CO · guidance

CO HCPF Physician-Administered Drugs (PAD) Billing Manual — PAD Prior Authorization Information

PADPriorAuthorizationInformation

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

EffectiveJanuary18,2022,aselectnumberofPADsaresubjecttopriorauthorization(PA)requirements.VisitthePADwebpageforallPADPApoliciesandprocedures.Providersmust:

SubmitaPARequest(PAR)totheutilizationmanagement(UM)vendorforanymemberreceivinganyofthePADslistedinAppendixY:Physician-AdministeredDrugMedicalBenefitPriorAuthorizationProceduresandCriteria,locatedonthePADwebpage.

EnsurethatanapprovedPAisonfilepriortoPADadministrationandthatthereisanapprovedPAonfileforeachofthePADsrequiringaPAwhichthememberreceives.

FollowallGeneralProviderandPADbillingpoliciesfoundintherespectivebillingmanualslocatedontheBillingManualswebpage.

ApprovalofaPARdoesnotguaranteeHealthFirstColoradopayment.

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WhensubmittingaPAR,providersmustrequestthetotalnumberofunitsappropriateandnecessaryforthecourseofthetreatmenttobecoveredbythePAandasindicatedforthespecifieddiagnosis.

Therequestedunitsshallnotincludewasteordiscardeddrugfromsingleormulti-usevialsnorshouldaPAberequestedforanyPADnotpurchaseddirectlybytheprovider.

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Retroactiveauthorizationsarenotusuallyallowed,withfewexceptionsduetoextenuatingcircumstances.

ExceptionsaregrantedonlywhentheproviderisabletodocumentthatappropriateactionwastakentomeetthesubmissionrequirementsandthattheproviderwaspreventedfromrequestingthePAastheresultofextenuating,unforeseen,anduncontrollablecircumstances.Requestsforretroactiveauthorizationmustcontainadetaileddescriptionandapplicabledocumentationofthecircumstancethatwasbeyondthecontroloftheproviderintherequestforretroactiveauthorization.

Office/clinicemployeenegligence,employerfailuretoprovidesufficient,well-trainedemployeesorfailuretoproperlymonitortheactivitiesofemployeesandagents(e.g.,billingservices)arenotconsideredextenuatingcircumstancesbeyondtheprovider'scontrol.Backtotop

WhensubmittingaPADPAR,theservicingprovideristhebillingprovider.Ifenteringtherendering/administeringproviderastheservicingprovider,theremaybeinstanceswheretherenderingprovidertypeisproducingaPARsubmissionerrorormayresultinadeniedclaim.Ensurethebillingprovider(typicallytheclinic/office)isenteredonthePARastheservicingprovidertosuccessfullysubmitthePARandtoavoidsubsequentPADclaimsprocessingissues.

ForanyapprovedPARonfileinwhichthebillingproviderwasnotenteredastheservicingprovider,thefollowingstepsmustbecompletedforthepertinentscenariotoensuretheinformationonthePARisaccurateandtoavoidPADclaimsprocessingissues:

SubmitanewPArequest.

PreviousPAwasapprovedwithincorrectproviderlistedastheservicingprovider

Yourrequesttoend-datethepreviousPAandincludethecaseID

FilearevisionrequestonthesubmittedPARinAtrezzo.

FollowtheinstructionsforHowtoMakeRevisionstoSubmittedRequest.

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WhenaPADlistedonAppendixYmeetscriteriaforalocalcoveragedetermination(LCD)and/oranationalcoveragedetermination(NCD)andisbilledtoMedicareasprimaryandHealthFirstColoradosecondary,noPAisneededandPARsubmissionisnotrequired.

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ProvidersmustsubmitaPARtoAcentraforanyPADlistedonAppendixYwhenamemberhasadditionalTPLhealthinsurancecoverage,otherthanMedicare.AcentrawillprocessaPARaccordingtothecriteriaonAppendixYandnotifytheproviderofthedeterminationperallPADPApolicyandprocedurerequirements.

Anyandalldeterminationlettersandclinicaldocumentation

AnoteoftheapprovalordenialmadebyTPL

AnyguidanceregardingPArequirementsrelatedtoCOBissuedpriortoMay1,2022,willnotbeconsideredandallmemberswithTPLwillrequireapriorauthorization.

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PaymentsforcertainHospitalSpecialtyDrugsarecarvedoutoftheEAPGmethodologyforOutpatientHospitalclaimswiththefirstdateofserviceonorafterAugust11,2018.

EffectiveJanuary1,2024,certainHospitalSpecialtyDrugsmaybeadministeredintheInpatientsettingandbereimbursedoutsideoftheAPR-DRGmethodologywhenbilledonanOutpatientHospitalclaim.Reimbursementisbasedonapercentageofacquisitioncost.

RefertoAppendixZlocatedontheBillingManualswebpageundertheAppendicesdrop-downforthecodesforthesedrugsandtheeffectivedatesfortheircarveout.

AnapprovedmemberspecificpriorauthorizationisrequiredpriortoadministrationofthePhysician-AdministeredDrug(PAD).

340BinventorycannotbeusedwhenaHospitalSpecialtyDrugisadministeredinanInpatientsettingandbilledonanOutpatientclaim.

RefertotheInpatient/Outpatient(IP/OP)BillingManualforadditionalpolicyinformationandbillingrequirements.

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: 8c4939690ce9639a5bc129840799bcc4a1b5a550dfb7743075b989a78ce93574

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