 |
|
|
|
DECEMBER 2025 |
|
At Colorado Access, caring for you and your success is our top priority as you serve our members. This monthly Provider Update serves as a highlight of important information and resources to help you as a contracted provider with us. |
|
Behavioral and Physical Health |
|
|
Discontinuation of Provider Specialty Type 64/477
On July 1, 2025, new specialty types (ST) were added under provider type (PT) 64 (substance use continuum) to align with BHA endorsements. Providers should no longer be enrolled with ST 477. All substance use disorder (SUD) providers who currently have an ST 477 enrollment must submit a maintenance request through Gainwell to modify your ST to align with your BHA endorsement for level of care. Claims with dates of service after December 31, 2025, will be denied when billed by provider specialty type 64/477. If you have any questions about this, please email hcpf_sudbenefits@state.co.us. |
MUE (Medically Unlikely Edits) Claim Processing Issue
We have identified a configuration issue with several codes that has allowed for more units to pay than allowed by the MUE. We have corrected this issue and will be reprocessing all affected claims back to July 1, 2025. The affected codes will deny in their entirety, and you will need to send a new or corrected claim with the corrected units per the MUE. |
Managed Care Claims Processing Changes
To continue getting reimbursed for providing covered services to Health First Colorado and CHP+ members, make sure you are enrolled, and that you submit claims with information that matches your enrollment record, otherwise your claims may be denied by your RAE or MCO. Any claims that are denied for this reason can be resubmitted once the appropriate information has been updated in the Provider Web Portal and claims are revised to include the appropriate NPI or taxonomy codes in the correct fields. RAEs and MCOs will implement this change on the following rolling basis:
-
November 3, 2025: Northeast Health Partners and Rocky Mountain Health Plans will flag incorrectly submitted claims, but they will not be denied.
-
December 1, 2025: Colorado Access will begin denying incorrectly submitted claims.
-
Anticipated January 5, 2026: Colorado Community Health Alliance, Denver Health, Kaiser Permanente, Northeast Health Partners and Rocky Mountain Health Plans will begin denying incorrectly submitted claims.
RAEs and MCOs have identified providers in their networks who will be impacted by these changes and will contact you directly if this applies to you.
These changes are being implemented to ensure that all claims are submitted and adjudicated in alignment with provider enrollment requirements to achieve the following goals:
-
Compliance with federal and state policy: Only properly enrolled providers may bill for services under Health First Colorado and CHP+.
-
Consistency across RAEs and MCOs: Establishing a uniform standard for claim processing.
-
Program integrity: Ensuring claims are paid only to properly enrolled providers strengthens accountability and reduces administrative burden caused by incorrect submissions.
If you have any questions, contact your RAE or MCO:
Learn more here. |
Reminder: Enhanced Standard Assessment (ESA)
As of November 15, 2025:
-
All children and adults being considered for residential treatment (Qualified Residential Treatment Program (QRTP), Psychiatric Residential Treatment Facility (PRTF), or Out-of-State High Intensity Residential Treatment (OHIRT)) will be required to undergo an ESA for initial Health First Colorado coverage authorization. This applies when residential services are to be directly reimbursed by HCPF. Continuing stay approval will also be required for periods of treatment longer than 30 days.
-
Any child already in an episode of care in a QRTP or a PRTF will receive an initial 30-day approval. OHIRT reviews will continue their regular 30-day review cadence.
Continued stay reviews began December 15, 2025, and occur every 30 days after.
Click here and here to learn more or email christina.winship@state.co.us if you have policy or enrollment questions. |
340B Rebate Model Pilot Program
Starting January 1, 2026, the Health Resources and Services Administration (HRSA) is implementing a 340B Rebate Model Pilot Program, where certain drug manufacturers will sell selected 340B drugs to covered entities at Wholesale Acquisition Cost (WAC). Covered entities will later get manufacturer rebates that reduce the final net price to the statutory 340B ceiling price. When billing Health First Colorado for prescription drugs purchased through the 340B Rebate Model Pilot Program:
Learn more here, and email korri.conilogue@state.co.us if you have any questions. |
Immunization Updates and Reminders
All recommended seasonal and routine immunizations are a benefit for all Health First Colorado members without cost sharing. Members under age 19 are also eligible to receive all immunizations available from the federal Vaccines for Children (VFC) Program at VFC-enrolled provider offices and pharmacies.
