Behavioral Health Policies, Standards, and Billing References

• Abbreviations and Acronyms
• Third Party Liability (TPL) [07/01/2022]
• Telehealth Policy [01/01/2021]
• Service Documentation Standards [01/01/2022]
• Treatment Plan Standards [07/01/2018]
• Neuro/Psychological Testing Policy [01/01/2022]
• Medicaid Service Providers [01/07/2018]
• Room and Board
• Court-Ordered Services
• Definition of Medical Necessity
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
• Covered Diagnoses
• Claiming Medicaid Services
• Outpatient Hospital Services
• Licensed Provider Claiming Under a Supervisor
• Missed Appointments
• Medicaid Supervision Policy
• Time Documentation Standards/Rules
• Current Procedural Terminology (CPT) Service Categories
• Medicaid State Plan Services
• Medicaid 1915(B)(3) Waiver Services
• Medicaid Place of Service Codes
• Medicaid Billing Provider Types Who Can Bill Under The Capitated Behavioral Health Benefit
• Modifiers for Medicaid Capitated Behavioral Health Benefit
• Targeted Case Management
• Peer Specialist Core Competencies
• FAQs on Urine Collection and Analysis [07/01/2018]

Abbreviations and Acronyms

This contains common abbreviations or acronyms not elsewhere explained in other resources.

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 the FAQ below.

Third Party Liability and Coordination of Benefits Frequently Asked Questions
Version 1.0, Created 7/1/2024

This FAQ is intended to provide guidance to providers serving Medicaid Members who have additional sources of insurance coverage.

Q1. What is Third Party Liability (TPL)?
A1. 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.

Q2. What is Coordination of Benefits (COB) and how does it work in general?
A2. 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.

Q3. Where can I find all of the coverages where a Medicaid Member is enrolled?
A3. 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.

Q4. 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?
A4. 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.

Q5. What can I do if I discover a Member has additional coverage after a service is provided?
A5. 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)

Q6. Am I allowed/required to collect a deductible, coinsurance, and/or copayments for the Primary Insurance from a Member who also has Medicaid coverage?
A6. 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.

Q7. Can I bill a Member for services that are not covered by Medicaid?
A7. 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).

Q8. What if I am contracted with an MCE but not contracted with the Primary Insurance?
A8. 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.

Q9. Can a provider who ‘Opts Out’ of Medicare with CMS serve Members who are dually eligible with Medicare and Medicaid?
A9. 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.

Q10. What steps should I take once I have identified all of a Medicaid Member’s coverages?
A10. 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.
   1. Add the other coverage to the Medicaid Provider Portal. (See the Provider Web Portal Quick Guide: Adding and Updating Third-Party Liability (TPL) Information).
   2. Update the provider records and Medicaid Provider Portal as coverages change.

Example:

*This illustrates a provider underbilling for services but receiving the full Directed Payment amount as required.

Q11. What happens when Medicaid has issued a Directed Payment for a service?
A11. 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:

*This illustrates a provider underbilling for services but receiving the full Directed Payment amount as required.

Q12. Are there any instances when a provider should not bill the Primary
Insurance first?
A12. 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.
 

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. 
4. Whether the individual served is engaged and/or benefiting form 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]

Medicaid has two categories of providers with separate requirements addressing each. The Medicaid Provider is the provider agency or independent practitioner who has a direct relationship with the state. It has a signed agreement with the state and MCE, when appropriate. The Medicaid Provider is documented as overseeing the member’s course of treatment, and can order, prescribe, or refer a member for services. This is the provider that can bill for services. The state specifies the requirements to be a Medicaid provider and the qualifications to enroll with Medicaid.

Medicaid Providers must enroll with Medicaid as a defined provider type (PT). A PT is distinct from a license, credential, or service category since some of our PTs are for groups of providers or do not require a specific professional license. For example, an LPC, LCSW, or LAC in private practice would enroll as PT 38 - “Licensed Behavioral Health Clinician”. Each PT also has specialty types - additional information/qualifications on the PT. For example, an SUD Continuum (PT 64) has different Specialty Types for the ASAM level of treatment offered. Many of our PTs have the same PT and Specialty Type. For example, a Licensed Psychologist (PT 37) has a specialty type of Licensed Psychologist. A list of Medicaid PTs that can bill for Medicaid services can be found on HCPF's website under the Medicaid Billing Provider Types Who Can Bill Under The Capitated Behavioral Health Benefit: in Appendix L.

Service Providers
The Medicaid Provider may in turn establish a relationship with a clinician, therapist, program staff, or paraprofessional who provides hands-on care to the Medicaid member. These are known as Service Providers. Any non-licensed professional that delivers Medicaid billable services must operate under the clinical supervision of a licensed professional, and the name of that licensed professional appears on the claim as the Rendering Provider.

Each coding page in the State Behavioral Health Services (SBHS) Billing Manual identifies the service providers that are acceptable to provide hands-on care if the service is within the scope of practice for the practitioner. Scope of Practice “means the extent of the authorization to provide health services granted to a health practitioner by a license issued to the practitioner in the state in which the principal part of the practitioner’s services is rendered, including any conditions imposed by the licensing authority (§ 12-245-101).”

Depending on the type of Medicaid service (physician services or BH services) and whether a professional practice act applies, there may be very specific requirements associated with who is eligible to provide hands-on care. If this is the case, such requirements must be followed for the service to be properly provided and reimbursed.

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.

