Behavioral Health Fee-for-Service (FFS) Benefits

Health First Colorado covers behavioral health services. Behavioral health services are primarily delivered by the Regional Accountable Entity (RAE). For those which are not, this benefit applies.

Who is eligible for behavioral health FFS services?

Enrolled members under these circumstances:

  1. Member does not have active enrollment in a RAE, or
  2. Member is being treated for a condition not eligible for reimbursement under the RAE (such as autistic disorder or gender identity disorder)

Reference the billing and policy manual for complete details.

What services are available?

A variety of CPT billing codes are available for billing. These include but are not limited to:

  • Psychotherapy and other mental health treatment
  • Neuropsychiatric testing and evaluation
  • Substance use disorder treatment

Beginning July 2018 members have up to 6 short-term behavioral health visits per fiscal year covered in the primary care setting, billed FFS to the fiscal agent Gainwell Technologies. Refer to the ACC Phase Two web page for exact details on this policy.

Reference the billing and policy manual for complete details.

Eligible Providers 

The following licensed providers are eligible to provide behavioral health services: Physician/psychiatrist, Psychologist, PsyD / Ph.D., Licensed clinical social worker (LSCW), Licensed marriage and family therapist (LMFT), Licensed professional counselor (LPC), Nurse Practitioner, Physician Assistant.

Reference the billing and policy manual for complete details.

How do I become an enrolled provider?

As a Health First Colorado (Colorado\'s Medicaid Program) provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance - it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.

The enrollment process is online and begins on the Provider Enrollment web page.

Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.

General Policies

  • All services must be medically necessary.
  • All claims must include the National Provider Identification (NPI) number of the enrolled provider who rendered the service.
  • All claims must include the NPI number of the enrolled provider who ordered the service, if rendered by a non-physician.
  • There are no co-pays for this benefit.

Reference the billing and policy manual for complete details.

How are services reimbursed?

Behavioral health FFS services are reimbursed according to the current Health First Colorado Fee Schedule. Reimbursement rates will vary by CPT code reported. The fee schedule shows the maximum allowed reimbursement for each CPT code. Submitted claims will be reimbursed according to 'lesser-of' pricing logic. This means that the line item will reimburse either at submitted charges or the fee schedule rate, whichever is lesser.

Providers must first enroll in the program to submit claims. Once they are enrolled, providers may submit claims directly by logging into the Provider Web Portal. Claims may be submitted by billing agencies on behalf of the provider.

Resources for enrollment and billing may be found at Provider Resources.

Recent News and Updates

  • Check the Provider Bulletin index for all provider bulletins related to the behavioral health FFS benefit.
  • National Correct Coding Initiative (NCCI) billing edits affect this benefit. Providers should be familiar with the information found on the Medicaid.gov NCCI Website, including the NCCI Policy Manual found there.

Policy Documents

Applicable Rules, Regulations, and Statutes

All Medicaid Rules, Regulations, and Statutes apply to the administration of the Colorado Medical Assistance Program at large, which providers are required to follow. The following are specifically called out as the ones governing the behavioral health benefit:

  • 42 CFR 440.130 - Federal regulation describing the minimum requirements for a State Medicaid Agency to cover behavioral health services.

Contact Information

  • Questions about claims and billing must be directed to the fiscal agent, Gainwell Technologies. A list of resources is available on the Provider Contact web page.
  • Questions about policy and coverage may be directed to the program administrator. Contact John Laukkanen at John.Laukkanen@state.co.us.