Colorado providers face a continuous stream of payer policy changes: coverage edits, prior authorization expansions, billing code revisions, and Medicaid reimbursement updates that affect day-to-day practice operations. This page surfaces every tracked policy change that explicitly names Colorado, so your billing and compliance teams can act before the effective date, not after a claim denial.
Effective January 1, 2027, UnitedHealthcare Community Plan in Colorado and Missouri will no longer accept paper submissions for post-service appeals. All appeals must be submitted electronically via the UnitedHealthcare Provider Portal or API. Paper appeals will not be reviewed.
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
This is a comprehensive Medicare Advantage coverage policy for molecular biomarker tests used in prostate cancer risk stratification (effective 10/1/2026). The policy establishes coverage criteria for tests like ArteraAI, EpiSwitch, IsoPSA, MyProstateScore 2.0, ProMark, and ProsTAV, with coverage determinations based on MAC-specific LCDs/LCAs that vary by geographic jurisdiction. Billing teams must identify the correct MAC jurisdiction and apply the corresponding LCD requirements for each test ordered.
This is a comprehensive Medicare Advantage bariatric surgery coverage policy (HUM-1020-005) effective October 1, 2026, that outlines coverage determinations, limitations, and coding requirements for various bariatric procedures. The policy applies Humana's Medicare Advantage coverage standards and references applicable MAC Local Coverage Determinations by geographic jurisdiction, with specific rules varying by state and MAC region.
Health First Colorado added daily limits and same day billing limits for a list of behavioral health and supportive service codes, active since Aug. 1, 2026 for some codes and effective Oct. 1, 2026 for others, and Regional Accountable Entities (RAEs) enforce them. Claims with dates of service of Aug. 1, 2026 or later deny if an updated provider license is not on file, and a recovery residence policy takes effect Oct. 1, 2026. This bulletin also covers a number of other changes with dates from Aug. 31, 2026 through Jan. 1, 2027, including the APR-DRG Version 42 update that moved to Jan. 1, 2027.
Aetna is implementing multiple billing and operational changes effective September 1, 2026, including new claim edits through the Claim and Code Review Program (CCRP) and a 15% payment reduction for certain radiology services billed with modifier CT. Additionally, commercial drug lists will be updated October 1, 2026, and providers must maintain current credentialing contact information to avoid removal from the directory.
This is a revised Medicare Advantage medical coverage policy for spinal fusion surgery (effective 09/01/2026) that consolidates coverage determination, limitations, coding information, and evidence summaries for cervical, lumbar, and thoracic spinal fusion procedures. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) across geographic jurisdictions and outlines covered procedures including traditional fusion, minimally invasive approaches (DLIF, XLIF, MITLIF), sacroiliac joint fusion, and interlaminar fusion techniques. Billing teams must align claims submission with the applicable MAC LCD based on patient location and ensure procedures meet specific medical necessity criteria outlined in the referenced determinations.
This is a comprehensive Medicare Advantage coverage policy for Benign Prostatic Hyperplasia treatments effective September 1, 2026. The policy outlines coverage determinations for multiple BPH treatment modalities including surgical procedures (TURP, prostatectomy, laser therapies), temporary implanted devices, stents, and diagnostic testing. The policy references multiple MAC-specific Local Coverage Determinations (LCDs) that vary by geographic jurisdiction, requiring billing teams to verify applicable coverage rules based on patient location.
Humana Medicare Advantage has revised its Ambulatory Cardiac Monitoring Devices policy effective September 1, 2026. The policy provides updated coverage guidance for various cardiac monitoring technologies (Holter monitors, patch recorders, external loop monitors, implantable loop recorders, and mobile cardiac outpatient telemetry) with MAC-specific coverage determinations by geographic jurisdiction. The policy document appears incomplete but establishes that medical necessity determinations will follow applicable NCDs and LCDs based on the member's jurisdiction.
