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Behavioral Health FAQ Library

The Behavioral Health FAQ Library serves as a repository of FAQ topics related to the Office of Medicaid and CHP Behavioral Health Initiatives and Coverage (BHIC).

Comprehensive Provider FAQ
Essential Provider FAQ
Peer Support FAQ
Third Party Liability & Coordination of Benefits

Comprehensive Provider FAQ

Q: Can my agency enroll with HCPF as both a Comprehensive Safety Net Provider and an Essential Safety Net Provider?

  • A: Yes, a provider agency may enroll as both a Comprehensive Provider (PT 78) and an Essential Provider depending on the scope of services being provided and with appropriate licensure and approvals by the BHA.

Q: As a Comprehensive Provider, will my agency be able to be both the Billing Provider and the Rendering Provider on claims?

  • A: No, Comprehensive Providers can only act as the Billing Provider and Pay-To Provider. The individual licensed practitioner delivering or supervising the service must be listed as the Rendering Provider on the claim.
    Per HIPAA 837 encounter requirements, HCPF is not allowed to vary Medicaid billing requirements from the standards described in the 837 Implementation Guide.
    According to the Technical Report Type 3 (TR3), which provides implementation instructions for electronic transactions under HIPAA, the rendering provider's information must be included if the rendering provider differs from the billing provider. If the rendering provider is the same as the billing provider, only the billing provider's information should be sent, and the rendering provider's details should be omitted.
    Additionally, 42 CFR 455 Subpart E 455.410 (b) stipulates: The State Medicaid agency must require all ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan to be enrolled as participating providers.

Q: How are Comprehensive Providers (PT 78) reimbursed?
A: Comprehensive Providers are reimbursed via prospective payment system (PPS), which is a payment model that pays providers a standard rate for any qualifying encounter with a patient, regardless of what or how many specific services were rendered.  This data is used to calculate a provider-specific PPS rate that reflects the actual costs of delivering services. New comprehensive providers will receive a “statewide PPS” rate until their cost reporting can be completed. Current Comprehensive Provider rates are published in the SBHS Billing Manual, Appendix D.

Q: What is the difference between Comprehensive Safety Net Provider and Essential Safety Net Provider reimbursement from HCPF?
A: To support BHA’s implementation of new Safety Net Providers, Comprehensive Safety Net Providers receive a prospective payment and Essential Safety Net Providers receive enhanced reimbursement rates. Learn more at HCPF’s Safety Net webpage.

Q: What additional support is available, when my concerns or issues are not addressed by the RAEs I am contracted or attempting to contract with? 
A: Providers are asked to contact the RAE they are directly contracted with to resolve any concerns. Contact information for all RAEs and CHP+ Managed Care Organizations is available on the HCPF Provider Help page. 
HCPF understands that situations may arise where escalating provider concerns may be necessary after having exhausted collaborative efforts with the RAE. The Provider Escalation Request form is available if challenges with claims, denials, conflicting guidance between RAEs, or other concerns are not being resolved at the RAE level and HCPF involvement is being requested. This form comes to HCPF where concerns are logged and forwarded to the appropriate RAEs to respond. Use of this form helps HCPF identify common issues, trends or systemic challenges that providers experience.

Essential Provider FAQ

Q: What is the difference between an Essential Safety Net Provider/Essential Provider and an Essential Community Provider?
A: An Essential Safety Net Provider, also known as an Essential Provider, is a status obtained through BHA approval, whereas an Essential Community Provider is a designation obtained by the federal government or HCPF directly.  They are completely different programs, though similar in name.

Peer Support FAQ

Are Peer services billable?

  • Effective July 1, 2025, HCPF limited the codes that can be billed for individual contributions by Peer Support Professionals to the following:
    • H0038: Self-help/Peer Services
    • H0023: Behavioral Health Outreach Service
  • Peer Support Professionals may deliver services within their scope as part of a multidisciplinary team for individuals with behavioral health needs. As part of a multidisciplinary team, Peers may participate in the delivery of team-based services. For a comprehensive list of codes Peers can deliver as part of a multidisciplinary team, please refer the Updated Peer Support Policy webpage.

How are Peer Services reimbursed by Medicaid?
Peer Support services are reimbursed through the Capitated Behavioral Health Benefit as outpatient behavioral health services. HCPF provides a set amount to RAEs to cover provision of all behavioral health services provided under the Capitation. RAEs are responsible to determine, based on member needs in the region, how best to spend the money, considering factors such as number of members using particular services and number of providers available. As part of contracting, RAEs negotiate rates with each provider. Providers negotiate and set contracts with the RAE(s) and then are able to bill for Peer Support services.

