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CO HCPF Inpatient/Outpatient (IP/OP) Billing Manual — Hospital Specialty Drug Policy

HospitalSpecialtyDrugPolicy

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

PaymentsforcertainHospitalSpecialtyDrugsarecarvedoutoftheEnhancedAmbulatoryPatientGroup(EAPG)methodologyforOutpatientHospitalclaimswiththefirstdateofserviceonorafterAugust11,2018.

EffectiveJanuary1,2024,certainHospitalSpecialtyDrugsmaybeadministeredintheInpatientsettingandbereimbursedoutsideoftheAll-PatientRefinedDiagnosisRelatedGroup(APR-DRG)methodologywhenbilledonanOutpatientHospitalclaim.Reimbursementisbasedonapercentageofacquisitioncost.

RefertoAppendixZlocatedontheBillingManualswebpageundertheAppendicesdrop-downforthecodesforthesedrugsandtheeffectivedatesfortheircarveout.

AnapprovedmemberspecificpriorauthorizationisrequiredpriortoadministrationofthePhysician-AdministeredDrug(PAD).

ThefollowingprocessesmustbecompletedpriortoadministrationoftheHospitalSpecialtyDrug:

AllHospitalSpecialtyDrugsrequiringaPAarelistedonAppendixZ

HospitalSpecialtyDrugpolicyandprocedurescanbefoundonthePhysician-AdministeredDrugswebpage

Retroactiveauthorizationisnotusuallyconsidered

AnapprovedPAonfiledoesnotguaranteepayment

Thefollowingbillingprocessesmustbecompletedafteradministration:

Outpatientclaimisbilled

CostperNDCunitmultipliedbythenumberofNDCunitsadministeredtothemember

ClaimwillbedeniediftheamountbilleddoesnotequalthenumberofNDCunitsbilledontheclaimmultipliedbytheinvoicedollaramountperNDCunitadministered

TheNDCoftheHospitalSpecialtyDrugadministeredtothemembermustbebilledontheline

TheamountofdrugadministeredtothemembermustbebilledontheclaimlineinbothHCPCSandNDCunits

Claimwillbedeniedifnoinvoiceisattached

AllPAD,340BandIP/OPpoliciesapply

TheOPclaimmustbesubmittedaftertheaffiliatedIPclaimispaid

Modifier“SE”mustbebilledontheclaimline

Noadditionalrevenueorprocedurecodesmaybebilledontheclaim

OutpatientclaimdateofservicemustbethedateofadministrationandwithintheaffiliatedinpatientclaimFromDateofService(FDOS)andToDateofService(TDOS)

CostperNDCunitmultipliedbythenumberofNDCunitsadministeredtothemember

ClaimwillbedeniedifamountbilleddoesnotequalthenumberofNDCunitsbilledontheclaimmultipliedbytheinvoicedollaramountperNDCunitadministered

TheNDCoftheHospitalSpecialtyDrugadministeredtothemembermustbebilledontheline

TheamountofdrugadministeredtothemembermustbebilledontheclaimlineinbothHCPCSandNDCunits

Claimwillbedeniedifnoinvoiceisattached

340BinventorycannotbeusedwhenaHospitalSpecialtyDrugisadministeredinanInpatientsettingandbilledonanOutpatientclaim.

RefertothePhysician-AdministeredDrugs(PAD)webpageforpolicyandprocedures.

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: ad73aedefb2b5f26eb8d850859e44d6ae5f1bebce70227bcd9cd2213e24bd589

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