Integrated Care Sustainability Policy

Starting July 1, 2025, the Colorado Department of Health Care Policy and Financing (HCPF) will implement the Integrated Care Sustainability Policy. This change should improve member health by increasing access to integrated care services for Health First Colorado (Colorado’s Medicaid program) members and building a sustainable reimbursement model for primary care providers who are incorporating behavioral health services into their practices.

The Integrated Care Sustainability Policy allows Primary Care Medical Providers (PCMPs)1 to bill Health Behavior Assessment and Intervention (HBAI) codes and Collaborative Care Model (CoCM) codes to Gainwell, and be reimbursed Fee-For-Service (FFS). For budgetary reasons, HCPF is restricting this policy to PCMPs with the intention of expanding the policy to all primary care providers in the future. Qualified, in-network PCMPs are eligible to bill Managed Care Organizations (MCOs). HCPF is subsequently transitioning the Short-Term Behavioral Health (STBH) Benefit from FFS to the Behavioral Health Capitation. The standard psychotherapy services that were billable under the STBH Benefit will continue to be covered by Medicaid when provided in a PCMP setting, however, these services must be billed to the member’s RAE effective July 1, 2025.

• History of Integrated Care in Colorado
• About this Policy
• Integrated Care Sustainability Policy
• About HBAI
• About CoCM
• For FQHC/RHC
• Sustainability Report
• Training Resources
• Frequently Asked Questions

History of Integrated Care in Colorado

Colorado has invested in multiple efforts to advance integrated care over the last decade. Most notably, the Center for Medicare and Medicaid Innovation (CMMI) awarded Colorado $65 million in the form of a cooperative agreement to test its State Innovation Model (SIM), a four-year (2015 to 2019) initiative aimed at transforming health care delivery and payment structures through the integration of physical and behavioral health. SIM supported integrated care in 344 primary care practices and four Community Mental Health Centers across Colorado.  When the SIM initiative ended in 2019, coordinated state activities and funding for integrated care largely ceased.

In July 2018, under ACC Phase II, HCPF implemented the STBH benefit to provide behavioral health services for short-term episodes of care for low-acuity conditions in primary care settings. While not designed as a solution for integrated care, practices and providers used the standard psychotherapy codes covered under the STBH Benefit to support integrated care programs that started under SIM.

In December 2023, as a result of HB22-1302, HCPF started distributing $29 million in grants to 81 clinics covering 145 sites, to establish or expand integrated care through capacity-building measures such as hiring, construction, and training. The funding focused on building capacity and did not change the reimbursement for l integrated care services. HB22-1302 mandated HCPF produce an Integrated Care Legislative Report to be delivered to the legislature in January 2025 recommending a sustainable reimbursement model for integrated care in Colorado. Informed by lessons learned from SIM, the STBH Benefit, the 1302 pilot and Legislative Report, and extensive stakeholdering, HCPF established the Integrated Care Sustainability Policy as a long-term approach to sustaining integrated care in Colorado. In April 2025, the Colorado General Assembly approved these recommendations and authorized ongoing funding for this sustainable integrated care approach. 

About this Policy

In an effort to increase access to integrated care services in a primary care setting, HCPF has opened the HBAI and CoCM codes to be billed by PCMPs starting July 1, 2025. Opening  these codes increases provider access to briefer interventions with members, as well as stackable code options for members with higher acuity. For additional information regarding HBAI and CoCM codes, please review the handouts linked under the “Resources” section at the bottom of the webpage.

Integrated Care Sustainability Policy

Medicaid Integrated Care Sustainability

Click here for a PDF version of this policy.

