CO · guidance

CO HCPF Outpatient Imaging and Radiology Billing Manual — Prior Authorization Requirements and Information

PriorAuthorizationRequirementsandInformation

activein force · 2026-07-26 – presentas-observed

HealthFirstColoradorequiresalloutpatienthospitalsandfree-standingradiology/X-rayfacilitycenterstoobtainapriorauthorization(priorauthorizationrequest,PAR)formostnon-emergentCT,non-emergentMRI,andallPETscans.APARprecedesthesubmissionofaclaimandmustbeapprovedinadvanceoftheclaim.ProcedureswhichrequireaPARcannotbeclaimedforwithoutanapprovedPARonrecord.RefertotheDepartment'sFeeSchedulelocatedontheProviderRatesandFeeSchedulewebpageforalistofallprocedurecodeswhichrequireaPAR.

AllImagingandRadiologyPARsandrevisionsareprocessedbytheColoradoPARProgramandmustbesubmittedusingAtrezzo,theAcentraportal.PARssubmittedviafaxormailwillnotbeprocessed.ThesePARswillbereturnedtoprovidersviamail.ThisrequirementonlyimpactsPARssubmittedtotheColoradoPARProgram.

Toensureclaimsarequicklyandaccuratelyprocessed,allclaimsforprocedureswhichrequireaPARmust:

ContainthecorrectBillingProviderIDnumber.

ContainprocedurecodeswhichmatchthecorrespondingPARonrecord.

ContainmodifiercodeswhichmatchthecorrespondingPARonrecord.

ContacttheColoradoPARProgramorvisittheDepartment'sColoradoPARProgramwebpageformoreinformation.

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Ifaprocedureispriorauthorizedbutthedesiredtestwaschangedjustpriortothetimeoftheservice,theproviderisresponsibleforsubmittingaPARrevisionwithadequatedocumentationwithin48hoursofthedateofserviceforthePARtobeprocessedbytheColoradoPARProgram.PARrevisionscanonlybesubmittedusingAtrezzo.ContacttheColoradoPARProgramwithquestionsregardinghowtoprocessPARrevisions.

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TorequestaPARexception,contacttheColoradoPARProgramorvisittheDepartment'sColoradoPARProgramwebpage.

EmergencyoutpatientimagingandradiologyproceduresareexemptfromPARrequirements.Tomarkaclaimasemergency,checktheemergencyindicatorfield.

AllPETandSPECTscanproceduresrequirepriorauthorizationregardlessofwhetheremergencyisindicated.

APARisnotrequiredwhenMedicare,MedicareAdvantageplans,orprivateinsurancehasmadeprimarypaymentontheclaim.Ifthirdpartyliability(TPL)carriershavenotmadepaymentontheclaim,theservicemustbepriorauthorizedtoensureitmeetsmedicalnecessitystandardsoftheHealthFirstColoradoprogram.

PARsarenotrequiredofanyImagingandRadiologyprocedurefortheprofessionalcomponentiftheprocedurebillingissplitbetweencomponents.Thetechnicalcomponentstillrequirespriorauthorization.

TheDepartmentwillallowretroactiveauthorizationswhenamember'seligibilityisdeterminedafterthedatethattheserviceisperformed.Whenamember'seligibilityisdeterminedafterthedateofservice,thememberisissuedaLoadLetter.TheLoadLettermustbesubmittedwiththesupportingclinicaldocumentationforthePARforaretroactiverequesttobeprocessedbyColoradoPAR.

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IfthePARisdenied,contacttheColoradoPARProgramorvisittheDepartment'sColoradoPARProgramwebpage.

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Itistheprovider'sresponsibilitytomaintainclinicaldocumentationtosupportproceduresprovidedinthemember'sfileintheeventofanauditorretroactivereview.SubmittedPARswithoutminimallyrequiredinformationorwithmissingorinadequateclinicalinformationwillresultinalackofinformation(LOI)denial.

AllacceptedPARsarereviewedbytheauthorizingagency.Theauthorizingagencyapprovesordenies,byindividuallineitem,eachrequestedserviceorsupplylistedonthePAR.

PaperPARformsandcompletioninstructionsarelocatedontheProviderFormswebpage.Theymustbecompletedandsignedbythemember'sphysicianandsubmittedtotheauthorizingagencyforapproval.

ProvidersshouldnotrenderproceduresorsubmitclaimsforproceduresthatrequirepriorauthorizationbeforethePARisapproved.Aftertheauthorizingagencyhasreviewedtherequest,thePARstatusistransmittedtothefiscalagent'spriorapprovalsystem.

ThestatusoftherequestedproceduresisavailablethroughtheProviderWebPortal.Inaddition,afteraPARhasbeenreviewed,boththeproviderandthememberreceiveaPARresponseletterdetailingthestatusoftherequestedprocedures.Someproceduresmaybeapprovedandothersdenied.CheckthePARresponsecarefullyassomelineitemsmaybeapprovedandothersdenied.

ApprovalofaPARdoesnotguaranteeHealthFirstColoradoreimbursementanddoesnotserveasatimelyfilingwaiver.AuthorizationonlyassuresthattheapprovedserviceisamedicalnecessityandisconsideredaHealthFirstColoradocoveredbenefit.

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: 291cb5a623d9607470d4b321ff06f633ce8c16c84bcf5937d12d66337983aacb

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