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Behavioral Health Policies, Standards, and Billing References

Third Party Liability (TPL) [07/01/2022]
Providers are responsible for billing the payor who has primary responsibility for a service. There is a hierarchy to payers when a member has multiple insurances or is eligible for multiple benefit coverages. In general, private insurance should be billed first and then federal or state payers would be secondary. Medicaid is called the payer of last resort because Federal regulations require that all available health insurance benefits be used before Medicaid considers payment. With few exceptions, claims for members with health insurance resources are denied when the claim does not show insurance payment or denial information. 

When a Medicaid practitioner serves a member who is covered by both Medicare and Medicaid [i.e. considered dually eligible], they must submit claims for processing by Medicare before billing the MCE. Medicaid practitioners who serve dually eligible members must be enrolled with Medicare to bill the responsible primary payor. Effective April 1, LPCs, LMFTs and LACs who serve Medicare members are required to enroll as Medicare providers. Claims for services provided by an unlicensed behavioral health practitioner under the supervision of a Medicare-enrolled provider submitting claims as the rendering provider can be submitted directly to the MCE. These claims must include the HO modifier in the first available position after any required modifiers, to indicate the practitioner performing the service is not eligible to be covered by Medicare. Claims for services not covered by Medicare can be submitted directly to the MCE.

Medicaid does not automatically pay commercial health insurance co-pays, coinsurance, or deductibles. If the commercial health insurance benefit is the same or more than the Health First Colorado benefit allowance, no additional payment will be made. Providers cannot bill members for the difference between commercial health insurance payments and their billed charges when Medicaid does not make additional payment. The provider also cannot bill members for co- pay/deductibles assessed by the TPL. A provider must be contracted with all coverages a member has in order to comply with TPL policies. A provider cannot use a primary coverage denial resulting from being an out-of-network provider as appropriate TPL documentation when billing Medicaid. For additional information on TPL, please refer to this published FAQ.

 

Telehealth Policy [01/01/2021]
Telehealth is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance. At one time, telehealth in Medicaid had been referred to as telemedicine. Under the Medicaid Capitated Behavioral Health Benefit MCEs have the flexibility to authorize the use of outpatient treatment services to be delivered via audiovisual and telephone modalities when it is clinically viable and appropriate. The BHA does not limit the use of telehealth at licensed and designated facilities. Services provided via telehealth should be indicated by Place of Service 02 – “Telehealth Provided Other than in Member’s Home” or 10 – “Telehealth Provided in Member’s Home”. These place of service codes are not included on any coding page but should be used per each MCEs policy guidance.
Other standard requirements for telehealth services provided to a member include: 

  1. All services must be synchronous. 
  2. Any health benefits provided through telehealth shall meet the same standard of care as in- person care. 
  3. The availability of services through telehealth in no way alters the scope of practice of any health care provider; nor does it authorize the delivery of health care services in a setting or manner not otherwise authorized by law. 
  4. Services may be delivered by telephone only when it is clinically appropriate, no other form of service delivery is possible, and this is documented in the clinical record. When a service is provided by telephone (Audio Only) modifier FQ should be used in the first available position on a claim.
  5. Members that are new to a provider must contact the provider to initiate services.
  6. Services for established members must be consistent with the members’ treatment plan. 
  7. Providers must document the member’s consent, either verbal or written, to receive telehealth services. 
  8. Record-keeping and member privacy standards should comply with normal BHA and Medicaid requirements, HIPAA and 42 CFR Part 2 requirements. 
  9. Services not otherwise covered by the BHA, or Health First Colorado are not covered when delivered via telehealth. 
  10. Providers may only bill procedure codes which they are contracted with a MCE to bill.

 

Service Documentation Standards [01/01/2022]

Providers have the discretion to design the format of a service note that captures documentation in line with these guidelines and general professional standards for clinical care. Documenting clinical encounters is essential to quality clinical care and lays the foundation for coding and billing, as well as telling the story of the person’s treatment over time. Documentation is also evidence of several important factors: 

  1. That a service was provided. 
  2. That there is clinical rationale and medical necessity for the service. 
  3. That the service code utilized is appropriate to the encounter. 