This is a comprehensive Medicare Advantage coverage policy for neuroablative techniques used to treat chronic pain, effective 08/06/2026. The policy defines coverage criteria, eligible procedures (including radiofrequency ablation, cryoablation, chemical neurolysis, and specialized devices like Intracept), and references MAC-specific LCDs and billing codes by geographic jurisdiction. Billing teams must verify applicable MAC guidelines for their state and ensure claims comply with local coverage determinations.
This is a comprehensive Medicare Advantage policy on neuroablative techniques for chronic pain management, effective 08/06/2026. The policy defines covered denervation procedures (radiofrequency ablation, cryoablation, facet denervation, basivertebral nerve ablation, and others) and references MAC-specific LCDs and NCDs that vary by geographic jurisdiction. Billing teams must verify applicable MAC requirements for their region before processing claims for these procedures.
This is a comprehensive Medicare Advantage policy on genetic testing for hereditary cancer syndromes, effective August 3, 2026. The policy establishes coverage guidelines for germline genetic testing across multiple cancer types (melanoma, gastric cancer, neuroendocrine tumors, renal cell carcinoma, and others) and references specific MAC-based Local Coverage Determinations (LCDs) that vary by geographic jurisdiction. Billing teams must verify applicable MAC jurisdiction and LCD requirements before processing claims.
Humana Medicare Advantage has revised its breast reconstruction coverage policy (effective 08/03/2026) to clarify medical necessity criteria for reconstruction procedures following mastectomy, trauma, or congenital abnormalities. The policy applies MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction and establishes criteria for determining coverage of implant removal, reduction mammaplasty, and related procedures. Billing teams must identify the appropriate MAC jurisdiction for each claim and apply the correct LCD requirements.
Humana Medicare Advantage has updated its Breast Excision and Mastectomy policy (HUM-1254-009) effective 08/03/2026. This revised policy clarifies coverage criteria for breast lesion excisions (CPT 19120, 19125), partial mastectomies (CPT 19301, 19302), and gynecomastia mastectomy (CPT 19300) across multiple MAC jurisdictions. The policy establishes specific medical necessity criteria based on biopsy results, lesion characteristics, and anatomical considerations, and applies jurisdiction-specific Local Coverage Determinations (LCDs) for Medicare Administrative Contractors.
This is a comprehensive Medicare Advantage policy for Benign Prostatic Hyperplasia (BPH) treatments that became effective on August 3, 2026. The policy outlines coverage for multiple surgical and minimally invasive treatment modalities including TURP, laser therapies, temporary implanted devices, and stents, with specific coverage determinations varying by MAC jurisdiction. Billing teams must verify applicable MAC-specific LCDs and NCDs by geographic location before processing BPH treatment claims.
Select Health published 6 policy changes including 2 new policies and 4 revisions. Major changes include discontinuation of Spravato coverage for commercial plans, new hyoid suspension coverage criteria for sleep apnea, and removal of cystoscopy requirements for sacral nerve stimulation. Additionally, 25 new genetic testing policies are being incorporated.
Molina Care Connections expands telehealth and in-person nurse practitioner services across 22 states with open scheduling for preventive care and chronic condition management. Developmental screening requirements for children ages 1-3 now mandate use of standardized global screening tools (CPT 96110) with specific documentation; domain-specific tools (M-CHAT, ASQ:SE) are no longer billable for this measure. Utilization management criteria and processes remain unchanged but are clarified for provider reference.
UnitedHealthcare Community Plan (Medicaid) now requires enhanced medical documentation for prior authorization of total hip and knee joint replacement surgeries (CPT 27447, 27130, 27132) when performed for osteoarthritis. New requirements include detailed imaging reports with specific findings and provider specialties who interpreted images, rolling out across multiple states with different effective dates.
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.
Colorado Medicaid is implementing rate reductions effective October 1, 2025, rolling back 1.6% fee increases across all professional and institutional claims due to state budget shortfall. Dental services, pediatric behavioral therapy, and some HCBS services face targeted reductions exceeding 1.6%, with dental codes reduced by 15.5%.