Room and Board

Room and Board services (lodging and meals) are provided to members residing in a facility for at least 24 hours. Room and board is not a covered Medicaid benefit and is not included in any per diem rate. Room and board are included in reimbursement when services are rendered in a hospital or PRTF and billed using a revenue code. BHA covers room and board for some Medicaid members when a facility is contracted with BHA for reimbursement. For example, RSATFs bill room and board to BHA or their designee for Medicaid members. BHA covers room and board for uninsured/ underinsured members in some settings when all contractual and safety net criteria is met by a provider. Check your BHA contract for more details.

Court-Ordered Services

Services that are ordered by a court (to include psychological testing, SUD treatment, residential care, etc.) are not automatically covered or excluded by Medicaid. Services must be covered under the Capitated BH Benefit and meet Medical Necessity criteria to be reimbursed by Medicaid.

Definition Of Medical Necessity

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 healthcare 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.

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 aged 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. The services covered under EPSDT are limited to those within the scope of the category of services listed in federal law at 42 U.S.C. § 1396d(a).

This means that EPSDT benefits include medically necessary treatments that a recipient under 21 years of age needs to stay as healthy as possible, and Medicaid must provide or arrange for (directly or through referral to appropriate agencies, organizations, or individuals) corrective treatment. EPSDT benefits are more robust than the adult Medicaid benefit package and include a separate medical necessity definition for services rendered to or requested for members under the age of 21, see 10 CCR 2505-10 § 8.280.4.E.

EPSDT makes short-term and long-term services available to all members under 21 years of age without many of the limits Medicaid imposes for services for members over the age of 21. The services must be prescribed by the member’s treating provider(s) and prior authorization may be required for some services.

Covered ​Diagnoses    

The Medicaid Capitated Behavioral Health Benefit identifies covered diagnoses using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The ICD-10-CM is the official system of assigning codes to diagnoses and procedures used by all health care settings, including hospitals, physicians, nursing homes (NH), home health agencies and other providers. ICD-10-CM code selection follows the Official ICD-10-CM Guidelines for Coding and Reporting, developed cooperatively by the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and the National Center for Health Statistics (NCHS). These guidelines are a companion document to the ICD-10-CM, and while not exhaustive, assist the user in situations where the ICD-10-CM does not provide direction. The ICD10-CM is updated annually, effective October 1st. The ICD-10-CM does not include diagnostic criteria, primarily because its principal function as an international system is to define categories that aid in the collection of basic health statistics. The Official ICD-10-CM Guidelines must be followed when submitting claims for payment. It is important to check all diagnosis codes for appropriate guidelines before submitting a claim. For example, diagnosis codes may have a required number of digits (must be coded to greatest specificity). While most diagnosis codes will not include diagnostic criteria, others will provide guidelines according to some clinical criteria (for example, F10.1 and F10.2, alcohol dependence vs. alcohol abuse which have distinct definitions and clinical indications).

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), on the other hand, is the universal authority in the United States for diagnosing psychiatric disorders. Clinicians are encouraged to base their diagnostic decisions on DSM-5 criteria, and reference tables in the DSM-5 for ICD-10-CM insurance billing information. DSM-5 and the ICD are compatible with one another, and the DSM-5 contains a crosswalk to both ICD-9 and ICD-10 codes. The ICD–10-CM was implemented on October 1, 2015.

1. Primary/Principal Diagnosis
   Identifying the appropriate diagnosis that drives clinical treatment or other BH services is essential for many reasons. Beyond clinical considerations, as it relates to billing and coding, the diagnosis in the first position of a claim has significant impact. If an intervention is provided for a diagnosis not related to the condition indicated in the first position, it is possible the claim could be denied if the diagnosis is not covered under the Capitated Behavioral Health Benefit. A member may have a pervasive condition, a genetic disorder, or a chronic condition, as well as an episodic BH need. The diagnosis listed in the first position of a claim should be directly related to the service being provided regardless of any other co-occurring diagnosis.
2. Non-Covered Diagnoses
   A covered diagnosis is required for reimbursement, unless it falls in one of the following categories: Screening, Assessment, Crisis, or Prevention/Early Intervention. (See Appendix I for specific codes allowed without a covered diagnosis.) For these services, a non-covered diagnosis may be reported when these services have been rendered to a Medicaid member for the purpose of evaluating and assessing to determine the presence of and/or diagnose a BH disorder(s). When no other diagnosis has been determined, R69 or Z03.89 may be used. These codes are specifically intended for use when persons without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is found not to exist.
3. Covered Diagnoses
   The tables below list the covered diagnoses under the Medicaid Capitated Behavioral Health Benefit. Codes that are not covered may be billed to a member’s MCO, or to FFS if the member is not enrolled with an MCO. BHA also covers the diagnosis codes in these tables, as well as additional codes. Contact your BHA program manager for the most current version of the CCAR Manual where additional BHA covered diagnosis codes can be found.

Effective January 1, 2024, for members under 21 years old, Autism Spectrum Disorder (F84.0-F84.9) are covered diagnoses for psychotherapy services only (90785, 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849,90853)

Covered Mental Health Diagnoses

Covered SUD Diagnoses

Covered SDOH Diagnoses for Members Under 21 when billing services covered under SB23-174 Coverage (see Appendix I for codes highlighted in BLUE)

Claiming For Medicaid Services

This section outlines claim information for the Colorado Medicaid Capitated Behavioral Health
Benefit and is designed to assist providers with the key details to obtain Medicaid reimbursement. For more specific claiming instructions refer to the following RAE links:

1. Responsibility for Code Assignments
   Coding consistency is a major initiative in the quest to improve quality reporting and accurate claims submission for BH services. Adherence to industry standards and approved coding principles ensures quality along with consistency in the reporting of these services. The ultimate responsibility for procedure code assignment lies with the rendering provider. Policies and procedures may document instances where procedure codes may be selected and assigned by authorized individuals (i.e. coders), who may change a procedure code to more accurately reflect the provider’s documentation. However, collaboration with the provider is required, as the provider is ultimately responsible for the coding and documentation.