All vaccines that are part of the VFC Program are only reimbursable when administered to members under age 19 and when administered by a VFC-enrolled provider using VFC vaccine products. Health First Colorado will not reimburse for the cost of vaccines that are available through the VFC Program or for the cost of vaccines that you get at no cost.
You must enroll with VFC and Health First Colorado and use VFC vaccines to get reimbursed for administering vaccines to members under age 19. Product and administration codes must always be included on any claims for vaccination.
Health First Colorado covers and reimburses vaccine counseling visits where you talk to families about the importance of vaccination. Do not bill for the vaccine counseling code and the vaccine administration code on the same date of service when vaccine administration codes are inclusive of counseling. Learn more here and here, and email christina.winship@state.co.us if you have any questions. |
Abortion Coverage
There are changes in coverage of abortion-related services in compliance with SB25-183 for the following eligibility categories, effective for dates of service beginning January 1, 2026:
-
Health First Colorado (TXIX), including Cover All Coloradans
-
Emergency Medicaid Services (EMS), also called the “Emergency Medical and Reproductive Health Care Program”
-
Child Health Plan Plus (CHP+)
Approved abortion codes listed below will be reimbursed with state-only funds for members enrolled in the above programs, regardless of circumstance. Members will not be subject to member deductibles, copayments, or coinsurance for these services and may not be billed for these services (CO Rev Stat §25.5-4-301).
If you are a CHP+ provider, you must submit your claims to your CHP+ Managed Care Organization (MCO) for manual reconciliation reimbursement.
You must submit separate claims for any services not specific to abortion care; non-abortion services must not be included on the abortion-related claim and may be denied and subject to recoupment (claw back) if improperly bundled.
Elective abortions are identified by diagnosis code Z33.2; no additional documentation is required for reimbursement of elective abortion-related services. Current system restrictions limiting abortion coverage to cases of incest, rape, or life endangerment will be removed, effective January 1, 2026.
Beginning January 1, 2026, you are no longer required to append Modifier 52 to CPT code S0199 to identify telemedicine services that were used to deliver any component of the abortion bundle. Telemedicine may be used for one or more components of S0199 (e.g., patient counseling, follow-up consultation, or confirmation of pregnancy). The Department of Health Care Policy and Finance (HCPF) will release future guidance regarding appropriate telemedicine informational modifiers for claim submission.
Treatment for Non-Viable Pregnancy
HCPF will continue to seek federal match regarding treatment related to nonviable pregnancies. No documentation is required for reimbursement on non-viable pregnancy treatment. When a member receives treatment for a non-viable pregnancy condition, an appropriate diagnosis code (listed below) is required:
-
O00.0-O00.9, Ectopic Pregnancy
-
O01.0-O01.9, Hydatidiform mole
-
O02.0-O02.9, Other abnormal products of conception
-
O02.1, Missed Abortion (incomplete miscarriage)
-
O03.0-O03.9, Spontaneous Abortion
-
O08.0-O08.9, Complications following ectopic and molar pregnancy
Abortion and Pregnancy-Related Procedure Codes
The following CPT codes are covered for abortion and pregnancy-related services:
59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 01964, 01965, 01966, 58120,
59100, 59812-59830, S0199, S0190, S0191
-
Surgical Procedure Codes: 10A07Z6, 10A07ZZ, 10A07ZW, 10A00ZZ, 10A07ZX, 10A08ZZ,
-
The Obstetrical Care Billing Manual will reflect these changes on January 1, 2026.
Questions?
|
Health First Colorado Behavioral Health Rendering
Provider Oversight (RPO) Policy
The final version of the RPO policy is now on the Behavioral Health Policies, Standards and Billing References webpage. Responses to frequently asked questions about the RPO policy will be posted soon. All Health First Colorado providers who are subject to this policy must submit this RPO attestation annually by January 1 to any Regional Accountable Entity (RAE) you are contracted with, to confirm your adherence to rules and standards outlined in the policy.