Nirsevimab is a covered benefit for members under two years of age without cost-sharing, effective August 3, 2023, and clesrovimab is a covered benefit for infants under eight months who are born during or entering their first RSV season, effective June 26, 2025, also without cost-sharing. Palivizumab is administered to eligible high-risk patients only when a long-acting monoclonal antibody is unavailable, and members may not receive Palivizumab after a long-acting monoclonal antibody in the same season. The 2025-2026 Synagis season runs from October 1, 2025 to April 1, 2026, with PARs accepted effective October 1, 2025, a maximum of five doses, and a dosing interval of no fewer than 26 days between injections, and the manufacturer announced in August 2025 its intention to discontinue Synagis at the end of 2025.
Professional claims (CMS 1500) are reduced by the 1.6% increase previously applied to fee-for-service rates for dates of service on or after October 1, 2025, with targeted rate reductions for dental codes and Pediatric Behavioral Therapy codes effective October 1, 2025. Manually priced DMEPOS and prosthetics claims that follow the MSRP less or invoice acquisition plus methods are reduced to MSRP less 13.78% or invoice acquisition cost plus 24.06%, effective October 1, 2025. Continuous glucose monitor products and supplies must carry the NDC, the HCPCS code and the modifier combination on claims beginning November 1, 2025, and CGMs for members enrolled in physical health managed care plans must be billed as fee-for-service claims.
Long-term home health and private duty nursing prior authorization requests require a Skilled Care Acuity Assessment and a Recommendation Letter from the Nurse Assessor, and both must be included with the PAR submission. Wheelchair-mounted robotic arms are not a covered benefit under the Health First Colorado DMEPOS program, effective August 1, 2025. Registered Behavior Technicians must hold an active certification to provide and bill for services, and providers have until August 31, 2025 to come into full compliance.
Several Health First Colorado changes take effect January 1, 2027, including the statewide NEMT broker transition to MediDrive, an Individual NPI requirement for behavioral health providers, and Phase 2 of the Weekly Caregiver Limit. Other changes took effect October 1 and October 13, 2026, including new prior authorization requirements for certain physician-administered drugs, licensure date mismatches that can cause claim denials, and new gender-affirming care rules for members under 18. Historical deadlines include the DRA Declaration due November 2, 2026.
UnitedHealthcare is reminding providers that multigene RNA panel testing for hereditary cancer is considered unproven and will be denied. Only DNA-only hereditary cancer panels and single-gene RNA testing remain covered under applicable medical policy and prior authorization requirements.
Health First Colorado requires Modifier U9 on all claim lines for behavioral health services delivered by pre-licensed clinicians or unlicensed professionals for dates of service beginning July 1, 2026, and requires the service provider's individual NPI in Box 19 of the CMS 1500 claim for dates of service beginning January 1, 2027. Remote patient monitoring codes 99445 and 99470 were loaded with incorrect rates, and claims for them are being reprocessed as applicable. FQHCs should not bill vaccine products or vaccine administration codes separately on the CMS 1500 claim, and LTSS claims may be denied for dates of service on or after October 1, 2026 when license dates on file with CDPHE do not match the Medicaid system. Other changes include phased weekly caregiver hour limits beginning July 1, 2026, a cap of 7 hours per week of Homemaker services from Legally Responsible Persons effective June 12, 2026, and the end of the Medicaid eConsult platform effective August 31, 2026.
A 2% across-the-board Health First Colorado provider rate reduction applies to dates of service beginning July 1, 2026, with exemptions for managed care, pharmacy, RHCs, FQHCs, pediatric behavioral therapy, select NICU and neonatal services, select maternity services, and family planning services. Procedure codes 97535 and 97537 are no longer covered as of July 1, 2026, and CPT 77063 became a covered benefit that must be billed on the same claim as CPT 77067. Effective August 1, 2026, PT 25 and PT 16 claims will be denied when billed for certain behavioral health supportive and team-based services in fee-for-service or to the Regional Accountable Entities.
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.
Health First Colorado claims are paid only when the billing, attending, rendering and referring provider IDs are actively enrolled and revalidated, and denied claims are to be corrected and resubmitted electronically as new claims. Claims requiring an OPR or attending provider begin denying effective July 1, 2024 when that provider is missing or not enrolled, and nursing facility claims with a missing or not enrolled attending provider are denied under the same EOB 1997 rule. Fee-for-service rates increase 2.0% for dates of service starting July 1, 2024, with targeted rate increases for listed services, and claims billed and paid at a lower rate cannot be adjusted up under the lower-of pricing logic.