2. Approved Claim Formats
   All claims for services must be submitted in an approved claim format. The two (2) approved claim formats are:

   1. Institutional Claims - UB-04/837I (Also known as CMS-1450)
      Institutional claims are submitted on the UB-04 paper format. The 837I is the electronic equivalent of the UB-04 and is subject to all HIPAA standards (transactions, privacy, and security). The UB-04 is used for all institutional provider billing with the exception of the professional component of physician’s services (see CO-1500 below). The following provider types use the UB-04/837I claim form:
      1. Inpatient Hospital
      2. Nursing Facility
      3. Home Health/Private Duty Nursing
      4. Hospice
      5. Psychiatric Residential Treatment Facility
      6. Dialysis Center
      7. Outpatient Hospital
      8. Outpatient Laboratory
      9. Hospital-Based Transportation
      10. Rural Health Clinic
      11. Federally Qualified Health Center
          
          For detailed instructions on completing the UB-04, refer to the Colorado MAP Billing Manuals; the 837I Transaction Data Guide; the 837I Implementation Guide or the Web Portal User Guide; and/or the appropriate RAE provider manual.
   2. Professional Claims - CO-1500/837P (Formerly known as CMS-1500)
      The 1500 claim form was developed primarily for outpatient services. These professional health service claims are submitted on a paper CMS-1500 claim form or in the electronic 837 Professional 4010A1 (837P) format. Paper CMS-1500 forms must be submitted using the scanned, red ink version. The following services are billed on the CO-1500/837P claim format:
      1. Practitioner Services
      2. Independent Laboratory Services
      3. Durable Medical Equipment and Supplies (DME)
      4. Non-Hospital Based Transportation
      5. Home and Community-Based Services (HCBS)
      6. Residential services described in Appendix C and billed using a code with a Residential primary category listed in Appendix I. [Although these are not outpatient services, they do not include room and board and are viewed as professional services]

   For detailed instructions on completing the CMS-1500, refer to the Colorado MAP Billing Manuals; the National Uniform Claim Committee (NUCC) 1500 Claim Form Map to the X12 837 Health Care Claim: Professional.9 the 837P Transaction Data Guide; the 837P Implementation Guide or the Web Portal User Guide; and/or the appropriate RAE provider manual.

Outpatient Hospital Services

Hospital services provided to a Medicaid member attributed to an MCE for a primary BH Diagnosis covered by an MCE are covered under the Capitated Behavioral Health Benefit according to the following parameters. MCEs have the responsibility to ensure these services are medically necessary and may deny a claim for this reason. Providers are able to appeal any claims denials.

1. Professional services provided in an inpatient hospital, outpatient hospital, or emergency room setting billed on a CMS-1500/ANSI 837-P claim form when the procedure(s) is listed in the State Behavioral Health Services (SBHS) Billing Manual.
2. Outpatient hospital services billed on a UB-04/ANSI 837-I X12 claim form that do not include a behavioral health service but are for a primary behavioral health diagnosis.
3. Intensive Outpatient Program (IOP) services performed in an outpatient hospital setting when the procedure is billed on a UB-04/ANSI 837-I X12 claim form.
4. Emergency room services for a primary mental health diagnosis billed on a UB-04/ANSI 837-I X12 claim form.
5. All inpatient services for a primary mental health diagnosis billed on a UB-04/ANSI 837-I X12 claim form, this includes all psychiatric and associated medical and facility services, labs, x-rays, supplies, occupational, physical, and speech therapy services, and other ancillary services. Split billing for behavioral health services provided in an inpatient setting is not permitted.

Exclusions:

1. Outpatient emergency room services for a primary SUD diagnosis billed on a UB-04/ANSI 837-I X12 claim form are billed fee-for-services (FFS).
2. All inpatient services for a primary SUD diagnosis billed on a UB-04/ANSI 837-I X12 claim form for ASAM level 4 criteria are billed FFS.
3. Hospital services billed on a UB-04/ANSI 837-I X12 claim form for a primary diagnosis of Autism Spectrum Disorder (F84.0-F84.9) are billed FFS. ASD is only considered a RAE-covered diagnosis for psychotherapy services for members under 21 years old.
4. Hospital services billed on a UB-04/ANSI 837-I X12 claim form for a primary diagnosis of Gender Dysphoria (F64.0-F64.9) are billed FFS. This is addressed in the Gender Affirming Care billing manual here.
5. Occupational Therapy (OT), Physical Therapy (PT), and Speech Therapy (ST) billed on a CMS1500/ANSI 837-P claim form are billed FFS regardless of diagnosis.

Licensed Provider Claiming Under a Supervisor

Practitioners who are enrolled with Medicaid and have applied for credentials with a Regional Accountable Entity (RAE) may submit claims under a supervising provider for a maximum of 90 days while completing contracting with a RAE. This policy applies to:

1. Newly licensed BH providers who were providing services to members under clinical supervision while they were working toward licensure.
2. Licensed BH providers who are hired by a group practice.

Missed Appointments

Medicaid cost sharing is only permitted as specified in sections 1902(a)(14), 1916 and 1916A of the Social Security Act and their implementing regulations at 42 CFR 447.50-57. Cost sharing under those statutes and regulations is only permissible for services under the state plan. There are no procedure codes for missed appointments (i.e. cancellations and/or “no shows”). A missed appointment is a “non-service” and is not reimbursable or reportable. From a risk management perspective, however, missed appointments should be documented in the clinical record.

