Colorado Provider Status and Payment for Services
CPS has a top priority to advocate for pharmacists’ payment of non-dispensing services and the ability to be reimbursed via all payment models for the healthcare and pharmacist care services they provide, like other healthcare providers. This page will serve to house information and resources regarding the main healthcare payers in Colorado, which include Medicaid, Medicare and Private/Commercial payers and considerations for cash-based payment models. For information about federal provider status, see the bottom of this page. For a more complete review of the expanded scope of practice that CPS helped pass in 2021, please see our related webpage: CO Advanced/Expanded Scope of Practice. CPS has also formed the Colorado Pharmacists Practice & Payment Network (CPPPN) (formerly the Colorado Pharmacist Professional Taskforce) consisting of over 40 pharmacy and healthcare entities. The purpose of this network is to form a community for sharing provider status experience, challenges, successes and needs. If you are interested in joining this network, please email your interest to [email protected] or to our CPS Pharmacy Practice Advancement Lead, Jessica Angleson, PharmD, MBA, BCPS at [email protected]. As always we are always open to your needs and feedback on provider status in CO. Specifically, CPS would like to know about barriers/rejections/problems so can continue to advocate and address these issues. Contact us at [email protected]. Pharmacist Services Billing Guides:Colorado Pharmacist Services Billing Guide: CPS has created a Pharmacist Services Billing Guide for Colorado to offer a comprehensive and fundamental resource for billing various major provider types. We welcome your input with edits, clarifications, and additions! Other Billing Guide(s): Pharmacy Practice Guidebook: Medical Billing, Coding and Documentation for Pharmacy Professionals CPS has partnered with the Washington State Pharmacy Association and endorses this Guidebook for a higher level of detail on billing and billing codes. CPS members receive an additional 25% off the price (details below!) The Pharmacy Practice Guidebook: Medical Billing, Coding and Documentation for Pharmacy Professionals is a comprehensive guide to over 175 CPT Codes. While the Pharmacist Services Billing Guide for Colorado instructs participants how to get started with medical billing and provides a comprehensive review of Colorado laws and scope of practice, this guidebook is a companion to our guide. It provides an in-depth review of over 175 CPT codes most appropriate for pharmacist professionals, a detailed guide to how to appropriately code patient care visits, and relevant G, J and Z-codes. It is available as a print or digital copy for purchase from LAD Publishing: https://ladbookstore.com/products/pharmacy-practice-guidebook. Email [email protected] to obtain the discount code if you are a member, or join and get the discount today!
Medicare:Authority to Bill: None, pharmacists are not currently recognized as Part B providers in the Social Security Act. Advocacy Asks: Sign on to national provider status bills (Equitable Community Access to Pharmacist Services Act (ECAPS), H.R. 1770, S. 2477 and Pharmacy and Medically Underserved Areas Enhancement Act, S. 1490): links to sign on here Provider Status (pharmacist.com)
Medicaid:Authority: Pharmacists in Colorado can enroll in Medicaid as medical providers and bill for certain services. The services covered include any care provided as part of Part 6 of the Practice Act. This includes collaborative practice agreements, collaborative drug therapy management (CDTM) and statewide drug therapy protocols, or SWPs). The bill that authorizes this was passed by CPS in 2021 and can be found here: HB 21-1275. Colorado Medicaid has produced a comprehensive billing guide that is updated regularly with any changes. This manual should serve as the primary resource for all pharmacists who wish to bill Medicaid for services. This includes how to enroll, what services are covered and billable codes.
Advocacy Asks: Continue to evaluate the breadth of this coverage. Ideally, payment would be for any services provided under a pharmacist's scope of practice, which we will continue to advocate for. More information can be found under the Colorado Pharmacist Services Billing Guide section.Private/Commercial:Authority: Pharmacists have mandated health plan coverage of services as a result of a bill passed in 2018 by CPS and can be found here: HB 18-1112.
To date, there are no pre-determined covered services or billing codes. These will be determined as part of the contracting agreement process with an individual payer. No laws exist that limit the type of services that could be paid (as long as the healthcare services provided by the pharmacist would also be a paid service to another provider type). This would open opportunities for chronic disease management, etc. Important: Pharmacists need to push forward with discussions with health plans to identify opportunities to partner with payers and provide value to their patients. In this way, contracts can be made to enroll pharmacists and subsequently ensure that pharmacists are paid for the services. Once agreements are made to provide services as part of a contract, pharmacists can be internally credentialed with that payer. Essential Steps: Enter your information into CAQH to have basic steps toward being credentialed with any payer; see the Colorado Pharmacist Services Billing Guide section for more details. Advocacy Asks: CPS continues to evaluate if a payment parity advocacy campaign is needed. We also ask that any pharmacist/entity that gets rejected from a payer network notify CPS so we can take appropriate steps. Cash:Authority: No specific authority is needed to charge cash-based services, however all services must remain under the Colorado Scope of Practice as outlined in the Pharmacy Practice Act. Details on advanced practice can be found at CO Advanced/Expanded Scope of Practice. Although not ideal for every patient, pharmacies may choose to offer advanced services for cash payment. Because pharmacists can provide a more accessible and flexible point of access for services, many patients are willing to pay directly without insurance for these services. This has been a successful model of care in Colorado in order to expand into advanced healthcare services already authorized by our expanded scope of practice. Suggested Initial Billing Process StepsPlease see the Colorado Pharmacist Services Billing Guide section for comprehensive pharmacy medical billing information. Pertinent links:
Provider Status Training ResourcesCPS provides these links as additional learning/training opportunities around provider status and payment for services. CPS does not endorse any single program and provides these solely as helpful information:
Community Health Worker Resources in Colorado:In 2023, The Colorado Legislature passed Senate Bill 23-002 to add community health worker (CHW) services as a Health First Colorado (Colorado’s Medicaid program) benefit starting July 1, 2025. Community pharmacies are a key resource in expanding access to CHW services, especially in underserved areas, where they are well-positioned to connect patients with necessary health resources.
CONTACT US!We are always striving to advance reimbursement and payment for pharmacy professional services in Colorado. Please email us with thoughts, needs, challenges, etc. [email protected]. |