Fee-for-service rates increase 2.0% for dates of service beginning July 1, 2024, with targeted rate rebalances for abortion, ambulatory surgical centers, anesthesia, dental, fee-for-service behavioral health, maternity and surgery. The dental fee schedule is updated for many preventive, endodontic, periodontic, diagnostic and crown codes, and DME manual pricing changes to acquisition cost plus 21.75% or MSRP less 13.34% for dates of service July 1, 2024 and later. Topical compounded pharmacy claims above $200.00 are subject to prior authorization criteria effective July 1, 2024, and claims for independent laboratory and radiology services begin denying effective August 1, 2024 when the OPR provider is missing or not enrolled.
Providers cannot bill Health First Colorado members for services covered by Health First Colorado, for services rendered but not prior authorized due to lack of information on a PAR, for the denied portion of a PAR, or for system-related denials such as billing errors or timely filing. Claims must be submitted and received within 365 days of the date of service. CPT codes 87505 and 87506 are expected to be covered benefits effective September 1, 2024 and require a PAR submitted through Acentra's Atrezzo portal.
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.
Health First Colorado system edits that require a valid prior authorization request (PAR) for Home and Community-Based Services (HCBS) payment are being reinstated, and claims billed without a valid PAR, or that exceed approved service units, will be denied once those edits are reinstated. Regional Accountable Entities (RAEs) have been directed to create prior authorization and retrospective review processes for outpatient psychotherapy that exceeds 24 sessions in a 12-month period, covering codes 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90846, 90847, 90849 and 90853 across all provider types. Effective January 1, 2026, the physician-administered drug (PAD) HCPCS codes J1442, Q5125, J2506, Q5111, Q5127, J9312, Q5101, Q5108, Q5122 and Q5130 are added to the list of PADs that require prior authorization.
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.
Colorado's April 2026 Health First Colorado provider bulletin (B2600537) reduces applicable fee-for-service rates to 85% of their Medicare benchmark effective April 1, 2026, and requires a qualifying ICD-10 diagnosis within the first four diagnosis code positions on outpatient remote patient monitoring claims effective April 1, 2026. Repeat initial inpatient or observation E/M codes 99221 through 99223 on the same date of service must be billed with modifier 77 when the repeat service is distinct and medically necessary. Hospital Specialty Drug claims must carry the NDC, the NDC units, the acquisition cost and a drug-specific invoice, and fee-for-service pharmacy claims moved to MedImpact effective April 1, 2026.
Provider licenses on file with Health First Colorado must be active on the date of service, and claims for providers with expired licenses will deny for EOB 3385 effective May 18, 2026. Pediatric Long-Term Home Health services require prior authorization for all new and existing members effective May 4, 2026, with full enforcement beginning June 1, 2026. The notice also covers vaccine counseling codes (90482, 90483, 90484), the Mircera routine dialysis drug designation effective May 1, 2026, updated mechanical stretching device criteria effective June 1, 2026, and Pediatric Behavioral Therapy change of provider forms for CPT 97151 effective June 1, 2026. This is from a May 2026 issue, so check current applicability for each date before acting.
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.
Humana Medicare Advantage revised its neuroablative techniques for chronic pain policy effective 11/01/2026. The policy update describes coverage criteria, limitations, and coding guidance for multiple denervation procedures (radiofrequency ablation, cryotherapy, facet denervation, basivertebral nerve ablation, and other neuroablative techniques). The practice must verify applicable MAC LCDs by geographic jurisdiction, obtain prior authorization as required, and ensure claims are submitted with correct coding and documentation.
This is a revised Medicare Advantage policy for low frequency, noncontact, nonthermal ultrasound (MIST Therapy) for wound care, effective October 1, 2026. The policy clarifies medical necessity criteria across multiple MAC jurisdictions, requiring that standard wound care demonstrate no improvement or be contraindicated before this therapy is covered. Billing teams must ensure claims include proper documentation of failed standard care and route requests through applicable regional MACs.
