Psychiatric Residential Treatment Facility Billing Manual

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General Policies

  • Health First Colorado (Colorado's Medicaid program) members have their behavioral health services paid for by Regional Accountable Entities (RAEs). Regional Accountable entities are managed care entities responsible for covering behavioral health benefits for nearly all Health First Colorado members.
  • See Program Rule 8.212 for details about the RAE program, including policy which exempts Health First Colorado members from RAE coverage. Only a  small percentage of members meeting very specific criteria will be exempt. Member exemption is determined by the Department of Health Care Policy & Financing (the Department).
    • Residential services for children or youth in the custody of the Colorado Department of Human Services -Division of Child Welfare or Division of Youth Services are among the members exempted from RAE coverage by Program Rule 8.212.
  • See the Department's Regional Accountable Entity web page for details about RAE coverage.
  • To verify if a Health First Colorado member's behavioral health services are covered by an RAE, providers must perform a member eligibility query in the Provider Web Portal. Each RAE may have its own similar tool for providers to query member eligibility. Both tools are valid for checking member eligibility.
  • The member eligibility query will display whether the RAE is responsible for covering the member's services. If the member is covered by the RAE, all claims for covered behavioral health services must be sent to the RAE for payment.
  • All behavioral health providers must be enrolled with Health First Colorado and contracted with the RAE. Providers must contact the RAE which serves their region to begin the enrollment process. Details are available on the Department's Regional Accountable Entity web page.
  • Providers who are denied RAE enrollment may not bill Gainwell fee-for-service (FFS) as an alternative reimbursement route. If the provider is denied RAE enrollment, this means that they may not treat Health First Colorado members for services covered by the RAE.
  • Providers who are denied RAE enrollment may still render and be reimbursed for services not covered by the RAE.
  • Providers must reference Appendix T for a list of RAE-covered services and conditions listed under the Appendices drop-down section on the Billing Manuals web page.
  • Billing information included below is only applicable to services rendered to children or youth in the custody of the Colorado Department of Human Services -Division of Child Welfare or Division of Youth Services, who are not covered by the RAE.

 

Psychiatric Residential Treatment Facilities (PRTFs)

Providers must be enrolled as a Health First Colorado provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to the Health First Colorado

Psychiatric Residential Treatment Facilities (PRTFs) provide comprehensive mental health treatment to children and adolescents (youth) who, due to mental illness, substance abuse, or severe emotional disturbance, need treatment that can most effectively be provided in a residential treatment facility. PRTF services are provided under the direction of a physician. The member must be:

  • Health First Colorado eligible
  • Determined to need PRTF care by an independent team. The team shall certify that:
    • Ambulatory care resources available in the community do not meet the treatment needs of the client.
    • Proper treatment of the client’s mental illness condition requires services on an inpatient basis under the direction of a physician.
    • The services can reasonably be expected to improve the client’s mental health or prevent further regression.      

Providers should refer to the Code of Colorado Regulations, Program Rules (10 C.C.R. 2505-10), for specific information when providing psychiatric residential treatment.

     
The client shall be not be eligible to receive services when: 

  1. 1. The client is no longer able to benefit from the service or is no longer progressing towards goals.
  2. The client is absent without leave in excess of 24 consecutive hours or has been removed from the facility and placed in non-PRTF services.
  3. The Interdisciplinary Team determines that the client has attained treatment goals.     

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Billing Information

Refer to the General Provider Information manual for general billing information. Health First Colorado benefits are provided through Psychiatric Residential Treatment Facilities (PRTFs) to enrolled members who reside in the facility on a per-diem basis.

PRTF Benefits

PRTFs are responsible for providing clinical services to members residing in their facilities.

The following code can be billed for services provided in a PRTF:
 

Code Description
0911

Treatment in a PRTF, per diem (1 unit per day)

The PRTF rate is inclusive of all services provided to the child in the facility by facility staff as part of the child’s Plan of Care. Services provided outside the facility or by non-facility staff are billed separately as fee-for-service. Examples of fee-for-service claims that may be billed separately may include Dental or Vision services

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Prior Authorization Requirements

PRTF services must be provided and billed only by a licensed and certified PRTF provider. PRTF Independent Teams complete a Level of Care Review and submit it to the referring agency for prior authorization. PRTFs are not required to submit any prior authorization documents to the fiscal agent.    

PRTFs outside of Colorado must work with the Regional Accountable Entities to submit for a prior authorization for services for our members.  

