96136 and 96137 require the SC modifier on fee-for-service claims, and vaccine counseling visits are billed with 90482, 90483 or 90484. This is from a June 2026 bulletin, so check current applicability before acting.
Get alerts when payers change rules like this one
We check Colorado Medicaid and other payers every day and email you when a change matches your specialty and state.
Get Colorado Medicaid alertsPolicy Monitoring is free. No card required.
What to do
Action · 43 steps
01REQUIREMENTS: Already effective July 1, 2026: Expect the 2.0% across-the-board reduction on fee-for-service claims with dates of service on or after that date, and check the Provider Rates and Fee Schedules web page, since rates will be updated in the Colorado interChange for those dates of service.
02Already effective July 1, 2026: Bill CPT 97151 as one unit per 365 days.
03Two units with modifier TJ may be billed on a different date of service only once per 365 days to signify recurring assessments within the prior authorization renewal process.
04Billing team: for Pediatric Behavioral Therapy claims, put the individual ordering or referring practitioner's NPI in the ordering/referring provider field for services that require an order, and confirm the practitioner is fully and actively enrolled as an OPR or rendering provider before submitting the claim.
05Claims submitted without a valid ordering provider NPI may be denied.
06Claims that bill more than one unit of 97151 without modifier TJ were paid in error and will be reprocessed, and overpayments will be recouped.
07Already effective July 1, 2026: Physician-administered drugs Spravato (J0013, G2082, G2083) and Qivigy (J1577) require a member-specific prior authorization request submitted to Acentra and approved before administration.
08Spravato billing: bill G2082 or G2083 for the visit, drug and two-hour observation, or bill J0013 with the most applicable E/M code for the visit and observation.
09Do not bill a J code and a G code on the same date of service, since that is duplicative and claims will be denied.
10Do not bill additional E/M codes unless a separate issue or condition is also addressed during the visit, and document that separate issue when additional E/M codes are billed on the same fee-for-service claim for the same date of service.
11Provider types 64 and 78 bill the visit to the Regional Accountable Entity and the drug and observation to fee-for-service Medicaid.
12Physician-administered drug billing: put the NDC on the line, bill the amount administered in both HCPCS and NDC units, and use the HCPCS and NDC unit guidance in the bulletin (for example, NDC 50458002800 for 28 mg with 28 HCPCS units and 1 NDC unit).
13Do not bill for a drug obtained at no cost; if billed for information only, the amount must be zero dollars.
14White, brown and clear-bagging are not usually allowed.
15Hospital specialty drugs J2507 (effective April 10, 2026) and J9029 (effective April 16, 2026) require prior authorization submitted to HCPF_PharmacyPAD@state.co.us and approved before administration.
16Brineura (J0567) Appendix Z criteria were updated.
17Physician-administered drug PARs for J3241, J3358, J3357 and J3380 follow the updated Appendix Y criteria.
18Neurological and psychological testing (96130, 96131, 96136, 96137): for fee-for-service, Rocky Mountain Health Plans PRIME, or Denver Health Medical Plan payment, use the SC modifier.
19For payment from a Regional Accountable Entity, do not use the SC modifier.
20Fee-for-service claims without the SC modifier will deny and direct the provider to bill the RAE, and claims that do not follow this process will need to be resubmitted.
21A covered diagnosis is not required for these codes.
22Immunizations: bill 90482, 90483 or 90484 for visits in which providers counsel about vaccination, and do not bill the vaccine counseling code and the vaccine administration code on the same date of service when the administration code includes counseling.
23CPT G0310 through G0315 will no longer be reimbursed for dates of service after June 30, 2026.
24Rate switch between 96110 and 96110 with modifier EP: retroactive to April 1, 2026, 96110 with modifier EP pays $18.39 and 96110 without a modifier pays $10.38.
25Claims with a first date of service after April 1, 2026 will be reprocessed.
26Already effective May 15, 2026: Outpatient PT, OT, speech and audiology Plan of Care physician signatures are no longer required on an initial Plan of Care when there is an existing physician order or referral and the therapist keeps documentation that the Plan of Care was delivered to the physician's office within 30 days of the initial evaluation.
