Outpatient Behavioral Health Fee-for-Service

• General Policies
• Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
• General Billing Information
• Benefit Policies 
  • Mental Health Services
    • Eligible Providers
    • Covered Benefits and Limitations
    • Mental Health Services Procedure Code Table
  • Outpatient Substance Use Disorder Services 
    • Eligible Providers
    • Methadone Clinics
    • Treatment Planning
    • Covered Benefits and Limitations
    • Substance Use Disorder Procedure Code Table
  • Additional Covered Services 
    • Additional Covered Services Procedure Code Table
  • Non-Covered Behavioral Health FFS Services
• Special Provision: EPSDT Services Can Exceed Policy Limitations For Members Age 20 And Younger
• Procedure/HCPCS Codes Overview
• CMS 1500 Paper Claim Reference Table
  • CMS 1500 Behavioral Health Claim Example
• Timely Filing
• Outpatient Behavioral Health Fee-For-Service Manual Revisions Log

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General Policies

• Health First Colorado (Colorado's Medicaid program) members have their behavioral health services paid for by Regional Accountable Entities (RAEs). Regional Accountable entities are managed care entities responsible for covering behavioral health benefits for nearly all Health First Colorado members.
• Beginning July 2018 members have up to six (6) short-term behavioral health visits per fiscal year covered in the primary care setting, billed FFS to the fiscal agent Gainwell Technologies. Visit the Accountable Care Collaborative Phase Two web page for exact details on this policy.
• See Program Rule 8.212 for details about the RAE program, including policy which exempts Health First Colorado members from RAE coverage. Only a small percentage of members meeting very specific criteria will be exempt. Member exemption is determined by the Department.
• Visit the Department's Regional Accountable Entity web page for details about RAE coverage.
• To verify if a Health First Colorado member's behavioral health services are covered by a RAE, providers must perform a member eligibility query in the Provider Web Portal. Each RAE may have its own similar tool for providers to query member eligibility. Both tools are valid for checking member eligibility.
• The member eligibility query will display whether the RAE is responsible for covering the member's services. If the member is covered by the RAE, all claims for covered behavioral health services must be sent to the RAE for payment.
• All behavioral health providers must be enrolled with the RAE. Providers must contact the RAE which serves their region to begin the enrollment process. Visit the Department's Regional Accountable Entity web page for details.
• Providers who are denied RAE enrollment may not bill Gainwell Technologies fee-for-service (FFS) as an alternative reimbursement route. If the provider is denied RAE enrollment this means that may not treat Health First Colorado members for services covered by the RAE.
• Providers who are denied RAE enrollment may still render and be reimbursed for services not covered by the RAE.
• A number of services, such as office administered drugs (e.g. Suboxone) are covered Health First Colorado benefits but are not covered by the RAE. These services must always be billed to Gainwell Technologies FFS. Reference the coverage diagram below.
• Providers must reference Appendix T located under the Appendices drop-down on the Billing Manuals web page for a list of RAE-covered services and conditions.

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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

8.280.4.E Other EPSDT Benefits

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

1. All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
2. For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
3. The service provides a safe environment or situation for the child.
4. The service is not for the convenience of the caregiver.
5. The service is medically necessary.
6. The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
7. The service is the least costly.

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General Billing Information

Refer to the General Provider Information Manual for general billing information.

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Benefit Policies

Outpatient Behavioral Health Services are a group of services designed to provide medically necessary behavioral health services to certain Health First Colorado members in order to restore these individuals to their highest possible functioning level. Services may be provided by any willing, qualified provider as described below. Services are provided on an outpatient basis and not during an inpatient hospital stay.

Behavioral Health is split into two (2) benefit categories: Mental Health services and Substance Use Disorder (SUD) services.

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Mental Health Services

Eligible Providers

Only the following enrolled provider types and qualifications are eligible to render Mental Health services to Health First Colorado members. Specific procedures may require different provider or qualifications, as listed.