Overview    

Starting July 1, 2025, the Colorado Department of Health Care Policy and Financing (HCPF) will implement the Integrated Care Sustainability Policy. This change should improve member health by increasing access to integrated care services for Health First Colorado (Colorado’s Medicaid program) members and building a sustainable reimbursement model for primary care providers who are incorporating behavioral health services into their practices.
The Integrated Care Sustainability Policy allows Primary Care Medical Providers (PCMPs)¹ to bill Health Behavior Assessment and Intervention (HBAI) codes and Collaborative Care Model (CoCM) codes to Gainwell, and be reimbursed Fee-For-Service (FFS). For budgetary reasons, HCPF is restricting this policy to PCMPs with the intention of expanding the policy to all primary care providers in the future. Qualified, in-network PCMPs are eligible to bill Managed Care Organizations (MCOs). HCPF is subsequently transitioning the Short-Term Behavioral Health (STBH) Benefit from FFS to the Behavioral Health Capitation. The standard psychotherapy services that were billable under the STBH Benefit will continue to be covered by Medicaid when provided in a PCMP setting, however, these services must be billed to the member’s RAE effective July 1, 2025.

^{1 A PCMP is a primary care provider that is contracted with a RAE to manage the health care needs of Health First Colorado members. PCMPs must be licensed to practice in Colorado and have an MD, DO, or NP provider license. They must also be licensed in a specialty such as pediatrics, family medicine, internal medicine, obstetrics and gynecology, or geriatrics. Additional information is available on the ACC Webpage.}

Background 

Colorado has invested in multiple efforts to advance integrated care² over the last decade. Most notably, the Center for Medicare and Medicaid Innovation (CMMI) awarded Colorado $65 million in the form of a cooperative agreement to test its State Innovation Model (SIM), a four-year (2015 to 2019) initiative aimed at transforming health care delivery and payment structures through the integration of physical and behavioral health. SIM supported integrated care in 344 primary care practices and four Community Mental Health Centers across Colorado.  When the SIM initiative ended in 2019, coordinated state activities and funding for integrated care largely ceased.

In July 2018, under ACC Phase II, HCPF implemented the STBH benefit to provide behavioral health services for short-term episodes of care for low-acuity conditions in primary care settings. While not designed as a solution for integrated care, practices and providers used the standard psychotherapy codes covered under the STBH Benefit to support integrated care programs that started under SIM.  

In December 2023, as a result of HB22-1302, HCPF started distributing $29 million in grants to 81 clinics covering 145 sites, to establish or expand integrated care through capacity-building measures such as hiring, construction, and training. The funding focused on building capacity and did not change the reimbursement for l integrated care services. HB22-1302 mandated HCPF produce an Integrated Care Legislative Report to be delivered to the legislature in January 2025 recommending a sustainable reimbursement model for integrated care in Colorado. Informed by lessons learned from SIM, the STBH Benefit, the 1302 pilot and Legislative Report, and extensive stakeholdering, HCPF established the Integrated Care Sustainability Policy as a long-term approach to sustaining integrated care in Colorado. In April 2025, the Colorado General Assembly approved these recommendations and authorized ongoing funding for this sustainable integrated care approach.

^{2 Integrated care is defined as “The care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.”}

HBAI and CoCM Codes

In an effort to increase access to integrated care services in a primary care setting, HCPF has opened the HBAI and CoCM codes to be billed by PCMPs starting July 1, 2025. Opening  these codes increases provider access to briefer interventions with members, as well as stackable code options for members with higher acuity. For additional information regarding HBAI and CoCM codes, please review the handouts linked under the “Resources” section at the bottom of the policy.

Integrated Care Sustainability Codes (Starting July 1, 2025)

^{3 Under SB23-174, members under 21 years old can receive behavioral health services without a covered diagnosis when billed by a Behavioral Health Provider. Please visit https://hcpf.colorado.gov/sb23-174-coverage-policy for more information.}

Integrated Care Per Member Per Month (PMPM) Payment

In addition to the new billing codes for integrated care, RAEs are required to make an integrated care PMPM payment available to Highly Integrated PCMPs. To be designated as Highly Integrated, PCMPs must meet the following criteria:

1. The practice has an established relationship with an integrated behavioral health provider available via telehealth to patients and caregivers who is readily available to provide brief interventions for patients with behavioral health conditions or those requiring support for behavior change, OR has an onsite integrated behavioral health provider who is available to deliver brief interventions for patients with behavioral health conditions or those needing assistance with behavior change; and
2. The practice has an identified interdisciplinary team of champions for advancing Integrated Behavioral Health programming and continuous quality of care; and
3. The practice utilizes a single integrated health record to consolidate a patient’s physical and behavioral health information, OR implements a protocol for effective information integration between these domains that allows timely, collaborative care.

