JANUARY 2026

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

Health First Colorado Behavioral Health Updates

Discontinuation of Provider Specialty Type 64/477

Provider Type and Specialty 64/477 No Longer Valid Please be advised that Specialty 477 - Substance Use Disorder - Clinics is no longer a valid specialty for Provider Type 64 - Substance Use Disorder (SUD) Continuum as of December 31, 2025. Claims submitted with this provider/specialty type combo will deny.

• Specialty 477 (Substance Use Disorder – Clinics) is no longer valid as of December 31, 2025.

• To keep your Provider Type 64 enrollment active, you must have a specialty that specifies an American Society of Addiction Medicine (ASAM) level.

• Refer to the specific specialties on the Find Your Provider Type webpage. for the list of valid specialties. • If your enrollment already includes an ASAM-designated specialty, you don’t need to take any action.

• Specialty 477 was automatically removed after December 31, 2025.

• If your Provider Type 64 enrollment had no other specialty attached by December 31, 2025, your enrollment will be terminated.

If you have any questions about this, please email hcpf_sudbenefits@state.co.us.

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?

• About abortion policy: Email Devinne Parsons at devinne.parsons@state.co.us.

• About the family planning expansion groups: Email Amanda Carlson at amanda.carlson@state.co.us.

• About CHP+: Email Amy Ryan at amy.ryan@state.co.us.

• About provider enrollment: Call the Provider Services Call Center.

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 should sign and submit this attestation to your RAE(s) by January 1 (or ASAP), indicating that all peer support professionals delivering behavioral health services to Medicaid members are either certified or are in the process of becoming certified.

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.

New Regional Accountable Entity (RAE) Network Management Provider Memo

This memo details how the RAEs will focus provider recruitment and network expansion efforts based on regional need and quality of care. RAEs will prioritize providers that fill network gaps and are able to demonstrate quality outcomes when building their networks. Read the memo here, and if you have any questions, email hcpf_bhbenefits@state.co.us.

News From HCPF

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:

• Tuesday, 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.

File Naming Requirements for X12 Transactions

As of January 7, 2026, the name of X12 files, such as an 835 electronic remittance advise or a 271 eligibility response, have changed. Please review details here and start implementing the new file name standards immediately to avoid any issues. Make sure to contact your trading partner to confirm they are using the new naming standards.

Reports will only be available for retrieval for 15 days. Please ensure your vendor has adjusted their system so they can retrieve reports before they expire. You may also get a copy of the Remittance Advice on the the Provider Web Portal if you are unable to obtain a copy from your vendor. If you have any questions, please contact the Provider Services Call Center.

Load Letters for Claims Submissions Outside Timely Filing Period

A load letter is not intended to provide proof of eligibility; you must verify eligibility and not rely on member notification. Load letters allow you to submit claims outside of the 365-day timely filing period if the member was retroactively enrolled. Load letters will only be granted for cases where the member’s eligibility was backdated. If a member’s eligibility has been updated within 365 days from the date of service, you can resubmit the claim without a load letter.

Member Billing

You are responsible for determining Health First Colorado coverage before rendering services. Members cannot be billed for services covered by Health First Colorado. Payment may be collected from or billed to a Health First Colorado member only if:

• They are not enrolled in Health First Colorado on the date of service

• Service is not covered by Health First Colorado, and the member was made aware prior to receiving the service. You must enter into a written agreement with the member under which they agree to pay for items and services that are non-reimbursable by Health First Colorado (C.R.S. § 25.5-4-301(1)(a)(I)).

  • If you have any questions about whether a service is covered by Health First Colorado, please contact the Provider Services Call Center.

Read more here about how to manage if a member has delayed or retroactive notification of eligibility, any denials of prior authorization requests, third-party liability balances, copays or deductibles, or claims denials.

Immunizations Updates and Reminders

All medically necessary immunizations are covered for all Health First Colorado members without cost sharing, including:

• A birth dose of the Hepatitis B vaccine

• The measles, mumps, rubella, and varicella (MMRV) combination vaccine for all children ages 1 through 12
  

Read more here (starting on page 23).

