- General Policies
- Program Overview
- Billing Information
- Program Benefits
- CMS 1500 Paper Claim Reference Table
- Timely Filing
- QRTP Revision Log
- 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.
- 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.
Qualified Residential Treatment Programs (QRTP) means a facility that provides residential trauma-informed treatment that is designed to address the needs, including clinical needs, of children with serious emotional or behavioral disorders or disturbances. As appropriate, QRTP treatment facilitates the participation of family members in the child’s treatment program, including siblings, and documents outreach to family members, including siblings. 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
Health First Colorado reimburses providers for medically necessary services furnished to eligible members.
Providers should refer to the Code of Colorado Regulations Program Rules (10 CCR 2505-10) for specific information when providing medical/surgical services.
Refer to the General Provider Information manual for general billing information.
Health First Colorado benefits are provided through Qualified Residential Treatment Programs (QRTPs) to enrolled members who reside in the facility on a per-diem basis. A QRTP facility may submit claims for members during the 14-day period allowed for completion of an Independent Assessment (IA).
Children placed in a QRTP by the Division of Youth Services (DYS) are allowed 30 days for completion of an IA.
The IA determines medical necessity. Any QRTP Reviews, conducted by a reviewer assigned by the Administrative Review Division (ARD), must also confirm the need for QRTP-level treatment. If the IA, or the QRTP Review, determines that the member does not require QRTP-level treatment, the Facility may continue to submit claims while locating a new placement for the member. The Facility may claim the per diem for up to 30 days after the IA or QRTP Review takes place.
Providers may not submit claims for reimbursement for children in the custody of DYS after an IA or a QRTP Review determines that the child does not require QRTP-level treatment.
QRTPs are responsible for providing mental health services to members residing in their facilities.
The following procedure codes can be billed for services provided in a QRTP:
|H0019||Behavioral health; long-term residential, without room and board, per diem (1 unit per day)||U1|
QRTP Non-Included Services:
- Mental health-related prescription drugs. Claims for prescription drugs are submitted to the Health First Colorado fiscal agent under the FFS Reimbursement Program or to the MCO for MCO-enrolled members.
- Services in a Psychiatric Residential Treatments Facility (PRTF).
- Room and board
The following days are not billable:
- The day of discharge.
- Days when the client is in detention.
- Days when the client receives none of the services included in the per diem rate due to elopement.
Days the client spends away from the facility, due to an M1 hold or a temporary pass, but still receiving covered services, are billable for up to 4 days.
CMS 1500 Paper Claim Reference Table
The paper claim reference table lists required and conditional fields for the CMS 1500 paper claim form for QRTF claims. For complete CMS 1500 paper claim instructions, please refer to the General Provider Information manual located on the Department's Billing Manuals web page.
The appropriate POS code for QRTP paper and electronic claim submissions services is 56 (Psychiatric Residential Treatment Center) and is identified by using the specific modifiers along with the procedure codes (see above table).
Instructions for completing and submitting electronic claims are available through the X12N Technical Report 3 (TR3) for the 837P (wpc-edi.com), 837P Companion Guide (in the EDI Support section of the Department's Web site), and in the Web Portal User Guide (via within the portal).
|CMS Field Number & Label||Field is?||Instructions|
|1. Insurance Type||Required||Place an "X" in the box marked as Medicaid.|
|1a. Insured's ID Number||Required||Enter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Medicaid Identification card. Example: A123456.|
|2. Patient's Name||Required||Enter the member's last name, first name, and middle initial.|
|3. Patient's Date of Birth/Sex||Required||Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.
Place an "X" in the appropriate box to indicate the sex of the member.
|4. Insured's Name||Not Required|
|5. Patient's Address||Not Required|
|6. Client Relationship to Insured||Conditional||Complete if the member is covered by a commercial health care insurance policy.|
|7. Insured's Address||Not Required|
|8. Reserved for NUCC Use||Not Required|
|9. Other Insured's Name||Not Required|
|9a. Other Insured's Policy or Group Number||Not Required|
|9b. Reserved for NUCC Use|
|9c. Reserved for NUCC Use|
|9d. Insurance Plan or Program Name||Not Required|
|10a-c. Is patient's condition related to?||Conditional||When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.|
|10d. Reserved for Local Use|
|11. Insured's Policy, Group or FECA Number||Not Required|
|11a. Insured's Date of Birth, Sex||Not Required|
|11b. Other Claim ID||Not Required|
|11c. Insurance Plan Name or Program Name||Not Required|
|11d. Is there another Health Benefit Plan?||Not Required|
|12. Patient's or Authorized Person's signature||Required||Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".
Enter the date the claim form was signed.
|13. Insured's or Authorized Person's Signature||Not Required|
|14. Date of Current Illness Injury or Pregnancy||Not Required|
|15. Other Date Not||Not Required|
|16. Date Patient Unable to Work in Current Occupation||Not Required|
|17. Name of Referring Physician||Conditional|
|18. Hospitalization Dates Related to Current Service||Not Required|
|19. Additional Claim Information||Conditional|
|20. Outside Lab?
|21. Diagnosis or Nature of Illness or Injury||Required||Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.
Enter applicable ICD-10 indicator.
|22. Medicaid Resubmission Code||Conditional||List the original reference number for resubmitted claims.
When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
|23. Prior Authorization||Not Required|
|24. Claim Line Detail||Information||The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.
Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.
Each claim form must be fully completed (totaled).
Do not file continuation claims (e.g., Page 1 of 2).
|24A. Dates of Service||Required||The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.
Single Date of Service: Enter the six digit date of service in the "From" field. Completion of the "To field is not required. Do not spread the date entry across the two fields.
Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
|24B. Place of Service||Required||Enter the Place of Service (POS) code that describes the location where services were rendered. The Health First Colorado accepts the CMS place of service codes.
|24C. EMG||Not Required|
|24D. Procedures, Services, or Supplies||Required||Enter the HCPCS procedure code that specifically describes the service for which payment is requested.
All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.
HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).
Only approved codes from the current CPT or HCPCS publications will be accepted.
|24D. Modifier||Conditional||Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.
|24E. Diagnosis Pointer||Required||Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.
At least one diagnosis code reference letter must be entered.
When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.
This field allows for the entry of 4 characters in the unshaded area.
|24F. $ Charges||Required||Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.
The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.
Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.
Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
|24G. Days or Units||Required||Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.
|24H. EPSDT/Family Plan||Conditional||EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
|24I. ID Qualifier||Not Required|
|24J. Rendering Provider ID #||Not Required||In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.|
|25. Federal Tax ID Number||Not Required|
|26. Patient's Account Number||Optional||Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).|
|27. Accept Assignment?||Required||The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.|
|28. Total Charge||Required||Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.|
|29. Amount Paid||Not Required|
|30. Rsvd for NUCC Use|
|31. Signature of Physician or Supplier Including Degrees or Credentials||Required||Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.
Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
|32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #
|Required||Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
|33. Billing Provider
Info & Ph #
|Required||Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
|33a- NPI Number||Required|
|33b- Other ID #||If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.|
Qualified Residential Treatment Program Claim Example
For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.
|Revision Date||Section/Action||Made by|
|10/1/2021||Created new benefit||HCPF|
|10/29/2021||Place of Service and Payment Limits update||HCPF|
|12/8/2021||Updated Billing Guidance and Reference Table||HCPF|
|07/22/2022||DYS and ARD Billing Guidance added||HCPF|