CO · guidance
CO HCPF Physician-Administered Drugs (PAD) Billing Manual — PAD FAQs
PADFAQs
Yes.ManufacturerswhowishtheirdrugtobeeligibleforcoveragebyHealthFirstColoradomustenterintoarebateagreementwiththeCentersforMedicare&MedicaidServices(CMS).
RefertoAppendixX:HCPCS/NDCCrosswalkforBillingPAD.
No.TheNDCsubmittedtoHealthFirstColoradomustbetheactualNDCnumberonthepackageorcontainerfromwhichthemedicationwasadministered.ItisconsideredafraudulentbillingpracticetobillusinganNDCotherthantheoneadministered.
TheNDCisfoundonthedrugcontainer(i.e.,vial,bottle,ortube).TheNDCsubmittedtoHealthFirstColoradomustbetheactualNDCnumberonthepackageorvialfromwhichthemedicationwasadministered.
TheNDCsubmittedontheclaimmustbein11-digitformat.Informationonconvertingto11-digitformattingcanbefoundintheClaimSubmissionRequirementssectionofthismanual.
TheonlyexceptionisifthevialispartofakitthatcontainsmultipleproductsneededforadministrationofthePAD.Inthiscase,usetheNDConthekit.
Yes,thisrequirementappliestoalldrugproductsadministeredbyaclinicianinoutpatientsettings,includingphysician'soffice,clinic,hospitalandanyotheroutpatientsetting.TheonlyexceptionstotheNDCrequirementareinstitutionalinpatientclaims.
Yes,someradiopharmaceuticals,contrastmedia,devices,andvaccines/immunizationsmayrequireavalidHCPCS/NDCcombinations,eventhoughtheyarenotconsideredPADs.RefertoAppendixX:HCPCS/NDCCrosswalkforBillingPADforalistoftheseproducts.
RefertoAppendixX:HCPCS/NDCCrosswalkforBillingPADorcontacttheProviderServicesCallCenter.
HCPCScode
HCPCSdescription
NDCin11-digitformat
NDCdescription
ShouldtheHCPCS/NDCcombinationbeaddedtotheCrosswalk,itwillbeconsideredacoveredbenefit.
No.MedicarePartBCrossoverclaimsrequireNDCstobebilledwiththeHCPCScodes.
Yes.Although340Bpurchasedclaimsarenoteligiblefordrugrebates,HealthFirstColoradorequiresthesubmissionofthisdata.
Refertothe340BPolicyandProceduresManuallocatedontheBillingManualswebpageunderthePharmacydrop-down.
No.Theseprocessesarereferredtoas"white-bagging"and"brown-bagging",respectivelyandareusuallynotallowedundertheHealthFirstColoradoPADpolicy.
RefertothePharmacyResourceswebpageandthemostcurrentversionofAppendixPforadditionalinformation.
FormembershavingbothHealthFirstColoradoandMedicare(dual-eligible),providersmaybillforwasteddrugonasecondlinewiththeJWmodifieronMedicarePartBCrossoverclaims.
VisitthePADwebpage,whichincludesfrequentlyaskedquestions,priorauthorizationinformation,andlinkstoadditionalresources.
ContacttheProviderServicesCallCenter.
ContactColoradoPARforassistancewithorquestionsregardingallPADpriorauthorizations.
CommunicationisprovidedbytheDepartmentonaregularbasisviatheProviderNewswebpage,newsletters,emails,andmonthlybulletins;therefore,providersarestronglyencouragedtosignupforgeneralandspecificcommunicationtoensuretheystayuptodateonallissuedguidanceandreceiveallcommunicationfromtheDepartment.
Backtotop
Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
24d34b8fb22325fcaa4e2005f14f58b48f70e8f8bb6cc2d0e9529f111ea6ac6c
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