Medicaid Colorado – Ordering, Prescribing & Referring Providers – Laboratory and Radiology Services

Effective July 1, 2022, the federal requirement 42 CFR § 455.440 that claims for all Laboratory and Radiology services, rendered by any type of provider (including hospitals, Primary Care Medical Providers and obstetricians/gynecologists (OB/GYNs)), contain the National Provider Identifier (NPI) of the provider who ordered the services, and that the NPI is actively enrolled with Health First Colorado, will be enforced. The ordering NPI may be that of the qualified provider overseeing the member’s care, for example as is the case with maternity services.

Laboratory and Radiology services can be ordered by either a physician, physician assistant, osteopath, certified nurse midwife, or nurse practitioner. The ordering provider must also be actively enrolled with Health First Colorado. If these conditions are not met the claim may be denied.