CO · guidance
CO HCPF Outpatient Imaging and Radiology Billing Manual — Payment for Covered Services/Procedures
PaymentforCoveredServices/Procedures
RegardlessofwhetherHealthFirstColoradohasactuallyreimbursedtheprovider,billingmembersforcoveredproceduresisstrictlyprohibited.Balancebillingisprohibited.Ifreimbursementismade,providersmustacceptthispaymentaspaymentinfull.RefertoProgramRule8.012.TheprovidermayonlybillthememberforproceduresnotcoveredbyHealthFirstColorado.
(1)(a)(I)Exceptasprovidedinsection25.5-4-302andsubparagraph(III)ofthisparagraph(a),norecipientorestateoftherecipientshallbeliableforthecostorthecostremainingafterpaymentbyMedicaid,Medicare,oraprivateinsurerofmedicalbenefitsauthorizedbyTitleXIXofthesocialsecurityact,bythistitle,orbyrulespromulgatedbythestateboard,whichbenefitsarerenderedtotherecipientbyaproviderofmedicalservicesauthorizedtorendersuchserviceinthestateofColorado,exceptthosecontributionsrequiredpursuanttosection25.5-4-209(1).However,arecipientmayenterintoadocumentedagreementwithaproviderunderwhichtherecipientagreestopayforitemsorservicesthatarenonreimbursableunderthemedicalassistanceprogram.Underthesecircumstances,arecipientisliableforthecostofsuchservicesanditems.
Technical/lackofinformation(LOI)denialdoesnotmeanthoseproceduresarenotcovered.MembersmaynotbebilledforproceduresdeniedforLOI.
Procedurespartiallyapprovedarestillconsideredcoveredprocedures.Membersmaynotbebilledforthedeniedportionoftherequest.
Procedurestotallydeniedfornotmeetingmedicalnecessitycriteriaareconsiderednon-coveredservices.
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Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
124ae4ccdb460cdda75c97fabfa55c4db426a9a46e6257e7ca86b43af8f5879b
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