Peer Support Professionals cannot directly submit claims for the services they deliver. Only a provider enrolled with Medicaid can submit a claim to their RAE for behavioral health services. Behavioral health services delivered by a Peer Support Professional must be billed under the National Provider Identification (NPI) number of the Rendering Provider responsible for oversight.

Is transportation a reimbursable activity?
Code H0038 does cover transportation of professionals serving Health First Colorado members in circumstances where the delivery provider is traveling with the member in context of a skill building or coping skill building task. As an example, riding with a member on a bus line to help them learn a transit system or become comfortable with using the bus to get groceries would be a covered service. In these cases, the time spent in travel is part of the skill building activity and would be counted as part of the visit.

Where can I find more information and updates about reimbursement for Peer Support services?
Visit HCPF’s Behavioral Health Policies, Standards, and Billing References webpage and navigate to the Behavioral Health Peer Support Policy section to learn more.

Do Peers delivering Medicaid billable services need to have a certification?
The SMD letter #07-011 indicates that states must determine the minimum training and certification criteria for professionals delivering peer support services in a behavioral health context. HCPF follows the definitions of training and certification requirements for Peer Support Professionals in Behavioral Health Administration (BHA) rule. In alignment with the Medicaid Sustainability Memo published in June 2025, HCPF is implementing the following policy for Peer Support Professionals delivering behavioral health services billable to a Regional Accountable Entity (RAE) (henceforth referred to as Behavioral Health Peer Support Professionals).

Effective January 1, 2026, all Behavioral Health Peer Support Professionals must either be certified or be in the process of becoming certified in order for the services they deliver to be reimbursable by a Health First Colorado Regional Accountable Entity (RAE). 

In the process of becoming certified is defined as: Peers who have completed all 60 hours of required training and are in the process of completing their hours of experience and working towards certification. Services delivered by Behavioral Health Peer Support Professionals in the process of becoming certified are reimbursable for up to 6 months following the completion of required training.

Agencies must sign and submit this attestation to their Regional Accountable Entity (RAE) or RAEs by January 1st annually, indicating that all Behavioral Health Peer Support Professionals are either certified or are in the process of becoming certified.

What are the requirements regarding supervision of Peer Support Professionals?
Under federal Medicaid policies, unlicensed professionals (including Behavioral Health Peer Support Professionals) are not able to independently deliver Medicaid reimbursable behavioral health services because they do not hold a valid active license in Colorado. In order to reimburse for care delivered by these individuals, their services must be billed under a Rendering Provider.

For more information, visit the Health First Colorado Behavioral Health Rendering Provider Oversight (RPO) Policy section of the Behavioral Health Policies webpage.

What is the difference between Rendering Provider Oversight (RPO) and other types of supervision?
The Rendering Provider is the licensed clinician who is responsible for ensuring that the services being delivered are medically necessary.  They review the treatment plan goals and progress of the member receiving services, identify any new setbacks, and provide  oversight of behavioral health services delivered by the Peer Support Professional.

Agencies can choose to encourage or require other types of supervision, in addition to the requirement of Rendering Provider Oversight (RPO), depending on the needs of the professional. For example, a Peer Support Professional may also receive support with HR-related tasks from an Employment Supervisor, as well as mentorship from an experienced Peer Support Professional. These other types of professionals may be responsible for setting employee goals and reviews, giving job feedback, completing all HR-related tasks, as well as holding regular check-ins, evaluating work load, problem-solving strategies and providing moral support. However, they do not replace the role of a Rendering Provider who ensures Medicaid billable behavioral health services are delivered to members in accordance with all Medicaid rules and requirements.

Does my agency need to obtain a license from the BHA?

  • In order to enroll with Medicaid as a Recovery Support Services Organizations (RSSO), an agency must first obtain an RSSO designation from the BHA.
  • Clinical behavioral health providers who employ 9 or more licensed clinicians, as well as  agencies who deliver SUD services are required to obtain a Behavioral Health Entity (BHE) license through the BHA.
  • Please visit the BHA’s Behavioral Health Designation and Licensing page to find more information on what is required.

How does my agency become a Recovery Support Services Organization (RSSO provider type 89/889) and bill Health First Colorado for services?

  • Outreach the RAE(s) your agency is interested in contracting with to determine if there are network needs for the type of services you provide.
  • Obtain an RSSO designation from BHA.
  • Enroll with HCPF.
  • Contract with a Regional Accountable Entity for behavioral health services outlined in the State Behavioral Health Billing Manual.

