CO · guidance
CO HCPF Outpatient Imaging and Radiology Billing Manual — Billing Information
BillingInformation
HealthFirstColoradocomplieswithFederalMedicaidRegulationsin42CFR455.410(b)whichprovidethatMedicaidmustrequireallorderingorreferringphysiciansorotherprofessionalsprovidingservicesbeenrolledasproviders,and42CFR455.440,whichprovidesthatHealthFirstColoradomustrequireallclaimsforthepaymentofitemsandservicesthatwereordered,referred,andprescribedtoincludetheNationalProviderIdentifier(NPI)oftheordering,referringorprescribingphysicianorotherprofessional.
EffectiveJuly1,2022,theDepartmentwillenforcethefederalrequirement42CFR§455.440thatclaimsforallImagingandRadiologyservices,renderedbyanytypeofprovider,containtheNPIoftheproviderwhoorderedtheservices,andthattheNPIisactivelyenrolledwithHealthFirstColorado.TheorderingNPImaybethatofthequalifiedprovideroverseeingthemember’scare,forexampleasisthecasewithmaternityservices.
ProvidersareinstructedtoplacetheNPIoftheorderingproviderintothefollowinglocationsforclaimsubmission:
ProfessionalClaims
Paperclaimsusefield17.b
Electronicsubmissionsuseloop2420ewithqualifierDK.
ImagingandRadiologyservicescanbeorderedbyeitheraphysician,physicianassistant,advancedpracticenurseorpodiatrist.TheorderingprovidermustalsobeactivelyenrolledwithHealthFirstColorado.Iftheseconditionsarenotmettheclaimwillbedenied.
VisittheOPRClaimIdentifierProjectwebpageforfurtherinformationonthisproject.
RefertotheGeneralProviderInformationManuallocatedontheBillingManualswebpageforgeneralbillinginformation.
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Theprovider'sadherencetotheapplicationofpoliciesinthismanualismonitoredthrougheitherpost-paymentreviewofclaimsbytheDepartment,orcomputerauditsoreditsofclaims.Whencomputerauditsoreditsfailtofunctionproperly,theapplicationofpoliciesinthismanualremainineffect.Therefore,allclaimsshallbesubjecttoreviewbytheDepartment.
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Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
72873583423bfc496dfad0ccffd2290e814f0aef8d8c09dba409cb1d4227f2d3
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