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UB-04 Paper Claim Reference Table

The information in the following table provides instructions for completing form locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data form locators on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBC UB-04 Reference Manual.

All code values listed in the NUBC UB-04 Reference Manual for each form locator may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.

The UB-04 Certification document must be completed and attached to all claims submitted on the paper UB-04. Completed UB-04 paper Health First Colorado claims, including hardcopy Medicare claims, should be mailed to the correct fiscal agent address listed in Appendix A, under the Appendices drop-down section on the Billing Manuals web page.

Do not submit "continuation" claims. Each claim form has a set number of billing lines available for completion. Do not crowd more lines on the form.

Billing lines in excess of the designated number are not processed or acknowledged. Claims with more than one page may be submitted through the Provider Web Portal.

Bill with a date span (From and To dates of service) only if the service was provided every consecutive day within the span. The From and To dates must be in the same month.

The Paper Claim Reference Table below lists the required, optional and/or conditional form locators for submitting the paper UB-04 claim form to Health First Colorado for nursing facility services.

Form Locator and Labels Completion Format Instructions
1. Billing Provider Name, Address, Telephone Number Text Required
Enter the provider or agency name and complete mailing address of the provider who is billing for the services:
  • Street
  • City
  • State
  • Zip Code
Abbreviate the state using standard post office abbreviations. Enter the telephone number.
2. Pay-to Name, Address, City, State Text Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:
  • Street/Post Office box City
  • State Zip Code
  • Abbreviate the state using standard post office abbreviations. Enter the telephone number.
3a. Patient Control Number Up to 20 characters: Letters, numbers or hyphens Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
3b. Medical Record Number 17 digits Optional
Enter the number assigned to the member to assist in retrieval of medical records.
4. Type of Bill 3 digits Required
For PRTF, use TOB 89X.
Enter the three-digit number indicating the specific type of bill. The three-digit code requires one digit each in the following sequences (Type of facility, Bill classification, and Frequency):
Digit 1 Type of Facility
1 Hospital
2 Skilled Nursing
3 Home Health Services
4 Religious Non-Medical Health Care Institution
6 Intermediate Care
7 Clinic (Rural Health/FQHC/Dialysis Center)
8 Special Facility (Hospice, RTCs)
Digit 2 Bill Classification (Except clinics & special facilities):
1 Inpatient (Including Medicare Part A)
2 Inpatient (Medicare Part B only)
3 Outpatient
4 Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
5 Intermediate Care Level I
6 Intermediate Care Level II
7 Sub-Acute Inpatient (Revenue Code 019X required with this bill type)
8 Swing Beds
9 Other
Digit 2 Bill Classification (Clinics Only):
1 Rural Health/FQHC
2 Hospital Based or Independent Renal Dialysis Center
3 Freestanding
4 Outpatient Rehabilitation Facility (ORF)
5 Comprehensive Outpatient Rehabilitation Facilities (CORFs)
6 Community Mental Health Center
Digit 2 Bill Classification (Special Facilities Only):
1 Hospice (Non-Hospital Based)
2 Hospice (Hospital Based)
3 Ambulatory Surgery Center
4 Freestanding Birthing Center
5 Critical Access Hospital
6 Residential Facility
Digit 3 Frequency:
0 Non-Payment/Zero Claim
1 Admit through discharge claim
2 Interim - First claim
3 Interim - Continuous claim
4 Interim - Last claim
7 Replacement of prior claim
8 Void of prior claim
5. Federal Tax Number None Submitted information is not entered into the claim processing system.
6. Statement covers period From/Through From:6 digits MMDDYY
Through: 6 digits MMDDYY
Required
Each date of service must be billed on a separate line (see FL 45). On paper split an entire month into 2 claims. This form locator must reflect the beginning and ending dates of service.
"From" date is the actual start date of services.

"From" date cannot be prior to the start date reported on the initial prior authorization, if applicable, or is the first date of an interim bill.

"Through" date is the actual discharge date, or final date of an interim bill.

"From" and "Through" dates cannot exceed a calendar month (e.g., bill 01/15/10 thru 01/31/10 and 02/01/10 thru 02/15/10, not 01/15/10 thru 02/15/10).

Dates must match the prior authorization if applicable. If member is admitted and discharged the same date, that date must appear in both fields.

