Outpatient Behavioral Health Fee-for-Service

• General Policies
• General Billing Information
  • Medical Necessity
  • Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
• Covered Services and Limitations
  • Services Not Covered by the FFS Behavioral Health Benefit
  • Opioid Treatment Program
• 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

The Fee-For-Service (FFS) Behavioral Health Benefit is a group of services designed to provide medically necessary behavioral health services to certain Health First Colorado (Colorado's Medicaid program) members. This Benefit includes both Mental Health services and Substance Use Disorder (SUD) services. Members are not required to obtain a referral from their Primary Care Physician (PCP) or Primary Care Medical Provider (PCMP) to receive these services.

Regional Accountable Entities (RAEs) are responsible for covering behavioral health services for nearly all Health First Colorado members. To verify if a Health First Colorado member's behavioral health services are covered, providers must perform a member eligibility query in the Provider Web Portal. The member eligibility query will display both a member’s Medicaid eligibility as well as which RAE a member is attributed to, which is responsible for covering the member's behavioral health services.

Members who are eligible for the FFS Behavioral Health Benefit are limited to:

• Members who do not have active enrollment in a RAE. See Program Rule 8.212 for the 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.
• Members being treated for a condition not eligible for reimbursement under the RAE (such as Autism Spectrum Disorder or Gender Identity Disorder).

Providers must reference APPENDIX I in the State Behavioral Health Services (SBHS) Billing Manual for a list of RAE-covered services, and the Diagnoses Section to confirm RAE-covered diagnoses. 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 FFS to the Health First Colorado fiscal agent, Gainwell Technologies.

A primary care provider can bill FFS up to six (6) short-term behavioral health visits per fiscal year. Visit the Accountable Care Collaborative Phase II web page for details on the Short-Term Behavioral Health Services policy.

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General Billing Information

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

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Medical Necessity

Medicaid can only reimburse for services that are considered Medically Necessary. According to 10 CCR 2505-10 section 8.076.1.8, a service is considered medically necessary when it:

1. Will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability. This may include a course of treatment that includes mere observation or no treatment at all. For members under age 21, per section 8.280.4E, this includes a reasonable expectation that the service will assist the member to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living.
2. Is provided in accordance with generally accepted professional standards for health care in the United States;
3. Is clinically appropriate in terms of type, frequency, extent, site, and duration;
4. Is not primarily for the economic benefit of the provider or primarily for the convenience of the member, caretaker, or provider;
5. Is delivered in the most appropriate setting(s) required by the member's condition;
6. Is not experimental or investigational; and
7. Is not more costly than other equally effective treatment options.

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

Federal Medicaid law, 42 U.S.C.§ 1396d(r), requires state Medicaid programs to provide EPSDT benefits for members under 21 years of age. This means Medicaid is required to cover any service for members age 20 or younger that is medically necessary “to correct or ameliorate a defect, physical or mental illness, or a condition identified by screening,” whether or not the service is covered under the Colorado State Medicaid Plan. “Ameliorate” means to “make more tolerable” or, in other words, to improve or maintain the member’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Even if the service will not cure the member’s condition, it must be covered if it is medically necessary to improve or maintain the member’s overall health.

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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Covered Services and Limitations

Updated July 2024

CPT codes, descriptions and other data only are copyright 1995 - 2023 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).

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

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 regularly consult monthly bulletins on the Provider 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 signing up on the Communications Mailing List. Bulletins include updates on approved procedure codes as well as the maximum allowable units billed per procedure.

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Services Not Covered by the FFS Behavioral Health Benefit

1. Services and covered diagnoses included under the responsibility of a RAE are not covered under the FFS Behavioral Health Benefit for members attributed to a RAE.
2. Court-Ordered services. Services that are ordered by a court are not automatically covered or excluded by Medicaid. Services must meet Medical Necessity criteria to be reimbursed by Medicaid.
3. Services provided by email, text message, facsimile transmission, and online research.
4. Room and board services.
5. Educational, vocational and job training services.
6. Habilitation services.
7. Services to inmates in public institutions (i.e. correctional facilities) as defined in 42 CFR § 435.1009.
8. 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.
9. Recreational and social activities.
10. Day treatment program services.
11. Peer advocate services.

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Opioid Treatment Providers

Opioid Treatment Providers (OTPs) must enroll as medical clinics, Provider Type 16, with Gainwell. See enrollment requirements for details. Individual rendering providers must have their own NPI number and enrollment.

An OTP may dispense Suboxone for take home dosing, however this dispensing is not considered a BH benefit. Rather, it is considered a pharmacy benefit, and the OTP is responsible to seek reimbursement for the drug under the pharmacy benefit.

Other ancillary medical services, as required by Methadone treatment guidelines outlined by SAMSHA, provided by OTPs (physical health assessments, blood draws, etc.) are considered physical health services. Therefore, these physical health services are never billed to the RAE. They are always billed to Gainwell.

Laboratory services, also required as part of treatment monitoring by OTPs managing Methadone treatment, require CLIA certification or a waiver.

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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