Practices are deemed Highly Integrated through the HCPF Practice Assessment Tool. Practices that have some level of integration, but are not Highly Integrated, will be eligible for additional points on the HCPF Practice Assessment Tool that may lead to a higher Medical Home PMPM separate from the Integrated Care PMPM. The PMPM amounts may vary depending on the RAE. For more information, please refer to the ACC PCMP Payment Fact Sheet.
MCOs are not required to offer PMPM payments to PCMPs.

How to Bill for Services

Providers
For initial implementation, practices must be contracted with a RAE as a PCMP to bill HBAI and CoCM codes, and to receive an integrated care PMPM. HCPF will monitor utilization and total costs quarterly and in the future evaluate if there is potential to expand approved providers. Providers who are not contracted with a RAE will have their HBAI and CoCM claims denied.
PCMPs must be contracted with an MCO in order to bill the MCO for HBAI and CoCM codes.

Reimbursement
Practices may submit claims for reimbursement of HBAI and CoCM codes for FFS reimbursement if they are contracted with a RAE or MCO as a PCMP. The billing provider provider on the claim must be the PCMP billing as one of the following primary care provider types: 

• 05 - Physician
• 16 - Clinic (primary care)
• 25 - Non-physician practitioner group
• 26 - Osteopath
• 32 - Federally Qualified Health Center (FQHC)
• 41 - Family/Pediatric Nurse Practitioner
• 45 - Rural Health Clinic (RHC)
• 51 - School Health Services

The rendering provider on the claim must be Medicaid-enrolled and oversee treatment. The billing provider must be enrolled as one of the following types:

• 37 - Licensed Psychologist (PhD, PsyD, EdD)
• 38 - Licensed Behavioral Health Clinician

Billing or rendering providers who are also behavioral health clinicians must be licensed as well as credentialed. Services provided by practitioners not eligible to enroll in Medicaid (e.g., unlicensed masters level provider) must be supervised by and billed under a Medicaid-enrolled provider who is documented as overseeing the member’s course of treatment. While an unlicensed provider can provide hands-on care to a member, the licensed provider who is an enrolled Medicaid provider is responsible for services and must be the “rendering provider” on the claim.
Billing providers must follow all standard and HCPF billing practices and policies. 

Payment
Rates for the HBAI and CoCM codes are aligned with Medicare rates. Payment for HBAI and CoCM codes will be made at the lesser of the provider's usual and customary charge or the Health First Colorado maximum allowable fee for the service, as published on the Health First Colorado Fee Schedule. 

HBAI and CoCM rates (current as of July 1, 2025) can be found here.

HBAI and CoCM codes are payable by MCOs at rates the MCO negotiates with PCMPs. FQHC and RHC guidance is available on the FQHC/RHC Fact Sheet.

About HBAI

Health Behavior Assessment and Intervention (HBAI) Services

Click here for a PDF Fact Sheet version of this information.

Overview    

Starting July 1, 2025, the Colorado Department of Health Care Policy and Financing (HCPF) established the Integrated Care Sustainability Policy to both increase access to integrated care services for members, and build a sustainable reimbursement model for primary care providers who are incorporating behavioral health services into their practices. 
A component of the Integrated Care Sustainability Policy includes allowance of Primary Care Medical Providers (PCMPs) to bill Health Behavior Assessment and Intervention (HBAI) codes and be reimbursed Fee-For-Service (FFS) or through a Managed Care Organization. 

Health Behavior Assessment and Intervention (HBAI) Codes 

HBAI codes focus on assessment and interventions to address behavioral health issues in a medical setting. HBAI services can be used to help assess and intervene in the psychological and behavioral factors affecting a member’s functioning. 
Billing
Practices must be contracted with a Regional Accountable Entity (RAE) or MCO as a PCMP to bill HBAI codes. PCMPs should use the most appropriate diagnosis when billing HBAI codes, however, a behavioral health diagnosis is not required.
Reimbursement
HBAI services are provided by a licensed behavioral health provider in collaboration with a medical provider. Services may be provided in person and/or through telehealth. Practices may submit claims for reimbursement of HBAI codes for FFS reimbursement if they are contracted with a RAE or MCO as a PCMP. The billing provider on the claim must be the PCMP billing as one of the following primary care provider types:

• 05 - Physician
• 16 - Clinic (primary care)
• 25 - Non-physician practitioner group
• 26 - Osteopath
• 32 - Federally Qualified Health Center (FQHC)
• 41 - Family/Pediatric Nurse Practitioner
• 45 - Rural Health Clinic (RHC)
• 51 - School Health Services

The rendering provider on the claim must be Medicaid-enrolled and oversee treatment. The rendering provider must be enrolled as one of the following types:

• 37 - Licensed Psychologist (PhD, PsyD, EdD)
• 38 - Licensed Behavioral Health Clinician

Post-masters level providers working towards clinical licensure may provide the HBAI service, however, the rendering provider on the claim must be listed as the licensed clinician that is enrolled in Medicaid that is either providing or supervising the integrated care service.
Billing or rendering providers who are also behavioral health clinicians must be licensed as well as credentialed. 
Restrictions
A HBAI code and a Collaborative Care Management (CoCM) code cannot be billed together for the same member in the same month. Additionally, a HBAI code and a psychotherapy code cannot be billed together on the same date of service.

Health Behavior Assessment and Intervention Codes

About CoCM

Collaborative Care Management

Click here for a PDF Fact Sheet version of this information.

Overview

Starting July 1, 2025, the Colorado Department of Health Care Policy and Financing (HCPF) established the Integrated Care Sustainability Policy to both increase access to integrated care services for members, and build a sustainable reimbursement model for primary care providers who are incorporating behavioral health services into their practices. HCPF envisions increasing access to integrated care will improve member health.
A component of the Integrated Care Sustainability Policy includes allowance of Primary Care Medical Providers (PCMPs) to bill Collaborative Care Management (CoCM) codes and be reimbursed Fee-For-Service (FFS) or through a Managed Care Organization (MCO).

Collaborative Care Management (CoCM) Codes

CoCM codes provide psychiatric care in a primary care setting.

Billing
Practices must be contracted with a Regional Accountable Entity (RAE) or MCO as a PCMP to bill CoCM codes. PCMPs should use the most appropriate diagnosis when billing CoCM codes, however, a behavioral health diagnosis is not required.

Reimbursement
CoCM services are provided through the use of three collaborators:

1. PCMP;
2. Behavioral health care manager; and
3. Psychiatric consultant.

The PCMP provides initial assessment and is responsible for administering validated rating scales. The behavioral health care manager follows up proactively and systematically using validated rating scales and a registry. Finally, a regular case load review is conducted by the behavioral health care manager and the psychiatric consultant.
The behavioral health care manager and the psychiatric consultant review the member’s treatment plan and status weekly. If the member is not improving, the behavioral health care manager discusses the member’s treatment plan for potential revision with the psychiatric consultant. Collaborators, including the psychiatric consultant and behavioral health care manager, are required to be embedded in the practice either in person and/or virtually as a regular part of the integrated care team. These providers must be employed or contracted by the PCMP. The behavioral health care manager may be any designated member of the care team with formal education or specialized training in behavioral health, who is available to provide services on a face-to-face basis.
Practices may submit claims for reimbursement of CoCM codes for FFS reimbursement if they are contracted with a RAE or MCO as a PCMP. The billing provider on the claim must be the PCMP billing as one of the following primary care provider types: 

• 05 - Physician
• 16 - Clinic (primary care)
• 25 - Non-physician practitioner group
• 26 - Osteopath
• 32 - Federally Qualified Health Center (FQHC)
• 41 - Family/Pediatric Nurse Practitioner
• 45 - Rural Health Clinic (RHC) 
• 51 - School Health Services

The rendering provider on the claim must be Medicaid-enrolled and oversee treatment. The billing provider must be enrolled as one of the following types:

• 37 - Licensed Psychologist (PhD, PsyD, EdD)
• 38 - Licensed Behavioral Health Clinician

Billing or rendering providers who are also behavioral health clinicians must be licensed as well as credentialed. 

