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Health First Colorado (Colorado's Medicaid Program) News and Updates (B2500527 - 09/2025)
Effective date
Oct 1, 2025
Identified
Jun 20, 2026
Summary
Starting November 1, 2025, claims for continuous glucose monitor products and supplies must include the NDC, the HCPCS procedure code and the modifier combination, and CGMs for members enrolled in physical health managed care plans (Denver Health and Rocky Mountain Health Plans) are submitted as fee-for-service claims. Effective October 1, 2025, Optune providers must submit prior authorization requests and claims using HCPCS E0766 instead of E1399, and NEMT mileage uses HCPCS A0425 only for ambulance trips, S0215 for non-ambulance and non-wheelchair van trips, and S0209 for wheelchair van trips. Jardiance, Synjardy and Synjardy XR became non-preferred on the Preferred Drug List effective October 1, 2025, and current users may continue without prior authorization until January 1, 2026.
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What to do
Action · 14 steps
01Already effective October 1, 2025: Providers of the Optune device must submit Prior Authorization Requests and claims using HCPCS E0766, which has a fixed reimbursement rate on the Health First Colorado Fee Schedule and is not manually priced.
02Providers with an approved PAR for Optune using E1399 may continue billing E1399 until that PAR reaches its end-date, even for dates of service after October 1, 2025.
03Already effective October 1, 2025: Jardiance, Synjardy and Synjardy XR are non-preferred on the Preferred Drug List, and members already using them may continue without prior authorization until January 1, 2026; prior authorization criteria are on the PDL or from Prime Therapeutics at 800-424-5725.
04Already effective November 1, 2025: On professional claims for CGM products and supplies, include the NDC of the product, the proper HCPCS procedure code and modifier combination, and submit the additional documentation required with the claim for CGM products that do not have an assigned NDC.
05Already effective November 1, 2025: DMEPOS providers who supply CGMs must submit fee-for-service claims for all members enrolled in physical health managed care plans (Denver Health and Rocky Mountain Health Plans).
06Already effective October 1, 2025: Colorado-specific MUEs and CO PTP edits apply to services that do not have NCCI edits, and the list is on the HCPF Behavioral Health Policies, Standards and Billing References web page.
07Already effective July 1, 2025: NEMT providers must use HCPCS A0425 only for ambulance trip mileage, S0215 only for non-ambulance and non-wheelchair van mileage at $3.00 per unit, and S0209 only for wheelchair van trip mileage at $3.00 per unit.
08Providers who continue to use A0425 for non-ambulance trip mileage will be subject to overpayment recovery, which may result in termination for cause.
09Span billing is not allowed for transportation providers, so each claim has one date of service, with the From Date of Service equal to the To Date of Service.
10DMEPOS billing reminder: Bill HCPCS J1642 per 10 USP units of heparin, by potency and not volume; for example, a 500-unit syringe is billed as 50 units.
11Deadline December 31, 2025: Specialty 477 is no longer valid for Provider Type 64, and Provider Type 64 enrollments with no other specialty attached by that date will be terminated.
12Timely filing: Providers can keep claims within timely filing by resubmitting every 60 days after the initial 365-day period from the date of service, and the previous ICN must be referenced on the claim if it is over 365 days old.
13RBT certification: Providers with staff actively pursuing RBT certification may continue delivering services through October 30, 2025 under the supervision of a qualified provider.
14Already effective November 1, 2025: Only providers with valid and active RBT certifications may provide and bill Adaptive Behavior Treatment by Protocol (97153) under Health First Colorado.
Codes mentioned
J1642E0766E1399A0425S0215S0209S513097153
Original notice
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2500527 - 09/2025)
hcpf.colorado.gov · Always check the source before changing claims.
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