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CO HCPF Lactation Support Services Billing Manual — Provider Qualifications and Enrollment

ProviderQualificationsandEnrollment

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

ProvidersmustbeenrolledasHealthFirstColoradoprovidersto:

TreataHealthFirstColoradomember

SubmitclaimsforpaymenttoHealthFirstColorado

VisittheProviderEnrollmentwebpageifinterestedinbecomingaHealthFirstColoradoprovider.

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LactationSupportServicesmayonlybeprovidedbyenrolledindividualproviderswithtraininginadvancedlactationsupport.Providersmaynotbillforservicesprovidedbyun-enrolledproviders,suchassupervisedinternsorpersonsundergoingtrainingtobecomeaCertifiedLactationEducator(CLE),CertifiedLactationCounselor(CLC),orInternationalBoard-CertifiedLactationConsultant(IBCLC).

Thefollowingenrolledprovidertypes(PT)mayprovideLactationSupportServices:

InternationalBoard-CertifiedLactationConsultant(IBCLC)–PT70

CertifiedLactationCounselor(CLC)-PT71

CertifiedLactationEducator(CLE)-PT71

Thefollowingenrolledprovidertypes(PT)mayprovideLactationSupportServicesifitiswithintheirscopeofpracticeaccordingtostatelicensingrequirementsandlawsandtheproviderhastraininginadvancedlactationsupport:

CertifiedProfessionalMidwife(CPM)/DirectEntryMidwife(DEM)-PT69

CertifiedMidwife(CM)-PT80

CertifiedNurseMidwife(CNM)-PT22

LicensedPhysician(MD)–PT05

LicensedOsteopath(DO)-PT26

LicensedPhysicianAssistant(PA)–PT39

LicensedAdvancedPracticeNurse(APN)–PT41

LicensedRegisteredNurse(RN)–PT24(enrolledasaNon-PhysicianPractitioner-Individual)

CertifiedRegisteredNurseAnesthetist(CRNA)–PT40

OccupationalTherapist(OT)–PT28

SpeechTherapist(SLP)–PT27

ProviderswhoarecurrentlyenrolledwiththeDepartmentasoneoftheprovidertypeslistedabovemayrenderLactationSupportServicesundertheirexistingproviderenrollment.

ProvidersmustmaintainanactivelactationcertificationandsubmitdocumentationofcurrentcertificationthroughtheProviderWebPortal.Acceptablecertificationsincludethefollowing:

CertifiedInternationalBoard-CertifiedLactationConsultant(IBCLC)withcurrentcertificationbytheInternationalBoardofLactationConsultantExaminers(IBLCE)

CertifiedLactationCounselor(CLC)withcurrentcertificationbytheAcademyofLactationPolicyandPractice,Inc.(ALPP)

CertifiedLactationEducator(CLE)withcurrentcertificationbytheChildbirthandPostpartumProfessionalAssociation(CAPPA).

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TheonlyfacilityprovidertypethatmaybillforLactationSupportServicesis:

Supply–PT14

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Whenclaimsaresubmittedusingasupplierasthebillingprovider,therenderingprovider’sNationalProviderIdentifier(NPI)listedontheclaimmustbetheindividualproviderwhorenderedtheservice.Therenderingproviderdoesnotneedtobeformallyaffiliatedwiththegroupinorderfortheclaimtobeprocessed.

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TheonlygroupprovidertypesthatmaybillforLactationSupportServicesare:

FederallyQualifiedHealthCenter(FQHC)–PT32

RuralHealthClinic(RHC)–PT45

IndianHealthServices(IHS)–PT61

Clinic–PT16

Non-PhysicianPractitionerGroup–PT25

Lactation/DoulaProfessionalGroup–PT72

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RefertotheFederallyQualifiedHealthCenter(FQHC)/RuralHealthClinic(RHC)billingmanualfordetailsregardingbillingLactationSupportServicesinanFQHC/RHCsetting.LactationSupportServicesprovidedbyanemployeeatanFQHC/RHCsitearebilledaspartoftheencounterratefortheFQHC/RHCandmayresultinapaymentwhendeliveredbyaproviderincludedintheFQHC/RHCvisitdefinition(10CCR8.700&8.740).LactationSupportServicesarenotbilledseparatelyonprofessionalclaimforms(CMS1500).LactationSupportServicesprovidedbyanemployeeatanFQHC/RHCsitethatarenotincludedintheFQHC/RHCvisitdefinitionshouldbeincludedintheFQHC/RHCcostreport.LactationsupportserviceproviderswhoprovideLactationSupportServicesataFQHCorRHCbutarenotemployedbytheFQHC/RHCcanbillforservicesseparatelyonaprofessionalclaimform(CMS1500)andusetheapplicablePlaceofServicecodes.TheseclaimsarereimbursedattheHealthFirstColoradoFeeSchedulerate.