Detail dates of service must be within the "Statement Covers Period" dates.
8a. Patient Identifier Text Submitted information is not entered into the claim processing system.
8b. Patient Name Up to 25 characters, letters & spaces Required
Enter the member's last name, first name and middle initial.
9a. Patient Address - Street Characters Letters & numbers Required
Enter the member's street/post office box as determined at the time of admission.
9b. Patient Address - City Text Required
Enter the member's city as determined at the time of admission
9c. Patient Address - State Text Required
Enter the member's state as determined at the time of admission.
9d. Patient Address - ZIP Digits Required
Enter the member's zip code as determined at the time of admission.
9e. Patient Address - Country Code Digits Optional
10. Birthdate 8 digits (MMDDCCYY) Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDCCYY format). Example: 01012010 for January 1, 2010.
11. Patient Sex 1 letter Required
Enter an M (male) or F (female) to indicate the member's sex.
12. Admission Date 6 digits Required
Enter the date care admitted to the PRTF.
13. Admission Hour 6 digits Not required
14. Admission Type 1 digit Required

Enter the following to identify the admission priority:
3 - Elective

The member's condition permits adequate time to schedule the availability of accommodations.
15. Source of Admission 1 digit Required

Enter the appropriate code. (To be used in conjunction with FL 14, Admission Type.)

8 - Court/Law Enforcement
9 - Information not available
16. Discharge Hour 2 digits Not Required
17. Patient Discharge Status 2 digits Required
Valid status codes for PRTFs include:
01 Discharged to Home or Self Care
05 Discharged/Transferred to Another type of institution
06 Discharged/Transferred to organized Home Health Care Program (HCBS)
07 Left Against Medical Advice
09 Admitted as an Inpatient to Hospital
20 Expired
30 Still Patient
31 Still Patient - Waiting Transfer to Long Term Psychiatric Hospital
32 Still Patient - Waiting Placement by Department of Social Services
Claims with Member Status of 30, 31 or 32 will pay for each day billed on the detail lines, including the through date of service shown at the header.

Claims with any other member status will not pay for the through date of service if it is billed on a detail line. When a member is discharged, the date of discharge is not covered.
18-28. Conditions Codes 2 digits Not required
29. Accident State 2 digits Optional
31 - 34. Occurrence Code/Date 2 digits & 6 digits Not Required
35-36. Occurrence Span Code From/ Through Digits Not required
38. Responsible Party Name/Address None Leave blank
39 - 41. Value Codes and Amounts 2 characters and up to 9 digits Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
Most Common Codes:
01 semiprivate rate (Accommodation Rate)
06 Medicare blood deductible
14 No fault including auto/other
15 Worker's Compensation
31 Member Liability Amount*
32 Multiple Member Ambulance Transport
37 Pints of Blood Furnished
38 Blood Deductible Pints
40 New Coverage Not Implemented by HMO
45 Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).
49 Hematocrit Reading - EPO Related
58 Arterial Blood Gas (PO2/PA2)
68 EPO-Drug
80 Covered Days
81 Non-Covered Days
Enter the deductible amount applied by indicated payer:
Deductible Payer A
B1 Deductible Payer B
C1 Deductible Payer C
Enter the amount applied to member's co-insurance by indicated payer:
A2 Coinsurance Payer A
B2 Coinsurance Payer B
C2 Coinsurance Payer C
Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C
For Rancho Coma Score bill with appropriate diagnosis for head injury.
Medicare & TPL - See A1-A3, B1-B3, & C1-C3 above
42. Revenue Code 4 digits Required
Enter the revenue code 0911

A revenue code must appear only once per date of service. If more than one of the same service is provided on the same day, combine the units and charges on one line accordingly.
43. Revenue code Description Text Required
Enter the revenue code description or abbreviated description.
44. HCPCS/Rates/ HIPPS Rate Codes 5 digits Not required
45. Service Date 6 digits For span bills only
Enter the date of service using MMDDYY format foe each detail line completed.

Each date of service must fall within the date span entered in the "Statement Covers Period" field (FL 6).
46. Service Units 3 digits Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit).

For span bills, the units of service reflect only those visits, miles or treatments provided on dates of service in FL 45.
47. Total Charges 9 digits Required

Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts.
A grand total on line 23 is required for all charges.
48. Non-covered Charges Up to 9 digits Conditional

Enter incurred charges that are not payable by the Health First Colorado.

Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges.)