Effective October 1, 2026, UnitedHealthcare will require prior authorization for HCPCS code J2860 (siltuximab injection) when administered in outpatient settings for cancer treatment. This applies to all UnitedHealthcare plan types including commercial, Medicare Advantage, Medicaid, and Exchange plans.
Effective September 1, 2026, UnitedHealthcare Community Plans will remove prior authorization requirements for electrical stimulation codes G0281 and G0282 in seven states. Billing teams must update their systems to stop requiring prior authorization for these codes to avoid unnecessary delays and claim processing issues.
Starting September 1, 2026, UnitedHealthcare will require prior authorization for vertebral body tethering (VBT) codes and upper/lower extremity prosthetics codes across multiple state Medicaid plans. The VBT codes were previously classified as unproven but are now considered proven in certain clinical circumstances, while the prosthetics codes are newly established AMA codes.
Humana Medicare Advantage has updated its policy on molecular diagnostic assays and breath testing for transplant rejection, effective 08/30/2026. This policy establishes coverage criteria and references for gene expression profiling tests, antigen-specific T-cell function assays, breath testing (BMAC/Heartsbreath), and donor-derived cell-free DNA tests used to monitor organ transplant recipients. Billing teams must verify MAC-specific Local Coverage Determinations (LCDs) by geographic jurisdiction, as coverage and coding requirements vary significantly by region.
Humana Medicare Advantage has updated its Liquid Biopsy coverage policy (Policy HUM-1151-014), effective 08/03/2026. This policy establishes coverage criteria for liquid biopsy tests (blood-based biomarker analysis for cancer detection and treatment monitoring) across multiple jurisdictions under Medicare Administrative Contractors. The policy requires medical necessity documentation and adherence to MAC-specific Local Coverage Determinations, with coverage determined through analytical/clinical validity standards and DEX Registry evaluation where CMS guidance is absent.
Anthem Blue Cross and Blue Shield is reminding providers in 12 states (including New York) that the Bundled Services and Supplies — Facility reimbursement policy applies to both inpatient and outpatient facility fees effective July 1, 2026. Providers are prohibited from balance-billing members based on this policy, and must review specific policy details on the provider website to ensure proper billing compliance.
Anthem Blue Cross and Blue Shield is reminding providers that the Bundled Services and Supplies — Facility reimbursement policy applies to both inpatient and outpatient facility fees effective July 1, 2026. Providers are prohibited from balance-billing members under this policy, and billing teams must ensure compliance with bundled service requirements to avoid claim denials and member disputes.
Starting July 1, 2026, UnitedHealthcare Community Plans (Medicaid) will require prior authorization for transcatheter heart valve procedures using codes 0569T and 0570T. These codes were previously classified as unproven but are now considered proven in certain clinical circumstances requiring medical necessity review.
Humana Medicare Advantage updated their advanced chest imaging policy to include specific medical necessity criteria for CT scans (CPT 71260, 71270) including detailed guidelines for pulmonary nodule follow-up imaging and preoperative/postoperative indications. The policy provides structured protocols for managing incidental pulmonary nodules based on size, type, and risk factors.
This is an informational newsletter (OfficeLink Updates - March 2026) containing multiple policy updates and operational guidance for Aetna providers. Key items include: (1) new claim edits effective June 1, 2026 as part of the Claim and Code Review Program (CCRP); (2) an update to the treatment room services policy (originally effective April 1, 2021); and (3) reminders about prior authorization submission procedures, provider profile maintenance, and behavioral health resources. The newsletter applies to Commercial and Medicare lines of business unless otherwise specified.
Humana updated their Medicare Advantage policy for skin and tissue substitutes/cellular and tissue-based products (CTPs), establishing coverage criteria for specific products like AlloDerm, Apligraf, and Epifix. The policy defines medical necessity requirements based on local coverage determinations for diabetic foot ulcers, venous leg ulcers, breast reconstruction, and burn treatment.
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