1. Physician
   1. Doctor of Osteopathy and Medicine
   2. Psychiatrist
2. Psychologist, PsyD/Ph.D
3. Masters Level Clinician
   1. Licensed Professional Counselor (LPC)
   2. Licensed Marriage and Family Therapist (LMFT)
   3. Licensed Clinical Social Worker (LCSW)
   4. Advanced Practice Nurse
4. Physician Assistant
5. Community Mental Health Center (CMHC)
6. Federally Qualified Health Center (FQHC)
7. Rural Health Clinic (RHC)
8. Hospital

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Covered Benefits and Limitations

The following services are covered:

1. Individual Psychotherapy - Therapeutic contact with one (1) member of more than 30 minutes, but no more than two (2) hours.
2. Individual Brief Psychotherapy - Therapeutic contact with one (1) member of up to and including 30 minutes.
3. Family Psychotherapy - Therapeutic contact of up to and including two (2) hours with one (1) member, typically a child/youth, with one (1) or more of the member's family members and/or caregivers present and included in the therapeutic process and communications.
4. Group Psychotherapy - Therapeutic contact with more than one (1) member of up to and including two (2) hours. Not all members in the group session need be Health First Colorado enrolled.
5. Behavioral Health Assessment - An initial or ongoing diagnostic evaluation of a member to determine the presence or absence of a behavioral health diagnosis, to identify behavioral health issues that impact health and functioning, and to develop an individual service/care plan.
6. Pharmacological Management - Monitoring of medications prescribed and consultation provided to members by a physician or other medical practitioner authorized to prescribe medications as defined by State law, including associated laboratory services as indicated.
7. Outpatient Day Treatment - Therapeutic contact with a member in a structured program of therapeutic activities lasting more than four (4) hours but less than 24 hours per day. When provided in an outpatient hospital program, may be called partial hospitalization". Services include:
   1. Assessment and monitoring
   2. Individual/group/family therapy
   3. Psychological testing
   4. Medical/nursing support
   5. Psychosocial education
   6. Skill development and socialization training focused on improving functional and behavioral deficits
   7. Medication management
   8. Expressive and activity therapies
8. Emergency / Crisis Services - Services provided during a mental health emergency which involve unscheduled, immediate, or special interventions in response to a crisis situation with a member, including associated laboratory services, as indicated.

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Mental Health Services Procedure Code Table

Updated March 2022

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Outpatient Substance Use Disorder Services

Eligible Providers

The following providers are eligible to provide Outpatient Substance Use Disorder (SUD) services to Health First Colorado members.

1. Licensed Health Practitioners who are also:
   1. Certified in addiction medicine by the American Society of Addiction Medicine (ASAM), the American Board of Addiction Medicine (ABAM), or the American Board of Preventive Medicine (ABPM), or
   2. Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction Counselors (ACD) by the Department of Regulatory Agencies (DORA), or
   3. National Certified Addiction Counselors II (NCAC II) or Master Addiction Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors (NAADAC), or
   4. Certified in addiction psychiatry by the American Board of Psychiatry and Neurology certified in Addiction Psychiatry (ABPN).

2. Licensed Clinicians.

   Licensed Clinician means a provider who is a clinical social worker licensed pursuant to CRS 12-43-404, marriage and family therapist licensed pursuant to CRS 12-43-504, professional counselor licensed pursuant to CRS 12-43-603, addiction counselor licensed pursuant to CRS 12-43-804, or psychologist (PsyD/Ph.D) licensed pursuant to CRS 12-43-304.

   Licensed Health Practitioner means an advanced practice nurse licensed pursuant to CRS 12-38-111.5, physician/psychiatrist licensed pursuant to CRS 12-36-101, or physician assistant licensed pursuant to CRS 12-36-107.4.

   The rendering provider's NPI must be indicated on the claim in the rendering/performing field.

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Methadone Clinics

Methadone Clinics must enroll as medical clinics Provider Type - 16 with the Health First Colorado fiscal agent, Gainwell Technologies. Visit the Information by Provider Type web page for details.

Individual rendering providers must have their own NPI number and enrollment.

Even though Suboxone is provided by Methadone Clinics it is not considered a SUD benefit. Rather, it is considered a physical health benefit. Other ancillary medical services provided by Methadone Clinics (physical health assessments, blood draws, etc.) are also considered physical health services. Therefore, these physical health services are never billed to the RAE. They are always billed to Gainwell Technologies.

Laboratory services require CLIA certification.

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Treatment Planning

An approved treatment plan must be in place for each client prior to the client receiving services. An initial assessment is required to establish a treatment plan. Treatment plans require approval from a licensed provider (above list) with the authority to approve treatment plans within their scope of practice.

All rendered services must be medically necessary, as defined in Rule Section 8.076.1.8, and must be detailed in the client's treatment plan and progress notes. Initial substance use disorder assessments are exempt from inclusion in the approved treatment plan.

Approved treatment plans must identify treatment goals and must explain how the proposed treatment services will achieve those stated goals.