Whether the individual served is engaged and/or benefiting from the service.

The following information must be documented for all clinical encounters submitted for reimbursement: 

  1. Date of Service (DOS) 
  2. Start and end time/duration of session and total contact time with person-served or collateral(s) 
  3. Session setting/place of service 
  4. Reason for the encounter, description of services provided, and interventions utilized 
  5. Provider’s dated signature and relevant qualifying credential. A title should be included where no credential is held.

Depending on the purpose and details of the encounter, including the type of service, duration and mode of delivery, details are included to indicate medical necessity of the services provided, including (as appropriate): 

  1. Documentation of consent to participate in the service (e.g. consenting to Telehealth) 
  2. The individual’s response to the service and/or demonstrated benefit from the service provided 
  3. Assessments, which may include treatment history, results of screening and/or diagnostic tools, Mental Status Exam (MSE), and clinical impressions.
  4. Relevance to the treatment/service plan. 
  5. Plan(s) for follow-up, including coordination of care, referrals, and recommendations

Shift Notes Documentation should include a description of all individual and group services rendered during the course of the shift/day. These can all be included in the same documentation or in a separate note as applicable (e.g. skills training group, individual therapy, med administration services, although included in the per diem, should be identified separately.)

 

Treatment Plan Standards [07/01/2018]

Clinical standards and best practice recommend that quality care should begin with a diagnostic evaluation or assessment of a member which would then inform a treatment/service plan. Outside of correct coding and appropriate documentation standards, Medicaid does not have any rules or guidelines that govern when an evaluation/assessment is completed, how frequently it is repeated, or what details are included. Additionally, while MCEs will audit providers and determine that assessments and treatment plans are documented and billed appropriately, there are no billing rules that require certain services to be billed before other services. For example, practitioners do not have to bill 90791 or H0032 before they bill 90834.

 

Neuro/Psychological Testing Policy [01/01/2022]

When a provider receives a referral for neuro/psychological testing the provider will determine the scope of testing needed based on a review of available member history and existing clinical documentation. Based on the primary condition being assessed or ruled out, a provider will identify the primary payer (RAE or FFS). 

  • RAE - If the referring diagnosis is part of the Capitated Behavioral Health Benefit (responsibility of the RAE), the provider should first seek Prior Authorization according to RAE policy. If the concluding diagnosis is a non-covered RAE diagnosis, the provider should still submit the claim to the RAE. 
  • FFS - If the referring diagnosis is part of the FFS benefit, then the provider needs to submit their claim to Gainwell for reimbursement. If the testing yields a diagnosis which is part of the Capitated Behavioral Health Benefit (responsibility of the RAE), the provider should still submit the claim to Gainwell and additionally use modifier code ‘SC’ to indicate it is an exception. 

 

Medicaid Service Providers [01/07/2018]

This is a list of practitioners who can provide hands-on care of behavioral health services. The services performed must be within the scope of the practitioner’s practice and license. This list is not meant to indicate who can enroll with or submit claims to Medicaid.

AcronymFull DescriptionRegulatory Reference
APNAdvanced Practice Nurse. Professional nurse licensed by the CO Board of Nursing who is recognized and included on the Advanced Practice Registry by the CO Board of Nursing.CRS 12-38-111.5; 3 CCR 716-1; SB 15- 
197
Bach LevelBachelor's Degree. Bachelor's degree in social work, counseling, psychology, or related field from an accredited institution. Providers with a bachelor’s degree or higher in a non-related field may perform the functions of a bachelor’s degree level staff person if they have one year in the behavioral health field. 10 CCR 2505-10
CASCertified Addiction Specialist. A CAS is an addiction counselor who may independently treat substance use and co-occurring disorders; conduct clinical assessments including diagnostic impression; provide treatment planning; coordinate referral and discharge planning; provide service coordination and case management; provide addiction counseling for individuals, families, and groups; and facilitate member, family, and community psychoeducation. A CAS may provide clinical supervision to individuals pursuing CAT and CAS.2 CCR 502-1; CRS 
12-245-804(3.5)(b)
CATCertified Addiction Technician. A CAT is an entry-level counselor who may collect biopsychosocial screening data; provide service coordination and case management; monitor compliance with case management plans; provide skill-based education; co-facilitate therapy groups with certified addiction specialists or licensed addiction counselors; provide member, family, and community addiction education; and coordinate referral and discharge resourcing and planning. Staff in the process of obtaining addiction technician credentials or certified addiction technicians must have all clinical documentation reviewed and co-signed by their clinical supervisor. CAT staff can only account for a maximum of one quarter or 25% of the counseling staff for all licensed programs. 10 CCR 2505-10 
8.746; CRS 12-245-805(3)(a), 
Certified/Registered Medical Assistant

