Outpatient Speech Therapy Benefit

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

Refer to the Speech Therapy Billing Manual for complete details.

A variety of Current Procedural Terminology (CPT) billing codes are available for billing by speech therapists. Refer to the Speech Therapy Billing Manual for more information.

Refer to the Speech Therapy Billing Manual for more information.

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. Visit the Why Become a Provider? web page.

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

Professional outpatient speech therapy services are reimbursed in accordance with the current Health First Colorado Fee Schedule. Reimbursement rates vary by the CPT code reported. The fee schedule shows the maximum allowable reimbursement for each CPT code. Submitted claims will be reimbursed either at the submitted charge or fee schedule rate. 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 Enhanced Ambulatory Patient Grouping (EAPG) reimbursement methodology.

Providers must first enroll in the program to submit claims. Once 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.

Visit the Provider Resources web page for resources on enrollment and billing.

• Health First Colorado reimburses outpatient speech therapy billing providers enrolled as clinics, non-physician practitioner groups, rehab agencies, hospitals or individual speech therapists. Services are reported using CPT codes.
• The professional claim is used for all billing types except hospitals, home health providers, and some rehabilitation agencies which use the institutional claim. Services may be rendered at the member's home and reported using CPT codes.
• The Home Health Program speech therapy benefit reimburses providers 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 in the school must coordinate with the school district for reimbursement.
• Nursing facilities provide speech therapy which is included in the per-diem payment.

Members with an approved Individualized Family Service Plan (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 place of a physician order.

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

"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.

Refer to the Speech Therapy Billing Manual for complete details.

• Refer to the Provider Bulletin Index located on the Bulletins web page 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 on the NCCI web page on the Centers for Medicare & Medicaid Services website, including the NCCI Policy Manual found there.
  • A primer on NCCI is located in the outpatient Speech Therapy Billing Manual.
• Provider webinars are available. Refer to the Provider Training Material section below.

Beginning April 2019, outpatient speech therapy services will require a Prior Authorization Request (PAR) after the allowed 12 sessions have been utilized 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.

Which CPT codes will require a PAR?

Refer to the Speech Therapy Billing Manual for all allowed Outpatient Speech Therapy procedure codes.

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 that 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?

Prior Authorization Requests are approved for up to a 12-month period effective July 1, 2022 (depending on medical necessity determined by the authorizing agency).

How does the requirement for a 90-day review of the Plan of Care (POC) align with the prior authorization period?

While the period for treatment allowed by a PAR may exceed 90 days, the requirements in the outpatient speech therapy billing and policy manual regarding the POC 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, prior authorization is not required if the primary insurer has made a payment on the claim. If the primary insurer will not cover the benefit, a PAR is required.

Will retroactive authorization requests be approved?

For children ages zero (0) to three (3) who are part of the EI program, retro-authorization requests will be approved for a window of 30 calendar days from the date on which the provider submits the authorization, even if this does not encompass the start date of the IFSP. The dates requested on the authorization must be within the dates on the IFSP.

• For example, an EI provider may submit a retroactive authorization on May 15 for an IFSP that began on April 22.

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

For members ages three-plus (3+), all authorizations must be approved before the delivery of covered treatment.

• All services must be medically necessary.
• All services must have a POC associated with them.
• All services must be ordered by an enrolled physician, physician assistant, or nurse practitioner.
  • Approved 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.

Refer to the Speech Therapy Billing Manual for complete details.

• Rehabilitative speech therapy services are covered for both children and adults, but only some adults have Habilitative speech therapies covered. Refer to the Speech Therapy Billing Manual for more information.
• All habilitative speech therapy services are covered for children.
• There is no yearly quantitative limit to services.

Refer to the Speech Therapy Billing Manual for complete details.

Refer to the Outpatient Speech Therapy Billing Manual located on the Billing Manuals web page under the CMS 1500 drop-down menu.

• Provider Billing Training Calendar and Signup
• Outpatient Speech-Language Pathology and the NCCI Billing Edits FAQs

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 govern 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 Medical Assistance Program Rule is clarified in the billing and policy manual.

• Questions about claims and billing must be directed to the fiscal agent, Gainwell Technologies. Visit the Provider Contacts web page for a list of resources.
• Questions about policy and coverage may be direct to the program administrator. Contact Devinne Parsons at Devinne.Parsons@state.co.us.

Webinars

• OPR Mandate FAQ Document

Past Webinars

• Speech Therapy Prior Authorization Q&A Meeting
  • Speech Therapy Prior Authorization Q&A Meeting 11/3/23 recording
  • Speech Therapy Prior Authorization Q&A Meeting 11/3/23 agenda
  • Speech Therapy Prior Authorization Q&A Meeting 11/3/23 presentation
• Speech Therapy Stakeholder Engagement Meeting 8/23/23
  • Speech Therapy Stakeholder Engagement Meeting 8/23/23 recording
  • Speech Therapy Stakeholder Engagement Meeting 8/23/23 presentation material
  • Speech Therapy Stakeholder Engagement Meeting 8/23/23 Q & A