Telehealth Coverage

Recent changes to Medicare’s telehealth coverage do not change Health First Colorado’s telehealth coverage. For dually eligible members with full Health First Colorado benefits, services should continue to be submitted to Medicare before submitting to Health First Colorado, unless otherwise noted in the billing manual or HCPF rule. Health First Colorado will pay based on the Health First Colorado allowable amount for services not covered by Medicare but which are covered by Health First Colorado. Learn more here.

Continuous Glucose Monitor (CGM) Updates

As of November 1, 2025, CGMs are billed to the pharmacy benefits or as a professional claim. All professional claims submitted for CGM products and supplies must include the National Drug Code (NDC) of the product, the proper Healthcare Common Procedure Coding System (HCPCS) procedure code, and modifier combination when submitting a claim. The Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Billing Manual will be updated to contain a crosswalk of the CGM product, HCPCS and modifiers that must be used when submitting claims. B2600533 January 2026 Page 13 CGMs that do not have an NDC or a wholesale acquisition cost must be submitted as a professional claim and require Questionnaire 20 to be submitted with the prior authorization request (PAR) and to the claim. Questionnaire 20 can be found on the Provider Forms web page under the durable medical equipment, prosthetics, orthotics & supplies (DMEPOS) forms drop-down. A new prior authorization request (PAR) will be required for CGMs that are billed to the pharmacy benefit.

House Bill 21-1327: Physical Therapists Prescribing Medical Equipment

House Bill 24-1327 was passed during the 2024 legislative session to authorize a licensed physical therapist to directly recommend and prescribe durable medical equipment (DME) to a Health First Colorado member without requesting the prescription from a licensed physician. Learn more here, and if you have any questions, email Devinne Parsons at devinne.parsons@state.co.us.

Wheelchair Mounted Robotic Arms: Updated Policy

As of November 25, 2025, wheelchair mounted robotic arms are now reviewed case by case under HCPF’s medically necessity criteria (10 CCR 2505-10 8.076.8). These devices are generally considered experimental or investigational because available clinical evidence is insufficient to demonstrate clinically meaningful benefit, functional improvement or reduction in caregiver burden. Requests for coverage will typically be denied as not medically necessary unless you submit compelling, member-specific clinical evidence demonstrating that the device meets Colorado’s medical necessity criteria.

These devices may be covered for members under age 21 under Early and Periodic Screening, Diagnostic, and Treatment (ESPDT) requirements (42 U.S.C. § 1396d(r)) when medically necessary to correct or ameliorate a physical or mental condition, even when not otherwise covered for adults. Requests will be subject to prior authorization with individualized review. Learn more here, and email Alaina Kelley at alaina.kelley@state.co.us if you have any questions.

New Transitions of Care (TOC) Codes

As of January 1, 2026, there are new TOC codes (99495 and 99496). If you are an outpatient provider, you’ll be able to bill the TOC codes for follow-up visits within 14 days of discharge from inpatient or observation-level care. TOC services play a critical role in reducing preventable readmissions and improving continuity of care for members following hospital or facility discharge. Learn more here and here (starting on page 24).

Claims Submission Compliance

If you submit claims to a RAE or Managed Care Organiztion (MCO), including CHP+, you may need to take action to continue receiving reimbursement for providing covered services to Health First Colorado and CHP+ members. RAEs and MCOs will begin rejecting or denying claims on a rolling basis for providers who:

• Have used incorrect information during enrollment in the Medicaid Managed Information System (MMIS)

• Submit claims with information that does not match your National Provider Identifier (NPI) Provider Type and/or Taxonomy Codes in MMIS

You may resubmit claims to your RAE/MCO with information that matches MMIS or when you have corrected your information in MMIS. Learn more here and here. If you have questions about whether you may be impacted by these upcoming changes or need help making changes to your claims, contact your RAE/MCO.

Quarter 1 Rate Update 2026

The Physician Administered Drugs (PAD) rates for the first quarter for 2026 have been updated as of January 1, 2026.

News from Colorado Access

Colorado Access Address Change

As of January 5, 2026, we have moved to 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.

New Federal Childhood Vaccine Requirements

Dr. Bill Wright, chief medical officer at Colorado Access, released a statement in response to recent federal childhood vaccine schedule changes: 

“Recent, unprecedented action by the federal government to overhaul the U.S. childhood vaccine schedule will result in fewer recommended vaccinations and therefore expose more children to the risk of preventable diseases. Creating tiers makes it unclear as to which vaccines are safe and effective in preventing disease, causing additional confusion for families. 

