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Pediatric Behavioral Therapies Billing Manual

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The purpose of this billing manual is to provide policy and billing guidance to providers to obtain reimbursement for behavioral therapy services. This manual is updated periodically to reflect changes in policy and regulations. It applies only to the Health First Colorado (Colorado's Medicaid program) Pediatric Behavioral Therapies (PBT) Benefit and does not address services available through other Health First Colorado benefits or any services available through Home and Community-Based Services (HCBS) waiver programs.

 

Pediatric Behavioral Therapies Benefit Overview

Behavioral therapy services are a treatment that helps change maladaptive behaviors. These services must be found to be medically necessary to be covered.

The Pediatric Behavioral Therapies benefit is available to Health First Colorado members who:

All PBT services must be pre-approved in a Prior Authorization Request (PAR) process. Visit the Provider Contact web page for the Colorado PAR information.

If a member requires support of a medically skilled caregiver to complete a task, such as bathing or hygiene, the associated task shall be considered skilled in nature and covered under other Health First Colorado state plan benefits. Visit the Home Health Program web page for more information.

If a member requires assistance with personal care tasks, those services are covered under other Health First Colorado state plan benefits. Visit the Pediatric Personal Care Benefit web page for more information.

Co-Treatment Matrix
The following chart represents co-treatment policy for PBT providers.

 

Telemedicine and Pediatric Behavioral Therapy:

Pediatric Behavioral Therapists are covered under the telemedicine policy. 

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General Benefit Policies

  1. All Outpatient therapy services must have a written order/prescription/referral by any of the following:
    • Physician (M.D. or D.O.)
    • Physician Assistant
    • Nurse Practitioner
    • Licensed Psychologist
  2. An approved Individualized Family Service Plan (IFSP) for Early Intervention Speech Therapy. (Senate bill 07-004 states the IFSP "shall qualify as meeting the standard for medically necessary services." Therefore, no physician is required to sign a work order for the IFSP.)
  3. Pursuant to the Affordable Care Act's requirements that State Medicaid Agencies ensure correct ordering, prescribing, and referring (OPR) National Provider Identification (NPI) numbers be on the claim form (42 CFR ยง 455.440).
  4. Therapies provided as part of a member's individualized education program (IEP) by a therapist in the school setting and billing the School Health Services Program are not separately reimbursable. These services are paid for by the school district and providers may not submit claims for services performed in the school setting. Visit the School Health Services Program web page for details.

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Payment for Covered Services

 
Regardless of whether Health First Colorado has actually reimbursed the provider, billing members for covered services is strictly prohibited. Balance billing is prohibited. If payment is made by Health First Colorado, providers must accept this payment as payment in full. Refer to Program Rule 8.012. The provider may only bill the member for services not covered by Health First Colorado.
  1. Members may be billed for non-covered services in accordance with C.R.S. 25.5-4- 301(1)(a)(I).
    • (1) (a) (I) Except as provided in section 25.5-4-302 and subparagraph (III) of this paragraph (a), no recipient or estate of the recipient shall be liable for the cost or the cost remaining after payment by Medicaid, Medicare, or a private insurer of medical benefits authorized by Title XIX of the social security act, by this title, or by rules promulgated by the state board, which benefits are rendered to the recipient by a provider of medical services authorized to render such service in the state of Colorado, except those contributions required pursuant to section 25.5-4- 209 (1). However, a recipient may enter into a documented agreement with a provider under which the recipient agrees to pay for items or services that are non-reimbursable under the medical assistance program. Under these circumstances, a recipient is liable for the cost of such services and items.
  2. If Prior Authorization Requests (PAR) for services are required, the following policy applies:
    • Technical/lack of information (LOI) denial does not mean those services are not covered. Members may not be billed for services denied for LOI.
    • Services partially approved are still considered covered services. Members may not be billed for the denied portion of the request.
    • Services totally denied for not meeting medical necessity criteria are considered non-covered services.