Is it permitted to use a self-reported diagnosis from the client or a diagnosis reported by another provider?
Yes, when newly engaging a client in Peer Services, agencies may obtain a member’s diagnosis from another provider through a Release of Information (ROI), if applicable. If the member does not yet have an official diagnosis, it is permissible to use ‘deferred diagnosis’ on the claim form.

Who do I contact for help with billing and coding questions?
Please reach out to your Regional Accountable Entity (RAE) or you can contact HCPF for questions about the State Behavioral Health Services Billing Manual at hcpf_bhcoding@state.co.us.

Third Party Liability and Coordination of Benefits FAQ

Created 7/1/2024

Q: What is Third Party Liability (TPL)? 

A: Under Federal regulation (See 42 CFR Part 433 Subpart D), “Third Party Liability” (TPL) means that payment is the responsibility of a third party other than the individual or the Medicaid Program. Medicaid is the payor of last resort. By law, virtually all other sources of health coverage must pay claims under their policies before Medicaid will pay for the care of an eligible individual. 

Q: What is Coordination of Benefits (COB) and how does it work in general?

A: Coordination of Benefits refers to the practice of ensuring that a claim is paid by the payor that is legally responsible for paying a claim as Primary with any secondary parties paying Secondary. Coordinating benefits makes sure that the correct party pays first by, 1) cost-avoiding (aka denying) claims where a known other party should be paying and/or 2) cost-recovering a claim that Medicaid erroneously paid that should have been paid by another party.

Q: Where can I find all of the coverages where a Medicaid Member is enrolled?

A: Providers have multiple options for establishing a Member's coverage. A Medicaid Member has a primary responsibility for disclosing all coverages in which they are enrolled. Additionally, a provider should verify both Medicaid and other coverage in the Medicaid Provider Portal (See Accessing Eligibility Verification Information).   The Medicaid Provider Portal captures other coverage information from the Medicaid Management Information System (MMIS), the Department of Health Care Policy & Financing’s (HCPF) system of record for TPL. TPL data is added to the MMIS from multiple sources under a hierarchy defined by HCPF and sources populate data into the system in different cadences.  Any additions of coverage or updates to existing coverage that are manually entered into the Provider Portal by providers are reviewed by HCPF’s Fiscal Agent staff before changes are accepted. The Fiscal Agent, Gainwell Technologies, is responsible for enrolling providers, providing billing assistance, etc. (See Fiscal Agent Responsibilities). The manual review occurs weekly so providers will not immediately see changes they have made. HCPF is working on enhancements to the Provider Portal processes to increase the frequency of manual reviews and to automate additions and updates of the TPL information.

Q: Are Children’s Health Plan (CHP), MCOs and other “Medicaid” Plans treated the same as “Medicaid - Title XIX” for purposes of TPL and coordination of benefits?

A: All programs and benefit aid types shown in the Medicaid Provider Portal are subject to coordination of benefits and remain the payor of last resort. Generally, Members with Title XIX Medicaid are able to have commercial insurance and/or Medicare.   If there is no other coverage for a Member, providers should follow standard Medicaid billing practices. Providers can find additional guidance regarding specific coverage types by viewing the Verifying Specific Coverage Types document. Providers can also reference this Verifying Eligibility Quick Guide for additional information on Member eligibility.

Q: What can I do if I discover a Member has additional coverage after a service is provided?

A: A provider should bill the Primary payor first under standard TPL policies.  If the provider has already received payment from Gainwell or the Managed Care Entity (MCE) prior to learning of the other coverage, the provider should immediately bill the other coverage for payment as Primary. If the provider receives payment from the other carrier, they need to return their Primary payment from Gainwell or the MCE. The provider should then rebill Gainwell or the MCE as Secondary. *If the provider receives a denial for being out of network with the Primary payor, they should not submit the claim for full payment to Gainwell or the MCE. Please see the response to Question 9 below. Providers contracted with an MCE should follow the applicable published timely filing guidelines for that MCE when resubmitting a claim. Providers can resubmit a Primary or Secondary fee-for-service claim to Gainwell for payment within 60 days from the date of a void or retraction. (See Timely Filing and Resubmissions)

Q: Am I allowed/required to collect a deductible, coinsurance, and/or copayments for the Primary Insurance from a Member who also has Medicaid coverage?

A: No. A provider is only allowed to collect appropriate Medicaid copays. There are no Medicaid copays for behavioral health services.   Providers cannot bill Members for the difference between commercial health insurance payments and their billed charges when Health First Colorado or an MCE does not make additional payment. The provider also cannot bill Members for copay/deductibles assessed by another payor.

Q: Can I bill a Member for services that are not covered by Medicaid?

