Outpatient Speech Therapy Benefit

Health First Colorado covers services provided by licensed speech therapists. Services take place in the office, hospital, home, and other settings. Speech therapy is also available through the Home Health Program and in the school as part of the School Health Services Program.

Who is eligible for outpatient speech therapy services?

Enrolled members ages 20 and under and adult clients in limited circumstances qualify for medically necessary services.

Reference the billing and policy manual for complete details.

What services are available?

A variety of CPT billing codes are available for billing by speech therapists. These include but are not limited to:

Evaluation Individual and group therapeutic treatment

 

Reference the billing and policy manual for complete details.

  • Alternative and augmentative communication device evaluation
  • Assistive technology assessment
  • Cognitive skill development
What services are not covered?

Reference the billing and policy manual for complete details.

How do I become an enrolled provider?

As a Health First Colorado (Colorado's Medicaid program) provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance - it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.

The enrollment process is online and begins on the Become a Provider page.

Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.

How are services reimbursed?

Professional outpatient speech therapy services are reimbursed according to the current Health First Colorado Fee Schedule. Reimbursement rates will vary by CPT code reported. The fee schedule shows the maximum allowed reimbursement for each CPT code. Submitted claims will be reimbursed according to "lesser-of" pricing logic. This means that the line item will reimburse either at submitted charges or the fee schedule rate, whichever is lesser.

Hospital providers of speech therapy are subject to EAPG reimbursement methodology.

Providers must first enroll in the program to submit claims. Once they are enrolled, providers may submit claims directly by logging into the Provider Web Portal. Claims may be submitted by billing agencies on behalf of the provider.

Resources for enrollment and billing may be found at Provider Resources.

What's the difference between outpatient speech therapy and other settings?
  • The outpatient speech therapy benefit reimburses billing providers who are enrolled as clinics, non-physician practitioner groups, rehab agencies, hospitals, or as individual speech therapists. Services are reported using CPT codes.
  • The professional claim type is used for all billing types except hospitals and some rehab agencies, which use the institutional claim type. Services may be rendered at the member's home and reported using CPT codes.
  • The Home Health Program speech therapy benefit reimburses providers who are enrolled as home health agencies. Different policies and billing requirements apply.
  • The School Health Services Program reimburses school districts for speech therapy provided to Medicaid members at school in accordance with an Individual Education Program (IEP). Speech therapists providing therapy in the school must coordinate with the district for reimbursement. Nursing facilities provide speech therapy. They are reimbursed for this as part of their per-diem payment.
How does the Early Intervention program fit into Health First Colorado?

Members with an approved IFSP for speech therapy services still have their services covered by Health First Colorado. Coverage policy and limitations are not different for members with an approved IFSP. An approved IFSP may serve as an "order for services", in lieu of a physician order.

Health First Colorado must be billed first for the member's speech therapy services as part of an IFSP. Early Intervention funding is only available for services not covered by Health First Colorado.

What's the difference between Rehabilitative and Habilitative services?

"Rehabilitative" means therapy that treats acute injuries and illnesses which are non-chronic conditions. Rehabilitative is therefore short-term in nature.

"Habilitative" means therapy that treats chronic conditions with the purpose of helping the member retain or improve skills and functioning that are affected by the chronic condition. Habilitative therapy may therefore be long-term in nature.

Reference the billing and policy manual for complete details.

Recent News and Updates

 

  • Check the Provider Bulletin index for all provider bulletins related to outpatient speech therapy.
  • National Correct Coding Initiative (NCCI) billing edits affect this benefit. Providers should be familiar with the information found on the Medicaid.gov NCCI website, including the NCCI Policy Manual found there.
  • Provider webinars are available. See the below section Provider Training Material.

Speech Therapy PAR Frequently Asked Questions]
Beginning April 2019, outpatient speech therapy services will require a Prior Authorization Request (PAR) to be approved before claims can be reimbursed. The PAR process begins at the ColoradoPAR web page.

Can adults who are not on the Alternative Benefit Plan (ABP) receive CPT 92609 for habilitative reasons?
Yes. This is the only exception to the coverage policy which requires adults to have the ABP to receive habilitative speech therapy.

All adults may access 92609 for rehabilitative and habilitative services. The outpatient speech therapy policy manual details this under the "Treatment" section on augmentative and alternative communication therapy.

30-day retro-active prior authorization requests allowed until 4/30/2019
The Department and eQHealth Solutions have reviewed outpatient Speech Therapy Prior Authorization Request (PARs), and have determined that all speech therapy providers will have until 4/30/2019 to submit prior authorization requests which are retroactive back to the date of request and/or 4/1/2019. This means the "begin date" of the treatment may be for a date which is before the "submission date" of the request. These PARs will not be denied for untimely submission, however they will still be reviewed for compliance with Department policy and rule, and medical necessity. Outpatient speech therapy claims will be denied for dates of service on/after 4/1/2019 if there is not an approved PAR on file for those services.