Medicaid Supervision Policy

Medicaid services provided by practitioners not enrolled in Medicaid must be supervised by and billed under a Medicaid-enrolled provider who is documented as overseeing the member’s course of treatment. Supervision for the purposes of Medicaid billing and rendering of services is distinct from clinical supervision standards for professional licensure under DORA. There are two domains of guidance that address supervision standards for Medicaid services: Behavioral Health Services and Physician and Other Licensed Practitioner Services. For Behavioral Health Services, CMS defers to Colorado’s Mental Health Practice Act, which specifies the type of oversight or supervision required to practice in the State. In general, a licensed BH clinician (Psychologist, LCSW, LPC, LAC, etc.) can operate independently as well as supervise the work of an unlicensed master’s or doctoral level provider who provides hands-on care of a member. While an unlicensed provider can “render” (or provide) hands-on care to a Medicaid member, the licensed provider who is an enrolled Medicaid provider is the one responsible for services and must be the “rendering provider” on the claim.

RAEs have published the Colorado Medicaid Standards For Unlicensed Practitioners policy
document. This establishes the standards that RAEs expect providers who are not licensed by BHA to meet. An annual attestation form must be submitted to the RAE affirming a provider is in compliance with this policy. This policy, the attestation form, and a Frequently Asked Questions (FAQ) resource are posted on HCPF's SBHS Billing Manual website.

For services provided in a medical/institutional setting, the supervision standards are addressed under Physician Services regulations.

1. “Personal supervision” means the definition specified at 42 CFR 410.32(b)(3)(iii), that is, the physician must be in attendance in the room during the performance of the service or procedure.
2. “Direct supervision” means the definition specified at 42 CFR 410.32(b)(3)(ii), that is, the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.
3. “General supervision” means the definition specified at 42 CFR 410.32(b)(3)(i), that is, the procedure or service is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.

Time Documentation Standards/Rules

When documenting, reporting and/or billing CPT® or HCPCS procedure codes, the units of service should be consistent with the time component defined in the procedure code description. CPT® and HCPCS procedure codes include both “timed” and “untimed” procedure codes.

“Timed” procedure codes specify a direct time increment in the procedure code description. The direct time component is only that time spent with the member and/or family in a billable activity. Non-direct time (i.e., pre-, and post-encounter time, drive time with the member to an encounter, etc.) is not included in the calculation of the time component. Examples of time-specific services are psychological testing (1 hour), psychotherapy (from 20 – 30 minutes up to 70 – 80 minutes), and case management (15 minutes).

“Untimed” procedure codes do not include specific direct time increments in the procedure code description. These procedure codes represent a service or procedure without regard to the length of the encounter. If there is no designated time in the procedure code description, the procedure code is reported or billed as one (1) unit (i.e., session, encounter), regardless of the number of minutes spent rendering the service. Examples of “untimed” services are psychiatric diagnostic interview exam, and medication management.

A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes has elapsed.

1. Fifteen (15) Minute Time-Based Procedure Codes
   Some CPT® and HCPCS procedure codes specify that the direct time spent in member contact is 15 minutes. The provider reports or bills these procedure codes with the appropriate number of 15-minute units of service using the following time intervals:

   Determining Billing Units for 15 Minute Timed Procedure Codes
   # of 15 Minute Units	Duration
   1 unit	Greater than or equal to 8 minutes and less than 23 minutes
   2 units	Greater than or equal to 23 minutes and less than 38 minutes
   3 units	Greater than or equal to 38 minutes and less than 53 minutes
   4 units	Greater than or equal to 53 minutes and less than 68 minutes
   5 units	Greater than or equal to 68 minutes and less than 83 minutes
   6 units	Greater than or equal to 83 minutes and less than 98 minutes
   7 units	Greater than or equal to 98 minutes and less than 113 minutes
   8 units	Greater than or equal to 113 minutes and less than 127 minutes

    

   The pattern continues in the same way for service times in excess of two (2) hours. For all services, providers should not report, or bill services rendered for less than eight (8) minutes. For case management services (T1017 and H0006) providers may not bill services rendered for less than eight (8) minutes, however bundling of these services is acceptable.

   While the above table provides guidance in rounding time into 15-minute increments, it does not imply that any minute until the eighth should be excluded from the total count. The time of direct treatment includes all time spent in member contact. The start and end time of the treatment service should be routinely documented in the member’s clinical record as part of the progress note.

2. One-Hour Time-Based Procedure Codes
   Some CPT and HCPCS procedure codes specify that the direct time spent in member contact is 1 hour. The provider reports or bills these procedure codes with the appropriate number of 1-hour units of service using the example time intervals given in the table below. The pattern continues in this manner.

   Determining Billing Units for 1-hour or 60 Minutes Timed Procedure Codes
   # of 60 Minute Units	Duration
   1 unit	Greater than or equal to 31 minutes and less than 91 minutes
   2 units	Greater than or equal to 91 minutes and less than 151 minutes
   3 units	Greater than or equal to 151 minutes and less than 211 minutes
   4 units	Greater than or equal to 211 minutes and less than 271 minutes
   5 units	Greater than or equal to 271 minutes and less than 331 minutes
   6 units	Greater than or equal to 331 minutes and less than 391 minutes
   7 units	Greater than or equal to 391 minutes and less than 451 minutes

    

3. Encounter Time-Based Procedure Codes
   Some CPT® and HCPCS procedure codes are reported as encounters (1 unit), but also specify an approximate amount of direct time in the procedure code description. For example, the CPT® procedure codes 90832 – 90838 for individual psychotherapy state “approximately ‘x’ minutes direct contact with the member.” HCPCS procedure codes G0176 – G0177 for partial hospitalization program (PHP) activity therapy and training and education services parenthetically state “45 minutes or more.” The actual start and stop time or the total amount of time (i.e. duration) spent with a member must be documented to support coding for encounters based on time.
4. Per Diem Procedure Codes
   Some CPT® and HCPCS procedure codes are reported by “day” units (per diem). This is defined by a calendar day and may or may not have a minimum duration indicated on the coding page. A per diem code should be claimed for the date of admission even if the member discharged the same day, and regardless of the amount of time the member was actually at the facility/program. A per diem code should not be claimed for the date of discharge unless it was the same date as the admission.

