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 a Colorado Pharmacist Professional Taskforce consisting of over 35 pharmacy and healthcare entities. The purpose of this taskforce is to form a network for sharing provider status experience, challenges, successes and needs. If you are interested in joining this taskforce, 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]. 

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!

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)

• Current ability to bill Medicare is limited to “incident to” services (includes Annual Wellness Visits).  These visits are all still billed under another type of provider (physician, advanced practice nurse)
• More information can be found in the  Pharmacist Services Billing Guide for Colorado.

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.

• Colorado Medicaid Pharmacists Services Billing Manual

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 about Medicaid billing can also be found in the  Pharmacist Services Billing Guide for Colorado.

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.

• This gives pharmacists the authority to bill healthcare services (and requires payment) if the services are provided in a health professional shortage area (geographical or population based) AND the plan provides coverage for the same services if provided by physician or advanced practice nurse.

• The caveat is that this bill specifically does NOT require plans to contract with pharmacists which means that they are NOT required to enroll them into their medical networks. This has been a challenge for enrollment for pharmacists. However, once enrolled, pharmacists are entitled to payment for healthcare services.

• It is important to note that for any payer, both credentialing and contracting are essential steps.  Without a contract/agreement of some sort, it is unlikely that even if credentialed, pharmacists will have a clear path to payment from a health plan.

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 Pharmacist Services Billing Guide for Colorado.

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 Steps

Please see the Colorado Pharmacist Services Billing Guide comprehensive pharmacy medical billing information

Pertinent links:

• Active CO pharmacist license - DORA
• Malpractice insurance (Pharmacist Mutual)
• NPI Application (NPPES)
• CAQH profile (commercial payers)
• Enroll as a provider (Medicaid, Private payer-see commercial payer websites)

Provider Status Training Resources

CPS 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:

• Beginner Billing Training: Professional Claims CMS 1500
• The Pharmacist Provider
• APhA  
• ASHP Provider Status Readiness and ASHP Billing and Reimbursement for Patient Care Clinical Services Certificate Program

• CPS CE Webinar: Do You Know What You Don’t Know? The Scope of Scope and Status of Provider Status

Additional 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].