Which CPT codes will require a PAR?

CPT codes 92507, 92508, 92526, and 92609 will require a PAR.

Will there be units of service available that do not require a Prior Authorization, like outpatient PT/OT?

No. All speech therapy procedure codes which require Prior Authorization will not have units of service available without a Prior Authorization. Evaluation procedure codes 92521, 92522, 92523, 92524, 92597, 92605, 92607, 92608, and 92618 will not require Prior Authorization.

Will current patients require a PAR beginning in April 2019, or will only new patients?

All claims for outpatient speech therapy will require a PAR to be reimbursed. Therefore, all patients, whether new or current, will require a PAR.

Can PARs be submitted prior to April 2019?

Yes. Providers have between 2-1-19 and 3-31-2019 to submit PARs ahead of the PAR requirement go-live date of 4-1-2019.

Will members be able to have active Prior Authorizations from more than one speech therapy provider concurrently?

Yes, so long as each PAR addresses different treatment goals. PARs for treatment which duplicates treatment of a currently active PAR will be denied. Providers must submit documentation that clearly supports the specific goals their therapy will be addressing.

What is the maximum allowed duration for an outpatient speech therapy Prior Authorization?

Six months.

How does the requirement for a 90-day review of the Plan of Care align with the Prior Authorization time span?

While the time span for treatment allowed by a PAR may exceed 90 days, the requirements found in the outpatient speech therapy billing and policy manual regarding the Plan of Care are still in effect. The Utilization Management (UM) vendor will check that the documentation is current during the review process.

Will Prior Authorization be required if the member has primary insurance coverage (commercial/Medicare)?

If Health First Colorado is the secondary payer then Prior Authorization is not required if the primary insurer has made payment on the claim. If the primary insurer will not cover the benefit then a PAR is required.

Will retroactive prior authorization requests be approved?

For children ages 0 to 3 who are under the direction of the Early Intervention program, retro-authorization requests will be approved for a window of 30 calendar days from the date on which the provider submits the PAR, even if this does not encompass the start-date of the IFSP. Dates requested on the PAR must be within the dates on the IFSP.

  • For example, an EI provider may submit a PAR retroactively on May 15th for an IFSP which began April 22nd.

However, claims will not be reimbursed until there is an approved PAR on file for the services requested.

For members ages 3+ all PARs must be approved prior to the delivery of covered treatment.

General Policies

 

  • All services must be medically necessary.
  • All services must have a plan of care associated with them.
  • All services must be ordered by an enrolled physician, physician assistant, or nurse practitioner.
    • Approved Individualized Family Service Plans (IFSPs) count as an order.
  • All claims must include the National Provider Identification (NPI) number of the enrolled provider who rendered the service.
  • All claims must include the NPI number of the enrolled provider who ordered the service.
  • Services provided to children in a school, with an IEP, must be reimbursed by the School District, not fee-for-service via the Provider Web Portal.
  • There are generally no co-payments applicable to this benefit. Co-payments are only required if the member is being treated in a hospital setting and is not a child (under age 19) or pregnant woman.
  • Reference the billing and policy manual for complete details.

 

General Benefit Limitations
  • Both children and adults have rehabilitative speech therapies covered, but only some adults have Habilitative speech therapies covered.
  • All children have Habilitative speech therapies covered. Prior Authorization is required for all ages effective April 1, 2019. Prior to this, Prior Authorization is only required for adult Habilitative services.
  • There is no yearly quantitative limit to services.
  • There is a daily quantitative limit of five units of speech therapy.
  • Reference the billing and policy manual for complete details.
Policy Documents

The Outpatient Speech Therapy Billing and Policy Manual is available on the Billing Manual web page, under the CMS 1500 drop-down menu > Speech Therapy.

Provider Training Material
Applicable Rules, Regulations, and Statutes

 

All Medicaid Rules, Regulations, and Statutes apply to the administration of the Colorado Medical Assistance Program at large, which providers are required to follow. The following are specifically called out as the ones governing the outpatient speech therapy benefit:

  • 42 CFR 440.110 - Federal regulation describing the minimum requirements for a State Medicaid Agency to cover therapies.
  • 10 CCR 2505-10 8.200.3.D.2 - Rule language describing the outpatient speech therapy benefit in the Colorado Medicaid Assistance Program. Rule is clarified in the billing and policy manual.
  • Contact Information
  • Questions about claims and billing must be directed to DXC technology. A list of resources is available on the Provider Help page.
  • Questions about policy and coverage may be direct to the program administrator. Contact Alex Weichselbaum at Alex.Weichselbaum@state.co.us.