A: A Medicaid Member may choose to privately pay for services that are NOT covered by Medicaid, including services determined not to be medically necessary. Failure by the provider to follow the proper process to obtain a prior authorization does not mean that a service is not covered by Medicaid or medically necessary. Additionally, if a provider chooses not to enroll with Medicaid or contract with an MCE, that does not qualify as documentation to bill a Member for services, nor does it deem a service as uncovered or not medically necessary. A Member is responsible for payment for the items provided or services rendered only when there is a written agreement in place. This written agreement is distinct from the standard consent form included in documentation a Member completes when they establish care with a provider. This agreement should, at a minimum, be signed prior to services being rendered and include a statement of the specific services being rendered, an explanation that the services are not covered by Medicaid, and that Medicaid cannot reimburse the Member for those services directly, and the full amount the Member will be responsible for paying. See C.R.S. § 25.5-4-301(1)(a)(1).

Q: What if I am contracted with an MCE but not contracted with the Primary Insurance? 

A: A provider must be contracted with a Member’s Primary Insurance in order to comply with TPL standards. A provider is required to bill the Primary Insurance and cannot submit claims to Gainwell or the MCE without TPL documentation. Claims that are submitted without TPL documentation will be denied by both Gainwell and an MCE.

Q: Can a provider who ‘Opts Out’ of Medicare with CMS serve Members who are dually eligible with Medicare and Medicaid? 

A: No. A provider must be contracted with a Member’s Primary Insurance in order to comply with TPL standards.  A provider who ‘Opts Out’ of Medicare would not be able to properly bill Medicare for covered services as the Primary coverage.  Additionally, this provider would not be able to bill Medicaid without the appropriate TPL documentation, and the provider would not be able to bill the Member.

Q: What steps should I take once I have identified all of a Medicaid Member’s coverages?

A: There are three (3) steps to getting reimbursement for services provided to a Medicaid Member with multiple health insurance coverages: 1) Bill the Primary Insurance for payment. 2) Bill the Secondary for payment with the Primary Insurance TPL payment and cost sharing information. 3) Store the other coverage information within the provider’s Member record and claim payment system(s) for use in future claim submissions. a) Add the other coverage to the Medicaid Provider Portal. (See the Provider Web Portal Quick Guide: Adding and Updating Third-Party Liability (TPL) Information. b) Update the provider records and Medicaid Provider Portal as coverages change. Example: Provider submits claim to Primary Insurance Primary Insurance pays provider $200.00 $80.00 Provider submits same claim to Gainwell or MCE - Includes TPL information with claim showing total paid to provider by Primary Insurance Gainwell refers to fee schedule MCE refers to contracted rate amount $200.00 $80.00 $84.00 Provider is paid the allowed rate less the TPL payment Provider receives total reimbursement from Gainwell/MCE $4.00 $4.00 Provider stores the other coverage for future billings

Q: What happens when Medicaid has issued a Directed Payment for a service?

A: The MCE is required to reimburse a provider a minimum of the Directed Payment published rate. The Directed Payment reimbursement will still follow general TPL guidelines where all payments from other coverage will be deducted from the amount of the Directed Payment rate. Example: Provider submits claim to Primary Insurance Primary Insurance pays provider Includes TPL information with claim showing total paid to provider by Primary Insurance $200.00 $80.00 Provider submits same claim to Gainwell or MCE - Gainwell refers to fee schedule MCE refers to Directed Payment rate amount $200.00 $80.00 $250.00* Provider is paid the allowed rate less the TPL payment Provider receives total reimbursement from Gainwell/MCE to ensure provider receives the PPS/Directed Payment amount $170.00 $170.00 Provider stores the other coverage for future billings *This illustrates a provider underbilling for services but receiving the full Directed Payment amount as required.

Q: Are there any instances when a provider should not bill the Primary Insurance first?

A: Providers should always bill a Member’s Primary Insurance prior to billing Medicaid or the MCE. Covered services for Primary Insurance policies vary by plan design. Billing the Primary Insurance allows a provider the opportunity to collect a higher reimbursement for covered services and also facilitates proper coordination of benefits, especially if the service’s coverage is questionable. When the Primary Insurance does not cover the service provided, a provider can submit the claim to Gainwell or the MCE.   HCPF recognizes that some behavioral health services are not routinely covered by Primary Insurance policies and may only be covered by Medicaid or the MCE. Behavioral health providers, can review services determined to be covered by Medicare, Medicaid and commercial insurances in Appendix I in the State Behavioral Health Services (SBHS) Billing Manual. For additional questions regarding TPL and COB policies, please send your inquiries to thirdparty_liability@state.co.us