27Already effective July 1, 2026: For behavioral health services delivered under oversight of a rendering provider, bill modifier U9 on all claims for services delivered by a pre-licensed clinician or unlicensed professional.
28Already effective June 1, 2026: Enrolled dentists (provider type 04) may order laboratory services.
29Interoperability PAR timeframes: expedited PARs are reviewed within 72 calendar hours and pends are not allowed on them, so include all documentation with the initial PAR.
30Standard PAR turnaround is seven calendar days, and all PARs including pends are processed within 21 calendar days.
31Additional pends on the same PAR will not be extended, so supply all information requested in the initial pend or the PAR will result in a technical denial.
32Already effective July 1, 2026: The Rapid Review PAR type is eliminated, so submit PARs as Expedited only when they meet the expedited criteria.
33Adjustments: send adjusted claims electronically through the Provider Web Portal or clearinghouse batch, and do not void and rebill unless the claim was billed in error or for an incorrect member.
34Records for managed care entity quality reviews: provide complete and timely records directly to the requesting MCE within 45 calendar days of receipt unless the MCE specifies otherwise.
35Already effective July 1, 2026: Hospital fee-for-service base rates (APR-DRG and EAPG) decrease 2.0%, and per diem rates for long-term acute care and spine and brain injury hospitals decrease 2.0%.
36Already effective July 1, 2026: Critical Access Hospitals, Rural Referral Centers and Sole Community Hospitals that are 340B-covered entities must submit the SE modifier on certain medical claims for physician-administered drugs.
37For carved-in Orphan Drugs given for an orphan-designated indication, omit the UD modifier and include the SE modifier.
38FQHC known issue: institutional claims with revenue code 900 and certain procedure codes are posting EOB 3361, a resolution is in progress, and impacted claims will be reprocessed in June upon implementation.
39EVV: make sure EVV visit duration matches the units billed, and correct discrepancies promptly, since the Department may consider corrective action plans or program integrity referrals if misalignment continues.
40Effective August 1, 2026: The Supportive Services Sustainability Strategy changes take effect for skill building, peer support and targeted case management.
41Future date: The residential behavioral health transition from fee-for-service to capitation for children in Child Welfare custody moves to July 1, 2027 under SB26-188.
42Dental adult services are capped at $3,000 per year for dates of service July 1, 2026 and after.
43Behavioral Health Group PT 77 enrollment: the enrollment requirement is not being implemented in July as previously published, and the impacted code list will be posted on the Behavioral Health web page.
Codes mentioned
961109613096131961369613797151A0100A0120S0215S0209G2082G2083J0013J1577904829048390484G0310G0311G0312G0313G0314G0315J2507J9029J0567J0561J3241J3380
Original notice
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600539 - 06/2026)
hcpf.colorado.gov · Always check the source before changing claims.
Related changes
See all Colorado Medicaid changes →Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600538 - 05/2026)HighNo effective date · Provider BulletinHealth First Colorado (Colorado's Medicaid Program) News and Updates (B2200482 - 09/2022)MediumEffective Sep 1, 2022 · Provider BulletinHealth First Colorado (Colorado's Medicaid Program) News and Updates (B2300501 - 11/2023)MediumNo effective date · Provider BulletinHealth First Colorado (Colorado's Medicaid Program) News and Updates (B2000455 - 11/2020)MediumEffective Jan 1, 2021 · Provider BulletinBrowse every Colorado Medicaid change in the policy list
Related policy hubs
Colorado Medicaid policiesCO policy changesFamily MedicineGeneral PracticeInternal MedicinePediatricsPsychiatryNeurologyUrologyRheumatologyDentistryPharmacyPhysical TherapyOccupational TherapySpeech TherapyAudiologyCode 96110Code 96130Code 96131Code 96136Code 96137Code 97151Code A0100Code A0120Code S0215Code S0209Code G2082Code G2083Code J0013Code J1577Code 90482Code 90483Code 90484Code G0310Code G0311Code G0312Code G0313Code G0314Code G0315Code J2507Code J9029Code J0567Code J0561Code J3241Code J3380