If you employ peer support professionals, you must also sign and submit this attestation to your RAE(s) by January 1, indicating that all peer support professionals delivering behavioral health services to Medicaid members are either certified or are in the process of becoming certified. |
Terminating Procedure Code H0006
Effective January 1, 2026, all RAEs will discontinue reimbursement for procedure code H0006 (Alcohol and/or Drug Service – Case Management). Services previously billed under this code should be submitted using existing behavioral health case management codes. Refer to the State Behavioral Health Services Billing Manual for applicable alternatives. |
National Diabetes Prevention Program
The Adams County Health Department provides National Diabetes Prevention Program (NDPP) and Diabetes Self-Management Education and Support (DSMES) classes to any Colorado resident for free. Click here to learn more in English and here to learn more in Spanish, and click here to view the current class schedules. |
News From HCPF |
|
|
Health First Colorado Behavioral Health Updates
Read more here. |
Colorado System of Care (CO-SOC) National Wraparound Implementation Center (NWIC) Potential Provider Forums
We are working with HCPF to implement CO-SOC Intensive Behavioral Health Services (including intensive in-home and community-based mental health services and intensive care coordination) for Health First Colorado members under age 21 who have been diagnosed with a mental health or behavioral disorder and for whom these services are medically necessary. The RAEs are responsible for developing a network of services. Learn more here.
HCPF is hosting national experts from NWIC to talk about the model. HCPF will present on the CO-SOC philosophy, the partnership with the RAEs, and the opportunities for funds to support expansion through the Workforce Capacity Center (WCC). There will also be an opportunity for questions and answers. Sign up for an upcoming forum with the below links, and learn more here:
- January 27, 2026, 11:00 a.m. to 12:30 p.m. Join Forum
If you are interested in providing any CO-SOC services in the future, please email amanda.berger@coaccess.com and providerrecruitment@coaccess.com. |
Entering Medicare or Other Insurance on Claims
Medicare replacement plans must be reported as “Medicare” on claims, and not as “third-party liability (TPL).” Refer to the Entering Other Insurance or Medicare Crossover Information Quick Guide for more information. Health First Colorado should always be the payer of last resort. You cannot bill members for copays or deductibles assessed by third-party resources. You cannot bill members for the difference between commercial health insurance payments and the billed charges when Health First Colorado does not make an additional payment. |
Important Revalidation Requirements
Please review the Provider Revalidation Dates Spreadsheet posted on the Revalidation webpage to confirm revalidation dates. This file is updated weekly and can be used to verify active enrollment for any provider. All providers are reminded that they must revalidate enrollment every five years per federal mandate from the Centers for Medicare and Medicaid Services (CMS). All provider IDs must be actively enrolled and revalidated with Health First Colorado for claims to be paid per rule 42 CFR § 455.410(b). Claims will deny if you have not revalidated by the deadline. Do not re-enroll if you are past your revalidation date. The link for revalidation remains on the Provider Web Portal account associated with the provider for six months after the revalidation date. If the revalidation link is no longer available, contact the Provider Services Call Center for next steps. Do not start a new application. |
Community Health Workers (CHW) in Medicaid: Postponed
With the state budget crisis, the governor extended and amended Executive Order D25 014 on October 31, 2025, making additional State Fiscal Year (SFY) 2025-26 reductions, including an additional delay to the Health First Colorado CHW benefit until January 1, 2028. If you have any questions, please email hcpf_chw_benefit@state.co.us. |
HCPF Provider Web Portal Login Reminders: User Inactivity and Timeouts
The HCPF Provider Web Portal allows up to 15 minutes of inactivity. If left idle for 15 minutes, the system will automatically log you out. To regain access, you may immediately return to the login page and enter your credentials. If you have multiple attempts with the wrong password, you may become temporarily locked out. If this happens, your account will automatically unlock after about 15 minutes, and you can try to log in again with the correct password. Learn more here. |
Interoperability Changes Beginning in January 2026
Several requirements set forth in the Centers for Medicare & Medicaid Services (CMS) Interoperability and Prior Authorization Rule are being implemented as required. The most notable changes are:
-
Pend for additional information will be reduced from 10 business days to seven calendar days.
-
Additional pends on the same PAR will not be extended. All information requested in the initial pend must be supplied or the PAR will result in a technical denial.
-
PARs submitted as expedited: no pends or requests for information will be allowed so as to comply with the rules’ requirement of three calendar days.