Current Procedural Terminology (CPT) Service Categories

Each CPT code falls into one of ten primary categories of service, or “Service categories”. These categories are not listed on the individual SBHS Billing Manual pages but can be found in Appendix I.

Prevention/Early Intervention Services
Prevention and Early Intervention Services include “screening and outreach to identify at-risk
populations, proactive efforts to educate and empower Members to choose and maintain healthy life behaviors and lifestyles that promote behavioral health. Services can be population-based, including peer, and group interventions, and are not restricted to face-to-face interventions.” Prevention and Early Intervention Services include:

• Mental health (MH) screenings
• Nurturing Parent Program
• Educational programs (safe and stable families)
• Senior workshops (common aging disorders)
• “Love and Logic” (healthy parenting skills)
• CASASTART (children at high risk for substance abuse (SA), delinquency, and academic failure)

Crisis Services
Crisis/Emergency Services are “provided during a MH emergency, which can involve unscheduled, immediate, or special interventions in response to a crisis with a member, including associated laboratory services, as indicated.” Services are designed to:

• Improve or minimize an acute crisis episode
• Assist the member in maintaining or recovering his/her level of functioning (LOF) by providing immediate intervention and/or treatment in a location most appropriate to the needs of the member and in the least restrictive environment available
• Prevent further exacerbation or deterioration and/or inpatient hospitalization, where possible
• Prevent injury to the member and/or others
• Stabilization is emphasized so that the member can actively participate in needs assessment and treatment/ service planning. Services are characterized by the need for highly coordinated services across a range of service systems. Crisis/Emergency Services are available on a 24-hour, 7-day a week basis.

Screening Services
Screening is provided to address the needs of those seeking BH treatment services in a timely manner. This brief assessment involves an initial appraisal of an individual’s need for services. If there are sufficient indications of a MI and/or substance-related disorder, further diagnostic assessment is warranted to determine the individual’s eligibility for admission to BH treatment services, as well as appropriate referrals and preliminary recommendations. Additionally, substance use screening can be used as a part of treatment. Screening services are often performed through specimen collection to test for the presence of alcohol and/or drugs. Results are discussed with the member during a Substance Use counseling session. Screenings often provide members with personal feedback about their increased risks due to substance use and may identify problems that can prompt individuals to change their substance use behavior.

Assessment Services 
Assessment Services are the process, both initial and ongoing, of collecting and evaluating information about a member for developing a profile on which to base treatment/service planning and referral (2 CCR 502-1, 190.1). An Assessment may also use a diagnostic tool to gather the information necessary in the Assessment Services process. These can include services related to Diagnosis, Psychological Testing/Neuropsychological Testing, or Treatment/Service Planning.

Treatment Services
Treatment services utilize a variety of methods to treat mental, behavioral, and substance use disorders. The goal is to alleviate emotional disturbances and reverse or change maladaptive patterns of behavior in order to encourage a member’s personal growth and development. Treatment services often utilize assessments to formulate and implement an individualized comprehensive written treatment/service plan that is used to promote the member’s highest possible level of independent functioning. For SUD diagnoses, treatment can include relapse planning, information about the process of addiction, and assist members to understand some of the underlying issues that lead them to use substances. Services that can be provided under this category can include Psychotherapy (individual, group, or family), Medication Management, Substance Use Treatment Services, Rehabilitation Services, Inpatient Services, Targeted Case Management (TCM) Services, Vocational Services, Intensive Treatment Services, Consultation Services, Medical Team Conference, or Other Professional Services.

Evaluation and Management (E/M) Services
E/M codes cover a broad range of services for members in both inpatient and outpatient settings. They are generic in the sense that they are intended to be used by all physicians, nurse practitioners, and physician assistants and to be used in primary and specialty care alike. For E/M codes covered under the Capitated BH Benefit see Appendix E in the SBHS Billing Manual.

DEFINITIONS:

• New patient: A new patient is defined as one who has not received any professional services from the prescriber or another prescriber of the exact same specialty and subspecialty who belongs to the same group within the past 3 years.
• Established patient: An established patient is one who has received professional services from the prescriber or another prescriber of the exact same specialty and subspecialty who belongs to the same group within the past 3 years.

There is no distinction made between new and established patients in the emergency Department.

Residential Services
Residential Services are any type of 24-hour care, excluding room and board, provided in a nonhospital, non-nursing home (NH) setting, where the contractor provides supervision in a therapeutic environment. Residential Services are appropriate for children, youth, adults and older adults whose MH issues and symptoms are severe enough to require a 24-hour structured program, but do not require hospitalization.”