Requirements
Practices billing these codes must meet the standards of the evidence-based Collaborative Care Model, which will be validated by the RAE through the HCPF Practice Assessment Tool a minimum of every three years. Minimum standards to bill CoCM codes, outlined in Section 8.5 of the HCPF Practice Assessment Tool, include the following three components:

1. Availability of a psychiatric consultant who collaborates with the primary care clinician or care team on medication management;
2. Availability of a care manager actively responsible for identifying and coordinating behavioral health needs for patients; and
3. A maintained care registry for patients with behavioral health needs that is utilized to monitor symptoms and identify and address gaps in care. The registry must be reviewed and signed off on by the psychiatric consultant.

Please note that practices that are designated “Highly Integrated” through the HCPF Practice Assessment Tool are not necessarily able to bill CoCM codes. Practices must meet the specific requirements outlined in Section 8.5 of the HCPF Practice Assessment Tool, and meet minimum Medicare standards, to bill these codes. 

Restrictions
A CoCM code and a Health Behavior Assessment and Intervention (HBAI) code cannot be billed together for the same member in the same calendar month.

Collaborative Care Model (CoCM) Codes

For FQHC/RHCs

FQHC/RHC Integrated Care Policy

Click here for a PDF Fact Sheet version of this information.

Integrated Care for FQHCs     

Effective July 1, 2025, FQHCs and RHCs may be reimbursed by Health First Colorado for Health Behavior Assessment & Intervention (HBAI) and Collaborative Care Model (CoCM) codes Fee-for-Service (FFS). These sessions will not require a covered behavioral health diagnosis. These claims should be billed using the 900 revenue code. Integrated care services at Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs), will follow standard reimbursement policies, including policies outlined in 10 CCR 2505-10 8.700. HBAI and CoCM procedure codes include:

If a member receives both a FFS integrated care service and a medical service on the same day, a FQHC must submit two (2) claims, one (1) with the HBAI or CoCM service using revenue code 900 and one (1) with the medical service using revenue code 529 for two (2) encounter rate payments from Health First Colorado.
A visit that includes a FFS integrated care service and other behavioral health services should include all behavioral health services in the visit on the claim billed to Health First Colorado.
Per 10 CCR 25-05-10 8.700 FQHCs or RHCs can receive one (1) encounter payment for a behavioral health visit for a single patient in one (1) day. The FQHC or RHC is not allowed to bill for a behavioral health psychotherapy visit (to their RAE) and an integrated care visit (HBAI and CoCM) for the same member on the same day. The Department conducts ongoing retroactive review and compliance activities monitoring all of these policies.
For additional details on the Integrated Care Benefit, including NCCI edits, please reference the Behavioral Health Billing Manual or the FQHC/RHC Billing Manual.

Sustainability Report

HB22-1302 Integrated Care Legislative Report

Training Resources

• IC Sustainability Recorded Training
• FQHC/RHC Sustainability Recorded Training
• IC Sustainability Slide Deck
• FQHCs/RHCs IC Sustainability Slide Deck
• Q & A from Trainings

Frequently Asked Questions

The following frequently asked questions (FAQs) are intended to provide guidance on the Integrated Care Sustainability policy, effective July 1, 2025. If your question is not answered here, email it to us at HCPF_IntegratedCare@state.co.us.

Click here for a PDF version of the FAQ.

Practice Assessment and PMPM

What is the Integrated Care PMPM?

• A PCMP is a primary care provider that is contracted with a RAE to manage the health care needs of Health First Colorado members. PCMPs must be licensed to practice in Colorado and have an MD, DO, or NP provider license. They must also be licensed in a specialty such as pediatrics, family medicine, internal medicine, obstetrics and gynecology, or geriatrics.
• PCMPs may receive additional payment for delivering highly integrated care if they meet the standards for integration of primary care and behavioral health outlined in the Practice Assessment. For information on the Integrated Care PMPM, please see ACC PCMP Payment Fact Sheet.

What is the Practice Assessment?

• A three-tier assessment to incentivize progress along the continuum of advanced primary care. For information on the Practice Assessment, please see ACC PCMP Payment Fact Sheet.

What requirements does my practice have to meet on the Practice Assessment to receive the Integrated Care PMPM?