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RefertotheIndianHealthServices(IHS)billingmanualfordetailsregardingbillingLactationSupportServicesinanoutpatientsetting.LactationSupportServicesprovidedatanIHSsitearebilledperencounteraspartoftheall-inclusiverate.Theyarenotbilledseparatelyonprofessionalclaimforms(CMS1500).BacktoTop

WhenclaimsaresubmittedusingClinicsandNon-PhysicianPractitionerGroupsasthebillingprovider,therenderingprovider’sNationalProviderIdentifier(NPI)listedontheclaimmustbetheindividualproviderwhorenderedtheservice.Therenderingprovidermustbeformallyaffiliatedwiththegroupinorderfortheclaimtobeprocessed.

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WhenclaimsaresubmittedusingtheLactation/DoulaProfessionalGroupasthebillingprovider,therenderingprovider’sNPIlistedontheclaimmustbetheindividualproviderwhorenderedtheservice.Therenderingprovidermustbeformallyaffiliatedwiththegroupinorderfortheclaimtobeprocessed.

ALactation/DoulaProfessionalGroupconsistsofanyofthefollowingprofessionalswhoareenrolledwiththeDepartmentasapprovedproviders:

InternationalBoard-CertifiedLactationConsultant(IBCLC)–PT70

CertifiedLactationCounselor–PT71

CertifiedLactationEducator–PT71

Doula–PT79

Thisbillingprovidertypemusthaveatleastone(1)IBCLCorDoulaaffiliatedwiththegroup.

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IndividualprovidersmaychoosetobetheirownbillingproviderforLactationSupportServices.ThefollowinglistofproviderscanhavebillingstatuswhenenrollingwithHealthFirstColorado:

InternationalBoard-CertifiedLactationConsultant(IBCLC)–PT70

CertifiedMidwife(CM)–PT80

CertifiedNurseMidwife(CNM)–PT22

LicensedPhysician(MD)–PT05

LicensedOsteopath(DO)-PT26

LicensedAdvancedPracticeNurse(APN)–PT41

CertifiedRegisteredNurseAnesthetist(CRNA)–PT40

OccupationalTherapist(OT)–PT28

SpeechTherapist(SLP)–PT27

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EnrolledDoulaproviderswhomeetIBCLC,CLCorCLEqualificationsper10C.C.R.2505-108.732.9mayprovidelactationsupportwithoutseparatePT70or71enrollment.

DoulaprovidersarerequiredtosubmitacopyoftheircurrentlactationcertificationtotheDepartmentforverificationpriortorenderingorbillingforLactationSupportServices.

EnrolleddoulaprovidersarerequiredtosubmitacopyoftheircurrentcertificationthroughtheProviderWebPortalasoneofthefollowing:

InternationalBoard-CertifiedLactationConsultant(IBCLC)withcurrentcertificationbytheInternationalBoardofLactationConsultantExaminers(IBLCE)

CertifiedLactationCounselor(CLC)withcurrentcertificationbytheAcademyofLactationPolicyandPractice,Inc.(ALPP)

CertifiedLactationEducator(CLE)withcurrentcertificationbytheChildbirthandPostpartumProfessionalAssociation(CAPPA)

Thisverificationprocessensurescompliancewithprogramstandardsandprotectscontinuedaccesstoreimbursement.ProviderswhodonotcompletethisstepwillbesubjecttoenforcementactionsinaccordancewithSection25.5-4-301,C.R.S.,and10C.C.R.2505-10,Section8.076.

EnrolledLactationSupportServiceproviders(IBCLC,CLC,orCLE)whomeetdoulaqualificationsper10C.C.R.2505-108.734.4mayprovidedoulaserviceswithoutseparateprovidertype79enrollment.RefertotheDoulabillingmanualforfurtherguidance.

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: 5c698891fb15234d6dd2780e4e72e4deae443bbe34cf75f8b18011c2eda25f26

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