Respite Care Services
Respite Care Services are Temporary or short-term care of a child, adolescent or adult provided by adults other than the birth parents, foster parents, adoptive parents, family members or caregivers with whom the Member normally resides, designed to give the usual caregivers some time away from the Member to allow them to emotionally recharge and become better prepared to handle the normal day-to-day challenges.” This service acknowledges that, while the services of primary caregivers may keep a member out of more intensive levels of care (i.e., inpatient hospital), there are occasional needs to substitute for these caregivers. Respite Care Services may be rendered when:

• The member’s primary caregivers are unable to provide the necessary illness-management support and thus the member is in need of additional support or relief
• The member and his/her primary caregivers experience the need for therapeutic relief from the stresses of their mutual cohabitation
• The member is experiencing a behavioral crisis and needs structured, short-term support
  Relief care giving is necessitated by unavoidable circumstances, such as a family emergency

Peer Support/Recovery Services
Peer Support/Recovery Services are “designed to provide choices and opportunities for adults with SMIs, youth with SEDs, or individuals with SUDs. Recovery-oriented services promote self-management of psychiatric symptoms, relapse prevention, treatment choices, mutual support, enrichment, and rights protection. Peer Support/Recovery Services also provide social supports and a lifeline for individuals who have difficulties developing and maintaining relationships. These services can be provided at schools, churches, or other community locations. Most recovery services are provided by BH peers or family members, whose qualifications are having a diagnosis of MI or substance use or being a family member of a person with MI and/or substance use.” Peer Support/Recovery Services include:

• Peer counseling and support services
• Peer-run drop-in centers
• Peer-run employment services
• Peer mentoring for children and adolescents
• Bipolar Education and Skills Training (BEST) courses
• National Alliance on Mental Illness (NAMI) courses
• Wellness Recovery Action Plan (WRAP) groups
• Member and family support groups
• Warm lines
• Advocacy services

Support Services
Support Services are not clinical but help facilitate a psychotherapy encounter and include such supports as childcare for a member receiving clinical care, Non-Emergent Medical Transportation (NEMT), and sign language services.

Medicaid State Plan Services

Inpatient Services include:

1. Inpatient hospital – under 21: a program of care for members under age twenty-one (21) in which the member remains twenty-four (24) hours a day in a psychiatric hospital, or other facility licensed as a hospital by the state. Members who are inpatient on their twenty-first birthday are entitled to receive inpatient benefits until discharged from the facility or until their twenty-second (22) birthday, whichever is earlier, as outlined in 42 CFR 441.151.
2. Inpatient hospital – adult 21-64: a program of psychiatric care in which the member remains twenty-four (24) hours a day in a facility licensed as a hospital by the state, excluding state institutions for mental disease (IMDs).
3. Inpatient hospital – 65 and over: a program of care for members age sixty-five (65) and over in which the member remains twenty-four (24) hours a day in institutions for mental diseases (IMD) or other facility licensed as a hospital by the state.

SUD Inpatient and Residential Services are Substance Use Disorder (SUD) treatment and withdrawal management services, including services along the continuum of care defined by the American Society of Addiction Medicine (ASAM). Services are provided to Medicaid beneficiaries with one or more diagnosed SUD(s). Services are determined according to medical necessity which include an assessment of level of clinical severity and function.

Outpatient Services are a program of care in which the member receives services in a hospital or other health care facility/office, but does not remain in the facility twenty-four (24) hours a day,
including:

1. Physician Services, including psychiatric care: BH services provided within the scope of practice of medicine as defined by State law.
2. Rehabilitative Services: Any remedial services recommended by a physician or other licensed practitioner of the healing arts, within the scope of his/her practice under State law, for maximum reduction of behavioral/emotional disability and restoration of a member to his/her best possible functional level, including:
   1. Individual BH Therapy: Therapeutic contact with one member.
   2. Individual Brief BH Therapy: Therapeutic contact with one member.
   3. Group BH Therapy: Therapeutic contact with more than one member.
   4. Family BH Therapy: Therapeutic contact with a member and family member(s), or other persons significant to the member, for improving member-family functioning.
   5. Family BH therapy is appropriate when intervention in the family interactions is expected to improve the member’s emotional/BH. The primary purpose of family BH therapy is treatment of the member.
   6. Behavioral Health Assessment: Clinical assessment of a member by a BH professional that determines the nature of the member’s problem(s), factors contributing to the problem(s), a member’s strengths, abilities, and resources to help solve the problem(s), and any existing diagnoses.
3. Pharmacologic 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
4. Outpatient Day Treatment: Therapeutic contact with a member in a structured, nonresidential program of therapeutic activities. Services include assessment and monitoring; individual/ group/ family therapy; medical/nursing support; psychosocial education; skill development and socialization training focused on improving functional and behavioral deficits; medication management; expressive and activity therapies; and coordination of needed services with other agencies. When provided in an outpatient hospital program, may be called "partial hospitalization."
5. Emergency/Crisis Services: Services provided during a BH emergency which involve unscheduled,immediate, or special interventions in response to crisis situation with a member/family, including associated laboratory services, as indicated.
6. Pharmacy Services: Prescribed drugs when used in accordance with 10 CCR 2505-10 Section 8.800, Pharmaceuticals.
7. Targeted Case Management: Case management services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational, and other services.
8. School-Based BH Services: BH services provided to school-aged children and adolescents onsite in their schools with the cooperation of the schools.
9. Drug Screening and Monitoring: Substance use disorder counseling services provided along with screening results to be discussed with member.
10. Medication-Assisted Treatment: Administration of Methadone or another approved controlled substance to an opiate-dependent person for the purpose of decreasing or eliminating dependence on opiate substances.