1. The practice has an established relationship with an integrated behavioral health provider available via telehealth to patients and caregivers who is readily available to provide brief interventions for patients with behavioral health conditions or those requiring support for behavior change, OR has an onsite integrated behavioral health provider who is available to deliver brief interventions for patients with behavioral health conditions or those needing assistance with behavior change;
2. The practice has an identified interdisciplinary team of champions for advancing Integrated Behavioral Health programming and continuous quality of care; and
3. The practice utilizes a single integrated health record to consolidate a patient’s physical and behavioral health information, OR implements a protocol for effective information integration between these domains that allows timely, collaborative care.

Health Behavior Assessment and Intervention Codes

What are the HBAI codes?

• HBAI codes focus on brief assessment and brief intervention to address behavioral health issues in a primary care setting. They are led by a behavioral health provider in collaboration with a medical provider, and do not require a behavioral health diagnosis to bill.

Which HBAI codes are covered?

• 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171

Can the HBAI codes be provided over telehealth?

• HBAI codes may be provided in-person and/or telehealth.

Who can provide HBAI services?

• HBAI services can be billed by a variety of mental health professionals, including Licensed Clinical Social Workers, Licensed Mental Counselors, Licensed Professional Counselors, Licensed Marriage Family Therapists as well as clinical psychologists, and psychiatrists. These services must be billed by a mental health professional enrolled as a PCMP.

Can you bill the HBAI assessment (96156) and a HBAI intervention (96158) on the same day?

• Yes.

What are the limitations for the HBAI codes?

• HBAI codes and Collaborative Care Management (CoCM) codes cannot be billed together for the same patient in the same calendar month.
• HBAI code and a psychotherapy code cannot be billed together on the same date of service. 
• HBAI codes are restricted to Medically Unlikely Edits (MUEs) per NCCI.

Collaborative Care Management Codes

What are the CoCM codes?

• CoCM codes focus on providing psychiatric care in a primary care setting. 

Which CoCM codes are covered?

• 99484, 99492, 99493, 99494, G0323, G2214

Can the CoCM codes be provided over telehealth?

• CoCM codes may be provided in-person and/or telehealth.

What is the role of the behavioral health care manager?

• The BCHM does outreach and engages patients in treatment directed by the primary care provider. They also perform initial and follow up assessments of the patient, create individualized care plans for patients, enter patients in a registry and track patient follow-up and progress.

Who can be a behavioral health care manager?

• The behavioral health care manager may be any designated member of the care team with formal education or specialized training in behavioral health, who is available to provide services on a face-to-face basis. This includes a Behavioral Health RN, Licensed Professional Counselor, Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, and Licensed Addiction Counselor. 

Who can be a psychiatric consultant?

• A psychiatrist, a psychiatric nurse practitioner, and a PA-C with psychiatric certification.

What is a registry?

• A registry tracks clinical outcomes and progress for patients and the population. It facilitates treatment-to-target by summarizing patient’s progress in an understandable and actionable way.

What are the limitations for CoCM codes?

• A CoCM code and a HBAI code cannot be billed together for the same patient in the same calendar month. 
• 99494 may be billed a maximum of two times per calendar month.
• Billing cannot exceed 2 hours and 10 minutes in the first calendar month, and 2 hours in subsequent calendar months.

Will RAEs require the Colorado Client Assessment Record (CCAR) for psychotherapy codes?

• No, the CCAR will not be required of PCMPs for integrated care services.

Can PCMPs use a psychiatry access line, such as CoPPCAP, for the psychiatric consultant?

• A requirement to bill CoCM codes includes weekly case load reviews between the psychiatric consultant and behavioral health care manager.
• If psychiatry access lines are being utilized to fit all requirements of the CoCM model, they are permitted for use.

Does the 50% + 1 minute rule apply to CoCM codes?

• Standard time based billing criteria apply. It is important to note that for billing the 60 min code and an additional 30 min code you must meet the full 60 min plus the next 16 min to bill both the codes for a total of 76 min to bill both codes. Not, 31 min for the 60 min code and 16 min for the 30 min code.
   