Approved treatment plans must identify the treatment services planned for use over the course of treatment. The amount, frequency, and duration of these treatment services must be included in the approved treatment plan.

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Covered Benefits and Limitations

LIMITATIONS

1. Members are not required to obtain a referral from their Primary Care Physician (PCP) or Primary Care Medical Provider (PCMP) to receive these services.
2. Members must have a treatment plan that is approved by a licensed practitioner listed above.
3. Outpatient Fee-for-Service Substance Use Disorder Treatment services may only be rendered by providers outlined above.
4. Services are covered only when the client has been diagnosed with at least one of the following:
   1. Alcohol use or induced disorder
   2. Amphetamine use or induced disorder
   3. Cannabis use or induced disorder
   4. Cocaine use or induced disorder
   5. Hallucinogen use or induced disorder
   6. Inhalant use or induced disorder
   7. Opioid use or induced disorder
   8. Phencyclidine use or induced disorder
   9. Sedative Hypnotic or Anxiolytic use or induced disorder
   10. Tobacco use disorder

COVERED SERVICES

Substance Use Disorder Assessment 
A substance use disorder assessment is an evaluation designed to determine the most appropriate level of care based on criteria established by the American Society of Addiction Medicine (ASAM), the extent of drug or alcohol use, abuse, or dependence and related problems, and the comprehensive treatment needs of a client with a substance use disorder diagnosis.

1. Course of treatment and changes in level of care must be based on best practices as defined by the current ASAM Patient Placement Criteria.
2. Re-assessments must be spaced appropriately throughout the course of treatment to ensure the treatment plan is effectively managing the client's changing needs.
3. Each complete assessment corresponds to one unit of service.
4. An assessment may involve more than one session and may span multiple days. If the assessment spans multiple days, the final day of the assessment is reported as the date of service.

Individual and Family Therapy 
Individual and family therapy is the planned treatment of a client's problem(s) as identified by an assessment and listed in the treatment/service plan. The intended outcome is the management and reduction, or resolution of the identified problem(s).

1. Individual and family therapy is limited to one client per session.
2. Individual and family therapy are billed at 15 minutes per unit.
   1. A session is considered a single encounter with the client that can encompass multiple timed units.
3. Family therapy must be directly related to the client's treatment for substance use disorder or dependence.
4. Individual therapy and family therapy sessions are allowed on the same date of service.

Group Therapy 
Group therapy refers to therapeutic substance use disorder counseling and treatment services, administered through groups of people who have similar needs, such as progression of disease, stage of recovery, and readiness for change.

1. Group therapy must include more than one patient.
2. A session of group therapy may last up to three hours and is billed in units of one hour each (e.g., a three-hour group session would consist of three units).
3. A unit of service may be billed separately for each client participating in the group therapy session.

Alcohol/Drug Screening and Counseling 
Alcohol/drug screening and counseling is the collection of urine followed by a counseling session with the client to review and discuss the results of the screening.

1. The analysis of the urine specimen (urinalysis) may only be billed by a provider with the appropriate CLIA certification for the test performed. Urinalysis is not part of the Outpatient Fee-For-Service SUD benefit.
2. Substance use disorder providers will only be reimbursed for collecting the urine specimen and providing a counseling session to review and discuss the results of the urinalysis. Claims submitted for the collection of the urine sample without the subsequent counseling of urinalysis results will not be reimbursed.
   1. If the client does not return for the counseling of their urinalysis results, the collection of the sample cannot be claimed.
3. Substance use disorder counseling services to discuss and counsel the client on the test results must be provided by an eligible rendering provider, as outlined in this manual.
4. The counseling portion of the service may be conducted during a session of individual or family therapy.
5. Multiple urine collections per date of service are not additionally reimbursed.
6. Alcohol / drug screening and counseling is limited to one unit per date of service.
   1. A unit of service is the single collection and subsequent counseling session.

Targeted Case Management 
Targeted case management refers to coordination and planning services provided with, or on behalf of, a client with a substance use disorder diagnosis.

1. The client does not need to be physically present for this service to be performed if it is done on the client's behalf.
2. Targeted case management services are limited to service planning, advocacy, and linkage to other appropriate medical services related to substance use disorder diagnosis, monitoring, and care coordination.
3. A unit of service equals one 15-minute increment of targeted case management and consists of at least one documented contact with a client or person acting on behalf of a client, identified during the case planning process.

