CO · guidance
CO HCPF Gender-Affirming Care Billing Manual — General Billing Information
GeneralBillingInformation
RefertotheGeneralProviderInformationManuallocatedontheBillingManualswebpageforgeneralbillinginformation.
BacktoTop
Manyproceduresthatarerestrictedtoamember'sassignedsexatbirthwillstillbemedicallynecessaryafterlegallychangingtheirgender.Ifagender-specificprocedureconflictswiththemember'sidentifiedgenderintheColoradoBenefitsManagementSystem(CBMS),pleasefollowthebillingguidancebelow:
CMS-1500/837PClaims:EntertheKXmodifierontheappropriatelineitems.
UB-04/837IClaims:Providersshouldenterconditioncode45toindicateaprocedureismedicallynecessarydespiteagenderconflict.
BacktoTop
Allpriorauthorizationrequestsmustprovidedocumentationdemonstratingthattheapplicablerequirementsin10CCR2505-108.735.4havebeenmet.Priorauthorizationrequestsforhormonetherapyservicesmustbesubmittedinaccordancewiththerequirementsin10CCR2505-108.800.7.
Forallcoveredservices,generalrequirementsforpriorauthorizationrequestsinclude:
Memberhasaclinicaldiagnosisofgenderdysphoria
Requestedserviceismedicallynecessary,asdefinedinsection8.076.1.8
Anyco-existingphysicalandbehavioralhealthconditionsdonotinterferewithdiagnosticclarityorcapacitytoconsent,andassociatedrisksandbenefitshavebeendiscussed
Memberhasgiveninformedconsentfortheservice
SubjecttotheexceptionsinC.R.S.§13-22-103,ifmemberisunder18yearsofage,member'sparent(s)orlegalguardianhasgiveninformedconsentfortheservice
Forhormonetherapyservices,inadditiontotheabovegeneralrequirements,themember'shealthcareprovidershallprovideanyinformationrequestedbytheFiscalAgentincluding,butnotlimitedto:
Membername,HealthFirstColoradoidentificationnumber,andbirthdate
Nameofthedrug(s)requested
Strengthandquantityofdrug(s)requested
Prescriber'snameandmedicallicensenumber,DrugEnforcementAdministrationnumber,orNationalProviderIdentifier
Forsurgicalprocedures,inadditiontotheabovegeneralrequirements,priorauthorizationrequestsmustprovidedocumentationdemonstratingthatthemember:
Is18yearsofageorolder
Thisrequirementdoesnotapplytomastectomysurgeries.
12continuousmonthsofhormonetherapyarerequiredformammoplasty,unlesshormonetherapyisnotclinicallyindicatedorisinconsistentwiththeclient’sdesires,goals,orexpressionsofgender-identity.
Understandsthepotentialeffectofthegender-affirmingsurgeryonfertility
BacktoTop
Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
53d7d01824553c90f8c3c1e00e6c41218619e2ee1f4ce5bddcb1d1b4f8fd9439
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.