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Health First Colorado (Colorado's Medicaid Program) News and Updates (B2400508 - 05/2024)
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Claims for some provider types can suspend or deny when a valid referring NPI is not listed. The OPR mandate is not currently denying claims for missing OPR NPIs, but claim denials are stated to begin July 1, 2024. NEMT claims billed with procedure code A0425 or S0209 above 52 units are suspended for review, and trips of 25 miles or more require the Verification Form for Transportation Services More Than 25 Miles, with claims without it denied beginning June 1, 2024.
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What to do
Action · 10 steps
01Already effective June 1, 2024: NEMT billing team attaches the Verification Form for Transportation Services More Than 25 Miles to each claim for a trip of 25 miles or more, since claims without the form are denied, and the form is signed by the member's treating or referring provider.
02Already effective June 1, 2024: NEMT billing team attaches a document to A0425 or S0209 claims above 52 units that shows the pick-up and destination addresses, date and time of the trip, the member's name or identifier, confirmation that the driver verified the member's identity, confirmation that the trip occurred, actual pick-up and drop-off times, the driver's name, the vehicle identification, and the treating medical provider's rationale and certification, since suspended claims are denied without it.
03Billing team confirms each OPR and attending provider on a claim is actively enrolled as an individual with Health First Colorado, and places the OPR NPI in CMS 1500 Field 17b or UB-04 Fields 76, 78 and 79 as applicable; claims with services requiring OPR providers post EOB 1997 if the OPR provider is not enrolled.
04Claim denials for the OPR mandate are stated to begin July 1, 2024, so check current applicability of that date rather than completing it.
05Billing team bills Avastin for AMD ophthalmology treatment as one claim line with HCPCS J7999 or C9257 paired with the matching NDC, with LT, RT or 50 appended to the CPT injection line.
06Hospital specialty drugs such as J9286 and J0225 require a member-specific PAR submitted directly to the Department and approved before the drug is administered.
07Billing team bills CPT 90611 for members 18 and up for dates of service on or after April 1, 2024, using the Immunizations Fee Schedule.
08Already effective July 1, 2024: hospice providers no longer submit EVV, and the EVV claim edit no longer generates EOB 3054 on the Remittance Advice, while other hospice billing requirements remain in effect.
09For CGM coverage, the treating practitioner must have an in-person or telehealth visit every six months after the initial prescription to assess adherence.
10Billing team submits ColoradoPAR modification requests in a timely manner, since Acentra cannot modify an expired PAR.
Codes mentioned
A9999J7999C925790611A0425S0209J9286J0225
Original notice
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2400508 - 05/2024)
hcpf.colorado.gov · Always check the source before changing claims.
Related changes
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