Please ensure all documentation is included with the initial PAR submission. These changes are required for Acentra Health Inc. and HCPF to be compliant with the Interoperability Turnaround Time Requirements. These changes will facilitate a faster turnaround time for PARs overall and decrease administrative burden for all parties once implemented. Learn more here. |
Preferred Drug List Status and Criteria Changes: Humira (Adalimumab) & Mounjaro (Tirzepatide)
Effective January 1, 2026:
-
Humira will be changed to non-preferred status on the Preferred Drug List (PDL). Current utilizers will need prior authorization to continue using Humira after this time. New adalimumab biosimilars will be available as preferred when this change occurs.
-
Preferred adalimumab products will include Yuflyma (adalimumab-AATY) syringe and auto injector, Adalimumab-AATY syringe and pen, Adalimumab-ADBM pen, Adalimumab-AACF syringe, Amjevita (adalimumab-ATTO) syringe and autoinjector and Cyltezo (adalimumab-ADBM) pen and syringe. Learn more here, refer to the PDL, or call Prime Therapeutics at 800-424-5725.
-
Prior authorization requests for members currently stabilized on Mounjaro (tirzepatide) 7.5 mg, 10 mg, 12.5 mg, or 15 mg product strengths may receive approval for one (1) year to allow for continuation of therapy with the prescribed Mounjaro (tirzepatide) product strength. Prior authorization requests occurring on or after this effective date for all other non-preferred products in the “GLP-1 Analogues” PDL drug class will be subject to meeting non-preferred drug criteria listed for the requested product on the PDL.
|
News from Colorado Access |
|
|
Colorado Access Claims Timely Filing Changing to 365 Days
Effective January 1, 2026, Colorado Access will extend the timely filing limit for original claims submission to 365 days from the date of service, starting with dates of service January 1, 2026. This applies to all Medicaid and CHP+ claims: When Colorado Access is the secondary payer, timely filing is 120 days from the date of the primary payer EOP. Corrected claims must be submitted 120 days from the date of the COA EOP (payment date). Provider carrier disputes (claim appeals) must be filed 60 days from the date of the COA EOP (payment date). |
Colorado Access Address Change
As of January 5, 2026, we will have a new physical address/office:
Colorado Access
Access Management Services
4643 South Ulster Street
Suite 700
Denver, CO 80237
The address for mailing claims or for provider carrier disputes (claim appeals) will not change, but it is preferred to submit claims electronically via a clearinghouse and provider carrier disputes in the Colorado Access provider portal. |
Online Directory
Is your information correct in our online directory where members search for care? Please go to our online directory, search for yourself, and check that your data is accurate. Use the form at the top of the page to report any discrepancies or email updates to providerdatamaintenance@coaccess.com. |
Trading Partner Agreement Required for Third-Party Billing Communications
As a reminder, we cannot release protected health information (PHI) – such as claims data, vouchers, or copies of contracts – to third-party billers or consultants without a valid Trading Partner Agreement on file. This agreement must be established between the provider and their third-party representative. We also require for you to email compliance@coaccess.com to authorize the third-party billing company to access member information on your behalf. This email should also include what information you’re allowing us to disclose.
You should be included in all communications involving third-party billers or consultants when PHI is involved. Our contracting and compliance teams are working tougher to ensure these agreements are requested, filed, and honored. We will share more detailed guidance in the provider manual and other future communications. |
Credentialing and Recredentialing Process Change
During this process, you have the right to:
-
Review information submitted to support your credentialing application
-
Correct erroneous information
-
Get the status of your credentialing or recredentialing application, upon request
If you have any questions, please email credentialing@coaccess.com. |
Clinical Practice Guidelines
We adopt clinical practice guidelines that are known to be effective in improving health outcomes to ensure adequate informational support for network providers and members. These guidelines include topics that relate to well-child care, perinatal, prenatal, and postpartum care for women, and conditions related to persons with a disability or special health care needs. We revised and updated these clinical practice guidelines during a recent review by a cohort of medical directors. You can find these clinical practice guidelines on our website. These guidelines are available to providers, members, and other interested parties at no cost. If you have any questions or have a suggestion for a clinical practice guideline or resource, please email us at qualityimprovement@coaccess.com. |
|
|
|
