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Health First Colorado covers outpatient imaging and radiology benefits. These services are provided by outpatient hospitals, x-ray facilities, and medical clinics.
All enrolled members have these services covered for medically necessary conditions.
Reference the billing and policy manual for complete details.
A variety of CPT billing codes are available for billing. These include but are not limited to:
As a Health First Colorado (Colorado's Medicaid Program) provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance – it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.
The enrollment process is online. See Why Become a Provider?
Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.
Outpatient imaging and radiology services are reimbursed in two ways, depending on how the provider is enrolled.
If the provider is an outpatient hospital their services will be reimbursed with the EAPG method.
If the provider is an x-ray facility, clinic, or radiology practice, services are reimbursed according to the current Health First Colorado Fee Schedule. Reimbursement rates will vary by CPT code reported. The fee schedule shows the maximum allowed reimbursement for each CPT code. Submitted claims will be reimbursed according to ‘lesser-of’ pricing logic. This means that the line item will reimburse either at submitted charges or the fee schedule rate, whichever is lesser.
Providers must first enroll into the program to submit claims. Once they are enrolled, providers may submit claims directly by logging into the Provider Web Portal. Claims may be submitted by billing agencies on behalf of the provider.
Resources for enrollment and billing may be found at Provider Resources.
APR-DRG hospital payment.
Co-pays for outpatient imaging and radiology services will vary by setting, and will depend on whether other services are performed in conjunction with the imaging. Providers should always refer to the provider web portal to check a member’s co-pay eligibility prior to rendering services. Detailed information can be found at HealthFirstColorado.com.
Non-emergent CT, MRI, and PET scans require Prior Authorization regardless of setting. The authorization process begins at the ColoradoPAR website.
Outpatient Imaging and Radiology Billing and Policy Manual
This manual is applicable to both CMS1500 (837p) and UB-04 (837i) claim types.
All Medicaid Rules, Regulations, and Statutes apply to the administration of the Colorado Medical Assistance Program at large, which providers are required to follow. The following are specific to the outpatient imaging and radiology benefit: