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Colorado MedicaidMedicaid · Administrative · Provider Bulletin · CO · General Practice, Pathology, Pediatrics +2 moreHigh impact

Health First Colorado (Colorado's Medicaid Program) News and Updates (B2500531 - 11/2025)

Effective date
Not stated in the notice
Identified
Jun 20, 2026

Summary

Claims sent to a Regional Accountable Entity (RAE) or Managed Care Organization (MCO) may be denied when the provider is not correctly enrolled or the claim information does not match the enrollment record, and the rollout is anticipated in stages: flagging without denial from November 3, 2025 for Northeast Health Partners and Rocky Mountain Health Plans, denials from December 1, 2025 for Colorado Access, and denials from January 5, 2026 for Colorado Community Health Alliance, Denver Health, Kaiser Permanente, Northeast Health Partners and Rocky Mountain Health Plans. Effective November 1, 2025, continuous glucose monitors (CGMs) may be billed as a pharmacy claim or a professional claim, and professional claims must include the product's National Drug Code (NDC), the proper HCPCS procedure code and the modifier combination. Effective December 1, 2025, HCPCS code A4287 has a conditional limit of 120 breast milk storage bags per month, and a prior authorization request must be submitted through the PAR Portal when more than 120 bags are needed in a month.

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What to do

Action · 10 steps
01Already effective November 1, 2025: For CGMs, submit professional claims with the product's NDC, the proper HCPCS procedure code and the modifier combination.
02CGMs without an NDC or Wholesale Acquisition Cost (WAC) must be submitted as a professional claim with Questionnaire 20 sent with the prior authorization request (PAR) and the claim, and CGMs billed to the pharmacy benefit need a new PAR.
03For members enrolled in Denver Health or Rocky Mountain Health Plans, submit fee-for-service claims for CGM products and supplies.
04Already effective December 1, 2025: For HCPCS A4287, submit a prior authorization request through the PAR Portal when more than 120 bags are needed in a month.
05Anticipated November 3, 2025 through January 5, 2026, depending on the RAE or MCO: Providers should verify that their information in the Provider Web Portal is correct and matches the information used when submitting claims.
06Claims denied for this reason can be resubmitted once the information is updated in the Provider Web Portal and claims are revised to include the appropriate NPI or Taxonomy Codes in the correct fields; refer to the Managed Care Claims Compliance fact sheet on the ACC Provider and Stakeholder Resource Center web page.
07Previously due December 12, 2025 (date passed; verify current applicability): ABA providers must ensure any Registered Behavior Technician (RBT) providing services under their supervision is actively certified by the Behavior Analyst Certification Board (BACB) or another recognized certification body, verify the active certification status of all RBTs on staff, and retain documentation for audit or program integrity reviews.
08After December 12, 2025, discontinue billing for services rendered by uncertified individuals.
09Already effective October 10, 2025: HCPCS G0480-G0483 have a combined unit limit of 16 per state fiscal year (July 1 through June 30) for substance-specific confirmatory lab tests, and the order for the drug test, the clinical indication or medical necessity and the lab results must be maintained in the member's medical record.
10Check current applicability before completing any of these past dates.

Codes mentioned

G0480G0483A4287

Original notice

Health First Colorado (Colorado's Medicaid Program) News and Updates (B2500531 - 11/2025)
hcpf.colorado.gov · Always check the source before changing claims.
View original ↗

Related changes

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Related policy hubs

Colorado Medicaid policiesCO policy changesGeneral PracticePathologyPediatricsPharmacyPsychiatryCode G0480Code G0483Code A4287

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