Ensuring Full Continuum SUD Benefits - Providers

Providers

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

The State of Colorado requires that providers use the American Society of Addiction Medicine (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.

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.

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: Apply with the Behavioral Health Administration (BHA) to be licensed for the specific ASAM level(s) of care that will be rendered and billed. For information on licensing, visit the BHA licensing, designation and approvals webpage.
• Step 2: Enroll with Health First Colorado and add the Specialty Provider Type(s) that matches the ASAM level(s) of care indicated on your BHA license. For information on enrollment, visit the Provider Enrollment webpage.
• Step 3: Contract with the Managed Care Entities (MCEs) that serve your region for billing. For more information on MCEs, visit the Accountable Care Collaborative (ACC) webpage.

Existing Health First Colorado Providers

Add SUD Services to an Existing Provider Enrollment

Existing Medicaid providers can add a Specialty Provider Type(s), which matches the ASAM level(s) of care indicated on their BHA license, to their current Medicaid enrollment by submitting a Provider Maintenance Request in the Provider Web Portal. For information, visit the Provider Maintenance Quick Guide.

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 type is 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 provider maintenance request. 

Frequently Asked Questions

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

Yes. A LAC is a Provider type 38 (Behavioral Health Clinician). A Licensed Addiction Counselor (LAC) 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 LAC 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 community health center (CMHC) by practitioners working under the supervision of a qualified provider.
2. Substance Use TCM Services are defined, per Colorado Medicaid State Plan Amendment, as services that assist individuals diagnosed with a substance use disorder, or who are 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 (PA). 
   
   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 the BHA.  

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