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Allowed Place of Service Codes

The following place of service codes are allowed:

 

  • Telemedicine place of service (POS) code 02 is available for specific procedure codes. Visit the Telemedicine - Provider Information web page for a list of allowed procedure codes.
  • Effective May 3, 2024, place of service 03 is an allowed place of service for all fee-for-service benefits. In order for community providers to bill fee-for-service to children in a school setting, the provider must follow school district policy. Please reference the Community Providers in a School Setting Policy memo.
  • Services provided at an Outpatient Hospital are reported on the institutional claim type and are reimbursed as part of the hospital's EAPG payment. Institutional claim types do not have the POS code field.
  • Rule allows for services to be rendered at a location of "Community". Since there is no exact POS code which aligns with this description, POS code 99 should be reported.

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General Billing Information

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down menu for general billing information.

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Eligible Providers

Organizations with a Tax ID must enroll as Provider Type 83 - Behavioral Therapy Clinic.

Eligible individuals to affiliate with Provider Type 83 are:

  • Psychologist with a doctorate degree - Provider Type 37
  • Licensed Behavioral Health Clinician - Provider Type 38
  • Behavioral Therapist - Provider Type 84

Provider Types 37, 38 and 84 must be affiliated with Provider Type 83.  

Providers who enrolled prior to 2019 and are currently Provider Type 25 must re-enroll as Provider Type 83 during the revalidation process. Providers may need to re-enroll as Provider Type 83 sooner if a Behavioral Therapist (Provider Type 84) is affiliating with the group. 

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Rendering and Billing Provider Numbers

PBT services must be billed using the 837 Professional (837P) transaction or CMS 1500 form, which requires using rendering and billing National Provider IDs (NPIs).

Each agency's specific billing number will be used to reimburse the provider.

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Pediatric Behavioral Therapy Benefit Procedure Code Table

Allowable Procedure Coding

  • 97153
  • 97154
  • 97155
  • 97158
  • 97151
  • 97151 TJ

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Prior Authorization Requests (PARs)

Independent therapists and therapy clinics must submit, and have approved, PARs for medically necessary services prior to rendering the services.

Prior Authorization Requests are approved for up to a six (6)-month period (depending on medical necessity determined by the authorizing agency).

  • Incomplete, incorrect or insufficient member information on a PAR request form will not be accepted.

Submit PARs for the number of units for each specific procedure code requested, not for the number of services. Modifiers must be included on both the PAR and claim submission. 

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PAR Requests Must Include:

  • Legibly written and signed ordering practitioner prescription or approved Plan of Care, to include:
    • Diagnosis (preferably with ICD-10 code)
    • Reason for therapy
    • The number of requested therapy sessions per week
    • Total duration of therapy
  • The member's treatment history, including current assessment and treatment. Include duration of previous treatment and treating diagnosis if completed by the requesting provider.
  • Current treatment diagnosis
  • Course of treatment, measurable goals and reasonable expectation of completed treatment
  • Documentation supporting medical necessity for the course and duration of treatment being requested
  • Assessment or progress notes submitted for documentation, must not be more than 60 days prior to submission of PAR request.
  • The billing provider name and address needs to be present in field #25 on the PAR.
  • The authorizing agency reviews all completed PARs and approves or denies, by individual line item, each requested service or supply listed on the PAR. PAR status inquiries can be made through the Provider Web Portal and results are included in PAR letters. Read the results carefully as some line items may be approved and others denied. Do not render or bill for services until the PAR has been processed
  • The claim must contain the PAR number for payment.

Approval of a PAR does not guarantee Health First Colorado payment and does not serve as a timely filing waiver. Prior authorization only assures that the service is considered a benefit of Health First Colorado. All claims, including those for prior authorized services, must meet eligibility and claim submission requirements (e.g., timely filing, third party resources payment pursued, required attachments included, etc.) before payment can be made.

Providers should direct inquiries to the authorizing agency, located on the Provider Contact web page, if the PAR is denied.

The Health First Colorado PAR forms are available on the Provider Forms web page or by contacting the ColoradoPAR Program.

Documentation of clinical Applied Behavior Analysis (ABA) services must meet Council of Autism Service Providers (CASP) minimum requirements.  Templates can be found at: https://www.casproviders.org/access-the-templates

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

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Pediatric Behavioral Therapy Claim Example

Pediatric Behavioral Therapy Claim Example Form

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Pediatric Behavioral Therapies Revisions Log