Each column requires a grand total.
50. Payer Name 1 letter and text Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.
51. Health Plan ID 8 digits Required
Enter the provider's Health Plan ID for each payer name.
Enter the eight-digit Health First Colorado provider number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
52. Release of Information N/A Submitted information is not entered into the claim processing system.
53. Assignment of Benefits N/A Submitted information is not entered into the claim processing system.
54. Prior Payments Up to 9 digits Inpatient - Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
55. Estimated Amount Due Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
56. National Provider Identifier (NPI) 10 digits Required
Enter the billing provider's 10-digit National Provider Identifier(NPI).
57. Other Provider ID   Optional
Submitted information is not entered into the claim processing system.
58. Insured's Name Up to 30 characters Required
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.
60. Insured's Unique ID Up to 20 characters Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
61. Insurance Group Name 14 letters Conditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.
62. Insurance Group Number 17 digits Conditional
Complete when there is third party coverage.

Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.
63. Treatment Authorization Code Up to 18 characters Conditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
64. Document Control Number none Conditional
65. Employer Name Text Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
66. Diagnosis Version Qualifier   Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0ICD-10-CM (DOS 10/1/15 and after)
67. Principal Diagnosis Code Up to 6 digits Required
Enter the exact ICD-10-CM diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
67A. - 67Q. - Other Diagnosis 6 digits Optional
Enter the exact ICD-10-CM diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
69. Admitting Diagnosis Code 6 digits Required

Enter the ICD-10-CM diagnosis code as stated by the physician at the time of admission.
70. Patient Reason Diagnosis   Submitted information is not entered into the claim processing system.
71. PPS Code   Submitted information is not entered into the claim processing system.
72. External Cause of Injury code (E-Code) 6 digits Optional
Enter the ICD-10-CM diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".
74. Principal Procedure Code/Date 7 characters and 6 digits Conditional

Enter the ICD-10-CM procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Enter the date using MMDDYY format. Apply the following criteria to determine the principle procedure:

The principal procedure is not performed for diagnostic or exploratory purposes. This code is related to definitive treatment, and

The principal procedure is most related to the primary diagnosis.
74A. Other Procedure Code/Date 7 characters and 6 digits Conditional

Complete when there are additional significant procedure codes.

Enter the ICD-10-CM procedure codes identifying all significant procedures other than the principle procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principle diagnosis. Enter the date using MMDDYY format.
76. Attending NPI - Required NPI - 10 digits Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL - Enter "1D" for Health First Colorado
Enter the attending physician's last and first name.
This form locator must be completed for all services.
77. Operating NPI   Optional
Submitted information is not entered into the claim processing system.
78 - 79. Other ID NPI - 10 digits Conditional

Complete when attending physician is not the PCP or to identify additional physicians.

Ordering, Prescribing, or Referring NPI - when applicable

NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility and PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted.

The attending physician's last and first name are optional.
80. Remarks Text Enter specific additional information necessary to process the claim or fulfill reporting requirements.
81. Code - QUAL/CODE/VALUE (a-d) Qualifier: 2 digits
Taxonomy Code: 10 digits
Optional
Complete both the qualifier and the taxonomy code for the billing provider in field 81CC-a.
Field 81CC-a must be billed with qualifier B3 for the taxonomy code to be captured in the claims processing system. If B3 is missing, no taxonomy code will be captured in the claims processing system.
Only one taxonomy code can be captured from field 81CC. If more than one taxonomy code is provided, only the first instance of B3 and taxonomy code will be captured in the claims processing system.

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Psychiatric Residential Treatment Facility Claim Example

Psychiatric Residential Treatment Facility Claim Example

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.

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Institutional Provider Certification

The Institutional Provider Certification form is located under the Claim Forms and Attachments drop-down section on the Provider Forms web page.

This document is an addendum to the UB-04 claim form and is required per 42 C.F.R. 445.18 (a)(1-2) to be attached to paper claims submitted on the UB-04.

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Psychiatric Residential Treatment Facilities (PRTFs)

Revisions Log

Revision Date Section/Action Made by
12/1/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive. HPE (now DXC)
2/27/2016 Updates based on the Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on the Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on the Colorado iC Stage II Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
3/13/2017 Updated the Type of Bill section in the Paper Claims Table to reflect the NUBC manual HCPF
5/26/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
6/15/2018 Updated timely filing information and removed references to LBOD, removed general billing information already available in the General Provider Information manual DXC
6/13/2019 Updated Appendices' links and verbiage. DXC
12/9/2019 Converted to web page. HCPF
8/7/2020 Updated item 81 of the Paper Claim Reference Table for taxonomy code billing DXC
4/22/2022 Update PRTF policies and language edits HCPF

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