Certified/Registered Medical Assistant. The U.S. Bureau of Labor identifies a medical assistant as an individual who completes administrative and clinical tasks in the offices of physicians, hospitals, and other healthcare facilities. 

Certification as a Certified Medical Assistant or a Registered Medical Assistant should be obtained through an accredited school 

CRS 12-36-106
CPSCertified Prevention Specialist. Credentialed by the CO Prevention Certification Board, under guidelines set by the International Certification and Reciprocity Consortium. Pass the IC&RC Examination for Prevention Specialists  
CRNACertified Registered Nurse Anesthetist. Licensed by the CO Board of NursingCRS 12-38-111.5
DODoctor of Osteopathy who is licensed by the CO Board of Medical Examiners CRS 12-36-101
InternAn intern must be from the clinical program of study that meets minimum credentials for service provided or code billed. Clinical programs of study are Masters, Doctoral, or Prescriber programs. Prescriber programs for APNs include preceptorships and mentorships. Bachelors-level programs are not clinical programs of study, and students in a bachelor's- level program will not be classified as interns under this definition. Interns will perform duties under the direct clinical supervision of appropriately licensed staff  
LACLicensed Addiction Counselor - holds a master's degree or higher in a clinical Behavioral Health specialization from an accredited college or university. Licensed by the Board of Addiction Counselor Examiners CRS 12-245-801; 4 
CCR 744-1; HB 19- 
1172 
LCSW

Licensed Clinical Social Worker - provider with master's or Doctoral degree from an accredited program offering full time course work approved by the Council on Social Work

Education (CSWE). Provider is licensed by the Colorado Board of Social Work Examiners 

CRS 12-43-403 
Licensed EdD, PhD, PsyD

Licensed Doctor of Education with a doctoral degree from an accredited program and who is licensed by the Colorado Board of Psychologist Examiners 

Licensed Doctor of Philosophy with a doctoral degree from an accredited program and who is licensed by the Colorado Board of Psychologist Examiners Licensed Doctor of Psychology with a doctoral degree from an accredited program and who is licensed by the Colorado Board of Psychologist Examiners 

CRS 12-43-303 and 
12-43-3043; CCR 
721-1
LMFT

Licensed Marriage and Family Therapist - provider possesses a master's degree or higher from a graduate program with course study accredited by the Commission on Accreditation for Marriage and Family Therapy Education (CAMFTE). 

Licensed by the CO Board of Marriage and Family Therapist Examiners. 