Medicaid 1915(B)(3) Waiver Services

1915 B3 Waiver Services are also called “alternative” services because these are alternatives to inpatient level of care. Alternative services are intended to serve adults with Serious Mental Illness (SMI) diagnoses or children/adolescents with a Serious Emotional Disturbance (SED) diagnosis in order to keep them supported and living in the community. Alternative services are BH services not included in our State Plan. However, each State must ensure that all BH services covered under the State Plan are available and accessible to enrollees of the 1915 B3 Waiver Program. Alternative services are broken down into 8 categories:

1. Prevention/Early Intervention services are proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive psychological health.
   1. Prevention and early intervention efforts include services such as BH screenings, the Nurturing Parent Program, educational programs promoting safe and stable families, senior workshops related to common aging disorders, and Love and Logic classes for healthy parenting skills.
2. Respite Care is temporary or short-term care of a child, youth or adult client that is provided by adults other than the birth parents, foster parents, adoptive parents, family members or caregivers that the client normally resides with, that is designed to give the parents, family members or caregivers some time away from the client, to allow them to emotionally recharge and become better prepared to handle the normal day-to-day challenges.
3. Intensive Case Management describes community-based services averaging more than one hour per week, provided to adults with serious behavioral health diagnoses who are at risk of hospitalization, incarceration and/or homelessness due to multiple needs and impaired level of functioning. Services are designed to provide adequate supports to ensure community living.
   1. Services are assessment, service plan development, multi-system referrals, assistance with obtaining wrap-around services and supportive living services, monitoring and follow-up.
4. Vocational Services are services designed to assist adults and adolescents who are ineligible for state vocational rehabilitation services and require long-term services and supports in developing skills consistent with maintaining employment and/or in obtaining employment.
   1. Services are skill and support development interventions, vocational assessment, and job coaching.
5. Recovery Services are designed to provide choices and opportunities for adults with serious behavioral health disorders. Recovery-oriented services promote self-management of psychiatric symptoms, focus on relapse prevention, treatment choices, mutual support, enrichment, and rights protection. Recovery services also provide social supports and a lifeline for individuals who have difficulties developing and maintaining relationships. These services can be provided at schools, churches, or other community locations.
   1. Recovery services are peer counseling and support services, peer-run drop-in centers, peer-run employment services, peer mentoring for children and adolescents, Bipolar Education and Skills Training (BEST) courses, National Alliance for the Mentally Ill (NAMI) courses, Wellness Recovery Action Planning (WRAP) groups, consumer and family support groups, warm lines, and advocacy services.
6. Clubhouses and drop-in center services are peer support services for people who have BH disorders, provided in Clubhouses and drop-in centers. In Clubhouses, individuals (members) utilize their skills for clerical work, data input, meal preparation, providing resource information or reaching out to fellow members. Staff and members work side by side, in a unique partnership.
   1. In drop-in centers, members plan and conduct programs and activities in a club-like setting. There are planned activities and opportunities for individuals to interact with social groups.
7. Assertive Community Treatment (ACT) is a service-delivery model that provides comprehensive, community-based treatment to adults with a serious behavioral health diagnosis. Services are highly individualized and are available 24 hours a day, seven days a week, 365 days a year to clients who need significant assistance and support to overcome the barriers and obstacles that confront them.
   1. ACT teams provide case management, initial and ongoing BH assessments, psychiatric services, employment and housing assistance, family support and education, and substance use disorder services.
8. Residential Services are defined as twenty-four (24) hour care, excluding room and board, provided in a non-hospital, non-nursing home setting, and are appropriate for individuals members) whose BH issues and symptoms are severe enough to require a 24-hour structured program but do not require hospitalization. Residential services are a variety of clinical interventions that, individually, may appear to be similar to traditional state plan services. By virtue of being provided in a setting where the client is living, in real-time (i.e. with immediate intervention possible), residential services become a unique and valuable service in their own right that cannot be duplicated in a non-structured community setting. These clinical interventions, coupled together, in real-time, in the setting where a client is living, become a tool for treating individuals in the most cost-effective manner and in the least restrictive setting.
   1. Clinical interventions provided in this setting are: assessment and monitoring of mental and physical health status; assessment and monitoring of safety, including suicidal ideation and other BH issues; assessment of level and quality of social interactions; assessment of/support for motivation for treatment; assessment of ability to provide for daily living needs; observation and assessment of group interactions; behavioral interventions to build effective social behaviors and coping strategies; behavioral interventions to reduce social withdrawal and inappropriate behaviors or thought processes; individual therapy; group therapy; family therapy; and medication management.

Medicaid Place of Service Codes

Medicaid Billing Provider Types Who Can Bill Under The Capitated Behavioral Health Benefit

Modifiers For Medicaid Capitated Behavioral Health Benefit

Effective January 1, 2024, HCPF removed the requirement for a first position modifier to identify a service as either a State Plan or B3 service on all codes. As a result, these modifiers were removed from this table.

Select Residential codes require a modifier to distinguish a service or level of care. These modifiers should be used in the first position on a claim.

The following modifiers should be added in the first available position on a claim when applicable.

NOTE: This table lists modifiers that can be used when billing Managed Care Entities under the Capitated Behavioral Health Benefit. There may be other modifiers required for billing Fee-For-Service or the Behavioral Health Administration (BHA).

Targeted Case Management

According to the Colorado State Plan, Targeted Case Management (TCM) is a covered benefit for an identified Target Group: "Medicaid clients enrolled in the [Capitated Behavioral Health Benefit] (a Section 1915(b) waiver program) who have or are being assessed for a mental health diagnosis(es) covered under the [Capitated Behavioral Health Benefit]."

Case management services are services furnished to assist individuals, eligible under the State Plan, in gaining access to needed medical, social, educational and other services. Case management does not include activities integral to the administration of foster care programs, or for which third parties are liable to pay.