All immunizations recommended by the Centers for Disease Control and Prevention (CDC) as of December 31, 2025, will continue to be fully covered by Health First Colorado (Colorado’s Medicaid program), Child Health Plan Plus (CHP+), and the Vaccines for Children program. Families may still choose to follow the 2025 vaccine schedule and will not have to pay for those vaccines out of pocket. I strongly encourage families to do so, as there is clear, well-documented evidence that vaccines are safe and effective.”

Read the full statement here.

Colorado Access Claims Timely Filing Changing to 365 Days

Effective January 1, 2026, Colorado Access extended 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 Colorado Access EOP (payment date). Provider carrier disputes (claim appeals) must be filed 60 days from the date of the Colorado Access EOP (payment date).

Update to Electronic Provider Add Forms

You must now be validated with the State of Colorado before submitting an add request. What’s changing:

• Attestation required: Submitters must confirm you have been validated with the State of Colorado when completing the add form.
  

• Form submission restriction: If attestation is not provided, the form cannot be submitted.

• Validation documentation: If a submitter attests to validation, but the State report does not confirm it, documentation will be required before you can be added to our systems.
  

  • In cases where the State report does not confirm validation, submitters will have five business days to provide documentation.

  • If documentation is not received within five business days, the request will be canceled.

Provide Behavioral Health Services in Another Language - Get Higher Reimbursements!

Did you know you can earn enhanced reimbursements for providing behavioral health services in languages other than English? Eligible outpatient providers can bill a 10% increased rate on direct outpatient behavioral health services offered in a member's identified language. Federally qualified health centers, community mental health centers, inpatient hospitals, and residential or bed-based services do not qualify for this incentive.

This incentive is the first of its kind, and it recognizes the additional effort, training, and expertise needed to deliver culturally and linguistically appropriate care.

This program is exclusive to us, Colorado Access, and does not apply to any other RAE services that use an interpreter. Please note that this program is only available to contracted outpatient behavioral health service providers. Talk to your assigned provider network manager to learn more.

EPSDT Training Update

Our biannual EPSDT training update is now available in our Learning Management System (LMS). The EPSDT program is a vital component of preventive care in Medicaid. This training helps you stay current with guidelines and best practices related to:

• Regular screenings and well-child visits

• Vaccinations and developmental assessments

• Early identification and treatment of health conditions

We encourage all network providers to take this training to remain aligned with program expectations and to continue delivering comprehensive, child-focused care. It will be refreshed every July and January. Access the training here. If you have any questions, please email providernetworkservices@coaccess.com.

Authorizing Third-Party Billing & Trading Partner Agreement (TPA) Requirements

If your practice uses a third-party billing company or other vendors to handle claims, remittances, or member information, we require written authorization and a TPA to ensure your billing company can access necessary information while keeping your practice HIPAA-compliant and protecting member data.

A third-party billing authorization is your written consent that allows us to share your provider and/or member information with a billing company or other third-party vendor that you use for billing purposes. We require written authorization by any provider whose information will be accessed by a third-party to document your consent to allow us to share your provider and/or member information with a third-party billing vendor.

Every third-party billing company/vendor must have a completed TPA on file with us. You only need to complete one per company/vendor (not per provider). A TPA is a formal agreement between us and the billing company/vendor and is valid only after we countersign it. This document must be issued by our compliance team. You can request it by emailing compliance@coaccess.com.

You must submit a written authorization email or letter to compliance@coaccess.com to authorize the third-party billing company/vendor access to both their member information on the provider’s behalf and provider information. Make sure to include:

• Provider name

• Name of the third-party billing company/vendor

• Confirmation of the relationship between the provider and the third-party billing company/vendor

• Description of the billing information that may be shared

The third-party billing company/vendor must have a completed TPA on file, and the TPA must be approved and countersigned by our executive leadership to be valid. Authorization remains valid until it’s revoked by the provider, or the provider and third-party billing company/vendor relationship ends. If your billing arrangement changes, notify us immediately in writing at compliance@coaccess.com.

If you have any questions, email compliance@coaccess.com.