Short-term Behavioral Health Visits

How will STBH visits work going forward? 

• Under this budget request, beginning on 7/1/2025 STBH visits will be covered by the behavioral health capitation through Regional Accountable Entities (RAE). 

Can PCMPs still bill psychotherapy (STBH) codes without a diagnosis?

• Diagnoses will be required to bill these codes, unless the patient is under 21 years of age. See Senate Bill 23-174 for more information.
  • A deferred diagnosis is acceptable.
  • All psychotherapy services need to be medically necessary.
  • Diagnosis for low acuity may include anxiety, depression, etc.

What does “medical necessity” mean?

• Medical necessity does NOT mean that services require prior authorization. 
• Physician services are reimbursable when the services are a benefit of Medicaid and meet the criteria of Medical Necessity as defined in 10 C.C.R. 2505-10 
• For more information, click here.

Is a treatment plan required to bill the STBH psychotherapy codes?

• Yes, a behavioral health treatment plan must be developed to determine medical necessity in order to bill the behavioral health capitation. Practices may develop their own document and/or template, or use an existing template to outline treatment plans. This plan is not required to be extensive, a 1 page document to outline the plan of behavioral health care is appropriate. 

What if my practice does not have the capacity to build treatment plans?

• The HBAI codes and CoCM codes will be available for practices to bill without a prior authorization, treatment plan, or diagnosis. The intention of this policy is to fill the gap the STBH codes will leave with the HBAI codes. HBAI codes also have 15 minute add ons to give another level of increased flexibility.

Does the policy prohibit RAEs from contracting with the PCMP for other codes?

• No.

Billing and Reimbursement

If you are a provider wanting to become a PCMP:

1. Practitioner holds an MD, DO, or NP provider license and is eligible to practice in Colorado
2. Provider enrolls with Health First Colorado
3. Practitioner is licensed as one of the following specialties: pediatrics, internal medicine, family medicine, obstetrics and gynecology, or geriatrics.
4. Provider contracts with the RAE covering the region in which their practice is located.
5. Providers become PCMPs.

Regional Provider Support: Provides information on how to become a provider and provider support through Regional Field Representatives.

Provider Enrollment in Health First Colorado

If you are a provider wanting to bill HBAI codes:

1. Provider becomes a PCMP by enrolling with Health First Colorado, contracting with the RAE covering the region in which their practice is located, and meeting certain licensing requirements.
2. Provider collaborates with a behavioral health provider who is Medicaid-enrolled, licensed, and credentialed with HCPF. 
3. Patient is seen in provider's office by PCMP and behavioral health provider.
4. Provider bills HBAI codes to HCPF as Fee-For-Service. 
   • Rendering provider must be the Medicaid-enrolled, licensed, and HCPF credentialed behavioral health clinician. 
   • Billing provider must be Provider type 05, 16, 25, 26, 32, 39, 45, or 61.
5. HCPF reimburses billing provider Fee-For-Service. 
   • Rates are aligned with Medicare rates and reimbursement.

If you are a provider wanting to bill CoCM codes:

1. Provider becomes PCMP by enrolling with Health First Colorado, contracting with the RAE covering the region in which their practice is located, and meeting certain licensing requirements.
2. Provider collaborates with a behavioral health care manager and psychiatric consultant who is Medicaid-enrolled, licensed, and credentialed with HCPF.
3. Patient is seen in provider's office by PCMP for initial assessment.
4. Patient is seen by the behavioral health care manager using validated rating scales and a registry.
5. Behavioral health care manager and psychiatric consultant conduct a regular (weekly) case load review.
6. Provider bills CoCM codes to HCPF as Fee-For-Service. 
   • Rendering provider must be the Medicaid-enrolled, licensed, and HCPF credentialed behavioral health clinician. 
   • Billing provider must be Provider type 05, 16, 25, 26, 32, 39, 45, 61.
7. HCPF reimburses billing provider Fee-For-Service. 
   • Rates are aligned with Medicare rates/reimbursement.

If you are a provider wanting the additional Integrated Care PMPM:

• Please visit Colorado’s ACC Phase III Primary Care Payment Structure.

Who do we list on the claim?