CRS 12-43-504 
LPCLicensed Professional Counselor - provider possesses a master's degree or higher in professional counseling from an accredited college or university. Licensed by the Colorado Board of Licensed Professional Counselor Examiners to practice professional counseling or mental health counseling CRS 12-43-603; 4 
CCR 737-1 
LPN/LVNLicensed Practical Nurse and Licensed Vocational Nurse. Graduated from an approved program of practical nursing. Licensed as a Practical Nurse from the CO Board of NursingCRS 12-38-103 
LPTLicensed Psychiatric Technician – provider performs selected acts requiring interpersonal and technical skills and includes the administering of selected treatments and selected medications prescribed by a licensed physician or dentist, in the care of and in the observation and recognition of symptoms and reactions of a patient with a behavioral or mental health disorder or an intellectual and developmental disability under the direction of a licensed physician and the supervision of a registered professional nurse. The selected acts in the care of a patient with a behavioral or mental health disorder or an intellectual and developmental disability must not require the substantial specialized skill, judgment, and knowledge required in professional nursing. CRS 12-295-103
MDDoctor of Medicine who is licensed by the CO Board of Medical Examiners CRS 12-36-101 
PAPhysician Assistant. Successfully completed the national certifying examination for PA's and is licensed by the CO Board of Medical Examiners CRS 12-36-106; SB 01-128
PSPeer Specialist. A peer specialist may also be referred to as a peer support specialist, recovery coach, peer and family recovery support specialist, peer mentor, family advocate or family systems navigator. A peer specialist “is a person who uses his or her lived experience of recovery from mental illness and/or addiction, plus skills learned in formal training, to deliver services in BH settings to promote mind-body recovery and resiliency.” A family advocate is a person whose “lived experience” is defined as having a family member who has a mental illness or substance use disorder and the knowledge of the BH care system gained through navigation and support of their family member. Peer Specialists perform a wide variety of non-clinical tasks to assist members “in regaining control over their own lives and recovery”6 processes. The following is a useful overview of the four major types of recovery support services: (1) peer mentoring or coaching, (2) recovery resource connecting, (3) facilitating and leading recovery groups, and (4) building community.8   Peer specialists assist members in navigating treatment systems for mental health and substance use disorders. Peer Specialists “promote self-determination, personal responsibility and the empowerment inherent in self-directed recovery.” 

Colorado does not require a peer specialist to be certified or licensed by DORA but to have formal training in specific content areas as outlined in Appendix P. 

See also HB 21- 1021 

QBHA

Qualified Behavioral Health Assistant. This support professional, non-clinical role works under supervision to carry out activities such as wellness promotion and education, community needs assessment, screening, referrals, crisis management, case management, orientation to services & care navigation, and individual and group interventions. 

  1. QBHAs are required to have training in specific content areas to include: 
  2. Understanding of Behavioral Health and Healthcare Systems 
  3. Empathy and Healthy Boundaries 
  4. Therapeutic Communication Skills 
  5. Case Management and Documentation 
  6. Crisis Intervention and Wellness 
  7. Trauma-Informed Care and Cultural Competency
SB 22-181 

Colorado does not require a Qualified Behavioral Health Assistant to be certified or licensed by DORA, but to have formal training through the Colorado Community College System (CCCS).
QMAPQualified Medication Administration Person. Successful completion of a State-approved medication administration course qualifies a QMAP to administer medications in settings authorized by law. A QMAP is employed by a licensed facility on a contractual, full- or part-time basis to provide direct care services, including medication administration to residents upon written order of a licensed physician or other licensed authorized practitioner. A QMAP may also be a person employed by a home health agency who functions as permanent direct care staff to licensed facilities, who is trained in medication administration, and who administers medication only to the residents of the licensed facility.6 CCR 1011-1, 24,2
RNRegistered Nurse. Graduated from an approved program of professional nursing and is licensed as a Professional Nurse by the CO Board of NursingCRS 12-38-103
RxNAdvanced Practice Nurse with Prescriptive Authority. Professional Nurse licensed by the CO Board of Nursing and who has been granted Prescriptive Authority by the CO Board of Nursing3 CCR 716-1-14, 1.14; CRS 12-38-111.5 and 12-38-111.6;
Unlicensed Ed/D, PhD, PsyD

Unlicensed Doctor of Education - provider possesses a Ed. D degree, doctoral level credentials. Received extensive training in research and/or clinical psychology but have not attained licensure by the CO Board of Psychologist Examiners 

Unlicensed Doctor of Psychology - provider possesses a Psy.D degree, doctoral level credentials. Received extensive training in research and/or clinical psychology but have not attained licensure by the CO Board of Psychologist Examiners 

Unlicensed Doctor of Philosophy - provider possesses a Ph. D degree, doctoral level credentials. Ph. D in philosophy signifies mastery of a broad discipline of learning together with demonstrated competence in a special field within that discipline

HB 21-1305 12-245-218 
Unlicensed Master LevelUnlicensed Master's Degree - provider has master's degree in a mental health field from an accredited college or university. Must be supervised in the provision of services by a Licensed Provider. Includes unlicensed psychotherapistHB 19-1172