Pediatric Behavioral Therapies Information for Providers

Who can access the Pediatric Behavioral Therapies benefit?

Behavioral therapies are a benefit for those Colorado Health First Colorado (Colorado's Medicaid Program) members who meet the following criteria:

• 20 years of age and younger
• Services are found to meet the EPSDT medical necessity criteria - see the EPSDT fact sheet for more information.

How to start providing Pediatric Behavioral Therapies

Enrollment: All providers wishing to serve Health First Colorado members must be a contracted Health First Colorado provider under Provider Type 83, Behavioral Therapy Group. For all providers, the group enrollment (practice, clinic, LLC, whatever) needs to be submitted first. After completing the Provider Type 83, Behavioral Therapy Group application, each individual provider must submit an application in the Online Provider Enrollment (OPE) tool. That application is Provider Type 84, Behavioral Therapy Individual. In that application, the individual should list the group/practice with which he/she is affiliated. Individual providers must affiliate with a group in each of their separate applications. Their applications will not be approved unless they have an affiliation listed.

Instructions on how to affiliate within the applications is contained in the Provider Training and/or the Provider Enrollment Reference Guide.

After completing the affiliation process, new providers need to look at Next Steps. They will need to submit TPA information to Gainwell Technologies in order to submit claims via the Provider Web Portal, and they will need to complete Gainwell Technologies provider training.

Providers must submit Behavioral Therapy PARs to the Department's third party Utilization Management (UM) vendor, Kepro, via the online PAR portal. For information on PAR submissions, please visit www.ColoradoPAR.com. Providers must have a valid Health First Colorado ID to submit a Prior Authorization Request (PAR) for Behavioral Therapies.

Behavioral Therapy providers will need to submit the following documents with the PAR request:

• Assessment Tool - Colorado will not mandate the use of one tool over another. The provider may choose what tool will be completed and submitted with the PAR request. The tool used must be a standardized norm referenced assessment that measures adaptive behaviors. The tool must be completed by the behavioral therapy provider.
• A letter of medical necessity.
• The client's Plan of Care detailing the requested services.

What happens once the Prior Authorization Request (PAR) is submitted?

The PAR will be reviewed by licensed clinical reviewers who will assess for behavioral health needs. The provider will receive notification via eQSuite of the number of hours that behavioral therapy services may be provided. An approved PAR is valid for up to a six (6) months, after which a new PAR must be completed and submitted. Both the provider and the Member receive the final PAR determination letter from the Department's fiscal agent.

Before the PAR is denied or partially denied, the doctor who requested the PAR will be called to discuss your PAR in a process called a Peer-to-Peer review. The Peer-to-Peer review may help prevent the PAR from being denied or partially denied.

If additional documentation is needed to perform the PAR review the UM vendor will call the provider who submitted your PAR to request the documents. If the UM vendor does not receive the required documentation within four (4) business days the PAR will be denied for lack of information. If this happens, you should work with your behavioral therapy provider to make sure that all the required documents are included in the PAR submission.

If the PAR is denied or partially denied PAR, the member can work with their behavioral therapy provider and their physician on these options:

• PAR Reconsideration: A PAR Reconsideration is similar to a second opinion and must be requested by the behavioral therapy provider. Additional documents not submitted with the original PAR may be submitted with the Reconsideration request. A different physician than the one who made the first PAR denial will re-review the PAR, along with any new information provided, and make a final PAR decision.
• Submit a new PAR that includes additional medical information needed for the PAR review.

Members also have the option to:

• Submit a written request for an appeal to the Office of Administrative Courts.

The member's Prior Authorization Request was denied and they want to appeal the decision. How do they appeal the PAR decision?

Members have the right to appeal and ask for a hearing if they do not agree with the PAR decision. They will have an appeal hearing with an Administrative Law Judge. They may represent themselves, or have a lawyer, a relative, a friend, or other spokesperson assist them as their authorized representative.

How to appeal:

1. They must request an appeal in writing. This is called a Letter of Appeal.
2. Their Letter of Appeal must include:

• Their name, address, phone number, and Health First Colorado number,
• Why they want a hearing, and
• A copy of the front page of the Notice of Action (letter notifying them of the PAR decision) they are appealing.

3. They may ask for a telephone hearing rather than appearing in person.
4. They should mail or fax their Letter of Appeal to:

Office of Administrative Courts
1525 Sherman Street, 4th Floor
Denver, CO 80203
Fax 303-866-5909

5. Their letter of appeal must be received by the Office of Administrative Courts no later than thirty (30) calendar days from the date of their Notice of Action (their denial letter). The date of the Notice of Action is located on the front of the denial letter.
6. The Office of Administrative Courts will contact them by mail with the date, time, and place of their hearing.

Benefits Codes

For current rates, please see the Provider Rates and Fee Schedule.

The Department's goal is to increase the number of providers across the state who accept Health First Colorado and help Health First Colorado members receive services. If you are interested in providing behavioral therapy services, please contact us at EPSDT@state.co.us

Additional Information

• Review Criteria
• EPSDT Fact Sheet
• Current Provider List
• Additional Training Information
• Pediatric Behavioral Therapies Benefit Billing Manual

For more information contact:
HCPF_EPSDT@state.co.us