• The billing provider is listed as the clinic/practice.
• The rendering provider is listed as the licensed clinician that is enrolled in Medicaid that is either providing or supervising the integrated care service.

How does a practice qualify to bill the HBAI and CoCM codes and receive the integrated care PMPM?

• Practices must be contracted with a RAE as a PCMP to participate in the components of the integrated care sustainability policy, including billing HBAI and CoCM codes, and receiving an integrated care PMPM. This is due to budget reasons, our intention is to allow all PCP’s to bill HBAI and CoCM codes in the coming years.

Are claims with Place of Service 22 (Outpatient Hospital) and Place of Service 19 (Off Campus – Outpatient Hospital) included in this benefit?

• Place of Service 19 and 22 are included in the Integrated Care policy for both HBAI and CoCM codes.

Who can be a billing provider for the HBAI and CoCM codes?

• Clinic (primary care);
• Federally Qualified Health Centers (FQHCs);
• Rural Health Clinic (RHC);  
• Indian Health Services provider (IHS); or  
• Non-physician practitioner group.

How do FQHCs bill?

• FQHCs may bill on the UB-04 claim if the visit meets the definition of an FQHC visit found in 10 CCR 2505-10 8.700.1.B. If the visit does not meet the definition of an FQHC visit, the FQHCs capture any applicable costs associated with HBAI and CoCM services on their cost reports. 
• When HBAI and CoCM codes are billed as an encounter, it’s a physical health encounter.

Who can be a rendering provider?

• Only the supervising physician or other listed practitioner may be listed as the rendering provider. Additionally, we require general supervision by a physician or other listed practitioner for behavioral health services provided by auxiliary personnel incident to the professional services of a physician or other listed practitioner.
• Rendering providers must be listed under Provider Type 37 or 38. To find your provider type, please refer to https://hcpf.colorado.gov/find-your-provider-type.

Can an unlicensed provider (masters level) provide services?

• While an unlicensed provider can 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.

How do we bill these new codes?

• Eligible PCMPs may submit claims for reimbursement of HBAI codes and CoCM codes for fee-for-service (FFS) reimbursement if they are contracted with a RAE as a PCMP. All PCMP FFS claims are billed to Gainwell/HCPF.

Do I need a diagnosis to bill HBAI or CoCM codes?

• No, but medical necessity must be shown. If the referring diagnosis is part of the FFS benefit, then the provider needs to submit their claim to Gainwell for reimbursement.

Is the diagnosis of “Annual wellness visit/Well Child” (Z codes) allowable for HBAI and CoCM codes? 

• Yes.

How will the HBAI and CoCM services work with the Managed Care Organizations (Rocky Mountain Health Plan Prime and Denver Health Medicaid Choice)?

• PCMPs must be contracted with an MCO in order to bill the MCO for HBAI and CoCM codes. HBAI and CoCM codes are payable by MCOs at rates the MCO negotiates with PCMPs.

What if a member is attributed to a RAE, but the behavioral health provider is not in that RAE?

• Behavioral health providers are encouraged to contract with multiple RAEs to promote a statewide behavioral health network. RAEs are required to offer single case agreements to any behavioral health provider with an existing relationship with a member and may choose to contract with that provider. RAEs also have the authority to determine which providers they credential into their network, and have been encouraged to include a variety of Behavioral Health providers. For more information, please visit Contracting Guidance for Behavioral Health Providers.

Is there guidance for behavioral health medication and Medication Assisted Treatment in the new policy?

• Nothing is changing for medications or MAT as HCPF transitions from ACC Phase II to ACC Phase III. MAT is allowed FFS and under the behavioral health capitation. Medications are FFS and paid for by HCPF.
• For information relating to FFS Physician-Administered Drugs, please refer to the May 2025 Provider Bulletin page 6.

Recap:
In order to participate in this policy beginning 7/1/25, a provider must be contracted with a RAE and must be a PCMP.

• To bill the STBH codes that are moving to the BH capitation, the provider must be PCMP.
• To bill HBAI and/or CoCM codes, the provider must be a PCMP.
• To receive the PMPM, the provider must be a PCMP.
   

Stay Informed

Contact Us: hcpf_integratedcare@state.co.us