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Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600533 - 01/2026)
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Effective January 1, 2026, the HCPCS codes J1442, Q5125, J2506, Q5111, Q5127, J9312, Q5101, Q5108, Q5122 and Q5130 are added to the physician-administered drug (PAD) list that requires prior authorization (PA). Effective January 1, 2026, outpatient providers can bill transitions of care codes 99495 and 99496 in place of E/M codes 99214 and 99215 for follow-up visits within 14 days of discharge from inpatient or observation-level care. Claims billed with 2026 HCPCS procedure codes may suspend for EOB 0000 beginning January 1, 2026, and all codes must be reviewed for medical necessity, prior authorization coverage standards and rates before they are reimbursable.
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What to do
Action · 11 steps
01Already effective January 1, 2026: For each PAD code listed above, submit a member-specific PA request to Acentra Health through the Atrezzo portal and receive approval before administering the drug to the member; these providers bill the professional claim type (CMS 1500 or 837P electronic format).
02Already effective January 1, 2026 for hospital specialty drugs: member-specific PA requests go directly to the Department at HCPF_PharmacyPAD@state.co.us and must be approved before administration.
03Already effective January 1, 2026 for transitions of care: within two business days of discharge, make two attempts at direct and interactive contact with the patient or caregiver covering the services received during admission, discharge diagnosis, patient status, follow-up services, medication reconciliation, and scheduling of a face-to-face or virtual visit; complete the visit within the timeframe for the complexity of medical decision making; and do not bill office, home visit or domiciliary E/M codes on the same date of service for the member, including 99202-99205 and 99211-99215.
04Use the Accountable Care Collaborative (ACC) Transitions of Care Billing Guidance Fact Sheet to confirm which provider types can use the TOC codes.
05Beginning January 2026 for ColoradoPAR requests: a standard PAR request is completed within seven calendar days, and a pend for additional information is reduced from 10 business days to seven calendar days; all information requested in the initial pend must be supplied, because additional pends on the same PAR will not be extended and the PAR will result in a technical denial; expedited PARs allow no pends, so include all documentation with the initial submission.
06Already effective February 1, 2026: Drug testing claims with dates of service on or after February 1, 2026 are reviewed against the Laboratory Services Billing Manual standards, which require that the service be ordered by a licensed healthcare professional, performed to diagnose conditions and illnesses with specific symptoms, and not a routine diagnostic test without apparent relationship to treatment or diagnosis for a specific illness, symptom, complaint or injury.
07Keep claims within timely filing by resubmitting every 60 days after the initial 365 days from the date of service, and reference the previous Internal Control Number (ICN) on the claim when it is over 365 days.
08Providers who batch bill through a vendor or clearinghouse should contact them immediately to confirm they are using the new X12 file naming standards, since trading partners begin receiving new response file names beginning January 8, 2026.
09Check the Provider Rates and Fee Schedule web page before billing 2026 HCPCS codes to confirm they are a covered benefit.
10For co-surgery, bill modifier 62 only for procedures listed on the Medicare Physician Fee Schedule Database with a co-surgery indicator of two (2); other procedures billed with this modifier will be denied.
11Check current applicability before completing any of these past dates.
Codes mentioned
J1442Q5125J2506Q5111Q5127J9312Q5101Q5108Q5122Q5130J1413J3402Q204299495994969921499215992029920599211H000600104Z33.21000550387503895345155876645615729558356500805057550580515355264954650572825728357287630206303050081558806304759840598415985059851598525985559856598570196401965019665812059100S0199S0190S0191
Original notice
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600533 - 01/2026)
hcpf.colorado.gov · Always check the source before changing claims.
Related changes
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Related policy hubs
Colorado Medicaid policiesCO policy changesFamily MedicineInternal MedicineNeurologyOncologyOB-GYNAnesthesiologyGeneral SurgeryPsychiatryPharmacyCode J1442Code Q5125Code J2506Code Q5111Code Q5127Code J9312Code Q5101Code Q5108Code Q5122Code Q5130Code J1413Code J3402Code Q2042Code 99495Code 99496Code 99214Code 99215Code 99202Code 99205Code 99211Code H0006Code 00104Code Z33.2Code 10005Code 50387Code 50389Code 53451Code 55876Code 64561Code 57295Code 58356Code 50080Code 50575Code 50580Code 51535Code 52649Code 54650Code 57282Code 57283Code 57287Code 63020Code 63030Code 50081Code 55880Code 63047Code 59840Code 59841Code 59850Code 59851Code 59852Code 59855Code 59856Code 59857Code 01964Code 01965Code 01966Code 58120Code 59100Code S0199Code S0190Code S0191