Ensuring Full Continuum SUD Benefits - Providers

Providers

This page is designed to support providers including facilities, clinics, offices, practices, programs, residential facilities, hospitals, as well as individuals, both licensed and unlicensed, who are providing Substance Use Disorder services in the outpatient and inpatient (both residential and hospital) settings.

Health First Colorado covers the entire care continuum for Substance Use Disorder (SUD) treatment: withdrawal management, inpatient, residential, intensive outpatient, medication assisted therapy, and individual and group outpatient services.

The State of Colorado requires that providers use ASAM criteria for determining medical necessity for Residential and Inpatient levels of care. The adult ASAM assessment guide is a tool that outlines how level of care determinations are made.

Covered services include:

• Outpatient SUD services including 1.0, 2.1 (IOP)
• “Inpatient” Residential Services (not including Bed Costs) 3.1, 3.3, 3.5, 3.7, 3.2WM and 3.7WM
• Inpatient (Hospital) 3.7, 3.7WM and 4.0

In addition, MAT treatment specifically may be provided through any licensed provider, including those outside of the MCE BH Capitated delivery system and is reimbursed by Medicaid as a fee-for service to providers.

Providers New to Health First Colorado

Reasons to become a Health First Colorado Enrolled provider:

• Individuals being served are Health First Colorado members
• Medicaid provides a transparent structure for covering the full continuum of ASAM level of care services to all members with an SUD diagnosis.
• Health First Colorado members have low to no co-pays, and no deductible, which means providers are paid for their full service amount immediately from the health plan.
• Health First Colorado’s behavioral health payments are often faster than commercial payers, with 98% of claims paid within 10 days of billing.

To become a Health First Colorado SUD provider follow these 3 steps:

• Step 1: First, a provider must apply to become licensed through BHA to provide services at the specific ASAM levels of care or licensed as a prescriber to prescribe MAT medications. The following page provides detailed information about the SUD licensure requirements and process.
• Step 2: Next, a provider identifies their Health First Colorado provider type - Licensed Behavioral Health Clinician, or, more commonly, Substance Use Disorder- Clinic and enrolls for licensed ASAM levels.
• Step 3: Once enrolled as a Health First Colorado provider for one or more ASAM levels of care, a provider must contract with MCEs to serve members from one or more regions.

Existing Health First Colorado Providers

Add SUD Services to an Existing Provider Enrollment

Identifying what type of provider you are is the best place to begin. Once you have determined your provider type you can follow the correct process for engaging in providing SUD services within the scope of your practice to Health First Colorado Members. For the majority providers the following description of how to become a provider will apply. For Hospitals, FQHCs and CMHCs the process may differ slightly. You may contact hcpf_sudbenefits@state.co.us for more information.

Maintaining Provider Information

As the Department continues to work with the MCEs to support expansion of provider networks we ask that all providers ensure that their Medicaid enrollments are up to date. Please verify that you are enrolled for each specialty type (specialty types are the term for each ASAM level of care) that you are licensed to provide. Also, please ensure that your FACILITY level (based on unique street address location) correctly reflects the number of SUD treatment beds you have at that location. If you find that any of this information is outdated please update by completing a maintenance request. 

Frequently Asked Questions

Does Medicaid recognize a Licensed Addiction Counselors (LAC) as a qualified provider type?

Yes. An LAC is a Provider type 38 (Behavioral Health Clinician). Licensed Addiction Counselor (LAC) A Licensed Addiction Counselor is a person who holds a master’s degree or higher in a clinical Behavioral Health specialization (e.g., counseling, marriage and family, social work, psychology) from an accredited college or university. Based on education, training, knowledge, and experience, the scope of practice of a licensed addiction counselor includes Behavioral Health counseling and may include the treatment of substance use disorders, addictive behavioral disorders, and co-occurring mental health disorders, including clinical evaluation and diagnosis, treatment planning, service coordination, case management, clinical documentation, professional and ethical responsibilities, education and psychotherapy with members, family, and community, clinical supervisory responsibilities, and intervention. Refer to CRS 12-245-801.  

 Are Case Management Services covered for members receiving SUD services?

Yes. Targeted Case Management (TCM) Services The purpose of TCM is to assist individuals in gaining access to needed medical, social, educational, and other services. The primary goal of TCM is to optimize the functioning of members who have complex needs by coordinating the provision of quality treatment and support services in the most efficient and effective manner. (See Appendix N for more information on TCM).

1. Behavioral Health TCM Services: BH TCM services are defined, per Colorado Medicaid State Plan Amendment, as services that assist individuals diagnosed with or being assessed for a mental health disorder in gaining access to medical, social, educational, and other services. BH TCM services may be provided by the following qualified providers: Advanced Practice Nurse (APN), Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Addiction Counselor (LAC), Psychologist, Psy.D/Ph.D., Physician/Psychiatrist, Physician assistant (PA) BH TCM services may also be provided in a licensed CMHC by practitioners working under the supervision of a qualified provider.
2. Substance Use TCM Services Substance Use TCM Services are defined, per Colorado Medicaid State Plan Amendment, as services that assist individuals diagnosed with or being alcohol or drug dependent in gaining access to medical, social, educational, and other services. Substance Use TCM services must be provided by a qualified provider that is a licensed health practitioner with a certification in addiction counseling or a licensed clinician. Licensed health practitioners include: Advanced Practice Nurse (APN), Physician/Psychiatrist, Physician assistant. 
   
   Licensed clinicians include: Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), Licensed Addiction Counselor (LAC), Licensed Psychologist, Psy.D/Ph.D. Substance Use services may also be offered by practitioners working under the supervision of a qualified provider in facilities that have been licensed to provide SUD treatment by OBH.  

Provider Resources

• Provider Manual for Resident and Inpatient Substance Use Disorder (SUD) Services
• Introduction to the RSSO License
• Guidance for Fee-for-Service
• Standard RAE Provider Forms
• Community Behavioral Health Programs for Adults
• Uniform Services Coding Standards
• JAMA Research August 2022
• Provider Issues Form for Reporting MCE Concerns and Complaints

Provider Archives

• ACC Deliverables
• July Provider Forum Contingency Management Presentation