Examples of Case Management

Assessment of service needs:

• Comprehensive assessment/periodic reassessment of the individual’s need for medical, educational, social, or other services.
• Activities/Interventions to gather/confirm information coming from the Individual, family, and other sources in order to complete assessment.
• Determining with the individual/family/supports their ability to access and effectively link to these services and supports on their own and what type of help they will need, including how intensely and for how long case management services will be needed.
• Assisting the Individual and their Family/Supports in understanding what case management services include their limitations so that they can better participate in the case management assessment and treatment/service planning process

Development of a specific service plan that includes:

• Prioritizing with the Individual and their Family/Supports the referrals and linkages needed so the treatment/service plan reflects the case management assessment. As a result of the assessment, the case management plan will have a timeline for referral and linkage as well as the expected outcomes of the interventions.
• Specifies goals and actions to address the medical, social, educational, and other services needed by the individual.
• Identifies a course of action to respond to assessed needs.
• Developing, in conjunction with the Individual, a list of agreed upon case management interventions that will be used to help the Individual successfully link to services and supports.
• Develop with the Individual and Family/Supports the role of the persons providing case management services in coordinating care among treatment providers, other services, and natural/community supports.
• Develop with the Individual an agreed upon structure for regular meetings with the person(s) providing case management services to review progress and determine necessary changes to the treatment/service plan.

Referral and related activities to obtain needed services:

• To help an individual obtain needed service including activities that link them to medical, social, or educational providers or other services capable of providing services and assisting in referral/scheduling.
• Follow-up post appointments to ensure that the person providing case management services understands any changes or recommendations to treatment or to the content of the supports that will be provided, and that this information is also understood and able to be acted on effectively by the Individual/Family/Supports.

Monitoring and follow-up:

• Meeting via phone or face-to-face (all services can take place face-to-face or via phone) on a regularly scheduled basis with the individual and their Family/Supports to ensure that services are being provided according to the treatment/service plan, that the individual believes they are effective, and wishes to continue according to the current treatment/service plan to ensure the member is getting the services they need.
• Talking/meeting with Providers and Supports, with or without the Individual present, to coordinate care, assess the effectiveness of service, progress of the Individual towards goals and objectives on any treatment/service plan, and soliciting ideas for changes that will allow for more rapid progress towards the Individual’s recovery goals. Again, the overall purpose of these activities is to ensure the member is getting the services they need.

Case Management does not include the following:

• Case management activities that are an integral component of another covered Medicaid service.
• Direct delivery of medical, educational, social, or other services to which a Medicaid eligible member has been referred.
• Activities integral to the administration of foster care programs.
• Activities, for which a Medicaid eligible member may be eligible, but are integral to the administration of another non-medical program.

Peer Specialist Core Competencies

Combined Core Competencies for Colorado’s Peer Specialists, Recovery Coaches, and Family Advocates/Family Systems Navigators.

Updated and Approved by Behavioral Health Transformation Council 1/25/2013

*Item pertains specifically to Family Advocates Family Systems Navigators Sources of Information and Input:

1. Advocates for Recovery - Colorado Core Competencies for Recovery Coaches, (2010)
2. Blanch, A., Filson, B., & Penney, D. Engaging Women in Trauma-Informed Peer Support: A Guidebook (2012)
3. Colorado Mental Health Advocates' Forum Peer Specialist Core Competencies, as adopted by the Colorado Department of Health Care Policy and Financing (HCPF) in its Medicaid Community Mental Health Services Program Request for Proposals released December 2008.
4. Colorado Mental Health Advocates' Forum Consensus Statement on Resiliency (2012)
5. Colorado Mental Health Advocates' Forum Consensus Statement on Trauma-Informed Care (2012)
6. National Federation of Families for Children’s Mental Health Certified Parent Support Specialist Self Assessment Training Checklist, Sept. 2011, from the National Federation website.
7. SAMHSA's Working Definition of Recovery (Dec. 2011), retrieved from the U.S. Department of Health and Human Services,
8. Substance Abuse and Mental Health Services Administration website
9. House Bill 1193- Concerning Integrated System-of-Care Family Advocacy Programs for Mental Health Juvenile Justice Populations. (2011)

FAQs on Urine Collection and Analysis [07/01/2018]

Q1. Are urine collection and analysis tests reimbursed by Health First Colorado (Colorado’s Medicaid program)? 
A1. There are three components to a urinalysis (UA): collection, analysis, and counseling.  

1. Collection of a urine specimen alone is not reimbursable.
2. The analysis of the specimen is billed fee-for-service by the laboratory. According to rule and Laboratory billing guidelines, a physician’s order is required for a lab to bill for analysis. 
3. The review of results and counseling provided to a member can be billed to a Managed Care Entity (MCE) by using HCPCS code S9445.  

Q2. Are strip tests, or other testing that does not require a lab analysis, reimbursed by Health First Colorado?
A2. Health First Colorado does not reimburse for strip tests, dip sticks, or any other methodology considered “Direct Optical Observation”. Providers contracted with the Behavioral Health Administration can submit these services in their client-level encounter reporting using CPT Code 80305.

Q3. Are monthly UAs as a part of recovery support services reimbursable by Health First Colorado?
A3. If a physician orders the UA and a behavioral health practitioner offers counseling based on the testing results, then the UA can be reimbursed as described in question #1.

Q4. Does Health First Colorado reimburse court-ordered UAs (e.g. DUI treatment requirements, “Drug Court”, requirements for child visitation by county human services department, controlled substance monitoring, etc.)?
A4. A court order is not a factor that determines Health First Colorado reimbursement. A service is reimbursed if it is covered under the Capitated Behavioral Health Benefit and considered medically necessary.

Q5. Is there a limit to the number of UAs that can be ordered for an individual?
A5. There are no limitations on the number of UAs reimbursed as long as the service is medically necessary.