SUD Residential and Inpatient Services

For information about these services, refer to the Provider Manual for Residential and Inpatient SUD Services, located on the Ensuring Full Continuum SUD Benefits - Providers web page under the Provider Resources section.

Medication-Assisted Treatment (MAT) 
Medication Assisted Treatment (MAT) is a benefit for opioid addiction that includes a medication approved by the U.S. Food and Drug Administration (FDA) for opioid addiction detoxification or maintenance treatment.

1. When methadone is administered for MAT, the reimbursement for the medication's acquisition is bundled with the reimbursement for administration and dispensing under a single billing code. When other medications are used for MAT (e.g. Suboxone), the reimbursement for the medication is billed separately from the administration and dispensing using physician administered drug billing codes.
   1. Only licensed physicians, physician assistants, or nurse practitioners are eligible to administer MAT. All providers must comply with the Office of Behavioral Health's Opioid Medication Assisted Treatment program requirements set forth at 2 C.C.R. 502-1 21.320.
   2. Take-home dosing is permitted in accordance with Office of Behavioral Health rules at 2 CCR 502-1 21.320.8. Therefore, one unit of MAT must be reported for each date of service the client ingests the dose of methadone.
   3. If the client ingests their dose at the facility, the place of service must be reported as office. If the client ingests their dose at home, the place of service must be reported as home. Records must include documentation to substantiate claims for take-home doses.

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Substance Use Disorder Procedure Code Table

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Additional Covered Services

Health First Colorado Fee-For-Service covers additional services which are not covered by the RAE. These services are available to all members. Specific rendering provider requirements may apply to each service.

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Additional Covered Services Procedure Code Table

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Non-Covered Behavioral Health FFS Services

1. Covered diagnosis/procedure services provided to members participating in the Community Behavioral Health Services Program are not covered under the Mental Health fee-for-service benefit.
2. Services provided by email, telephone, text message, facsimile transmission, and online research.
3. Room and board services.
4. Educational, vocational and job training services.
5. Habilitation services.
6. Services to inmates in public institutions (i.e. correctional facilities) as defined in 42 CFR § 435.1009.
7. Mental health services to individuals residing in institutions for mental diseases as defined in 42 CFR § 435.1009 are not covered outside of the RAE
8. Recreational and social activities.
9. Day treatment program services.
10. Peer advocate services.
11. Court-ordered DUI services.
12. Reimbursement for contractual arrangements between the provider and a third party.

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Special Provision: EPSDT Services Can Exceed Policy Limitations For Members Age 20 And Younger

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Health First Colorado) program that requires the state Health First Colorado agency to cover services, products, or procedures for Health First Colorado members ages 20 and younger if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition (health problem) identified through a screening examination (includes any evaluation by a physician or other licensed clinician). EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.

EPSDT does not require the state Health First Colorado agency to provide any service, product, or procedure that is:

• Unsafe, ineffective, or experimental/investigational.
• Not medical in nature or not generally recognized as an accepted method of medical practice or treatment.

Service limitations on scope, amount, duration, frequency, and/or other specific criteria described in the above screening policies may be exceeded or may not apply as long as the provider documentation shows how the service, product, or procedure will correct, improve or maintain the recipient's health, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.

Providers may be subject to post-payment review to assure the use of a validated, standardized screening tool and medical justification for screens in excess of the stated benefit limits.

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Procedure/HCPCS Codes Overview

The codes used for submitting claims for services provided to Health First Colorado members represent services that are approved by the Centers for Medicare & Medicaid Services (CMS) and services that may be provided by an enrolled Health First Colorado provider.

The Healthcare Common Procedural Coding System (HCPCS) is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits.

HIPAA requires providers to comply with the coding guidelines of the AMA CPT Procedure Codes and the International Classification of Disease, Clinical Modification Diagnosis Codes. If there is no time designated in the official descriptor, the code represents one unit or session. Providers should refer to the monthly bulletins located on the Bulletins web page. To receive electronic provider bulletin notifications, an email address can be entered into the Provider Web Portal in the (MMIS) Provider Data Maintenance area or by filling out a publication preference form. Bulletins include updates on approved procedure codes as well as the maximum allowable units billed per procedure.

The following CMS 1500 Paper Claim Reference Table gives required and/or conditional fields for the paper CMS 1500 claim form for Behavioral Health claims:

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

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CMS 1500 Behavioral Health Claim Example

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for more information on timely filing policy, including the resubmission rules for denied claims.

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Outpatient Behavioral Health Fee-For-Service Manual Revisions Log