Qualified Residential Treatment Program (QRTP) and Psychiatric Residential Treatment Facility (PRTF) Prior Authorization and Nomenclature Stakeholder Engagement Questions and Answers

This webpage summarizes: 

Unanswered stakeholder questions received during the stakeholder engagement session held by the Department of Health Care Policy and Financing (HCPF) on June 18, 2025, regarding updates to utilization management and ongoing stay requirements for HCPF-funded QRTP and PRTF services and changes to nomenclature for out of state providers.

Below each item, HCPF has provided an interim response. 

Important Note: There are several stages of policy development and implementation. Any responses on this webpage represent a snapshot of HCPF’s position as of August 5, 2025 and should not be read as final policy determination.

General Policy Questions

Where can I find policy changes and updates shared in the stakeholder meeting, held on June 18, 2025?

The June 18, 2025, meeting presentation and recording are posted on the Qualified Residential Treatment Program (QRTP) and Psychiatric Residential Treatment Facility (PRTF) Prior Authorization and Nomenclature Stakeholder Meeting webpage.

How will the proposed changes impact QRTP and PRTF prior authorizations and stay requirements? 

• HCPF-funded QRTP current state: 
  • Independent Assessment (IA) required within 14 days of placement
  • No ongoing stay reviews
• HCPF-funded QRTP requirements starting Nov 15, 2025: 
  • Enhanced Standardized Assessment (ESA) required within 14 days of placement 
  • Ongoing stay reviews required. Ongoing stay reviews every 30 days will determine whether the member continues to demonstrate that the QRTP level of care is medically necessary
• HCPF-funded PRTF current state: 
  • Independent Team must certify the need for PRTF level of care
  • No ongoing stay reviews
• HCPF-funded PRTF requirements starting Nov 15, 2025:
  • Independent Team must certify the need for PRTF level of care
  • Assessment (ESA) required within 14 days of placement
  • Ongoing stay reviews required. Ongoing stay reviews every 30 days will determine whether the member continues to demonstrate that the PRTF level of care is medically necessary

Do the new stay requirements apply to both QRTP and PRTF programs?

Yes. ALL information herein applies to HCPF-funded QRTP and/or HCPF-funded PRTF unless the Regional Accountable Entities (RAEs) are identified in the answer.

When do the proposed changes take effect?

• Effective November 15, 2025, new episodes of care in a QRTP or PRTF will require an Enhanced Standardized Assessment (ESA) within 14 days of placement.
• Effective November 15, 2025, members in the middle of an episode of care at a QRTP or a PRTF will have up to 30 days of treatment before a continuing stay review.
• Episodes of care longer than 30 days after November 15, 2025, will require continuing stay reviews and approval from Acentra, the Utilization Management (UM) vendor. Members who have not yet undergone an Independent Assessment (IA) or ESA may be required to undergo an ESA as part of their continuing stay review.

How should referrals to out of state facilities be labeled now that the out of state providers are called Out of state High Intensity Residential Treatment (OHIRT)?

An ESA that recommends PRTF may be sufficient for out-of-state residential treatment. All out of state placements are reviewed for medical necessity by the UM vendor, on a case-by-case basis.

How can providers determine which Regional Accountable Entity (RAE)/Managed Care Organization (MCO) a Health First Colorado member is assigned to?

Providers are responsible for verifying the insurance for youth they are serving. Providers can check Health First Colorado eligibility and RAE/MCO assignment using the Provider Portal. The assigned RAE/MCO for Health First Colorado members occasionally changes.  These changes generally take place on the first of the month. It is HCPF’s policy that if a member changes RAEs/MCOs during the course of residential treatment, the new RAE/MCO will honor the initial authorization of the previous RAE/MCO. Continuing stay authorizations are then conducted by the member’s new RAE/MCO.

What is a Utilization Management (UM) vendor and what is their role in the implementation of this policy?

HCPF works with a UM vendor to ensure that the care members receive is the right care, at the right time, and not more than what’s needed. UM vendors facilitate prior authorizations, stay reviews, and more to ensure that medical services are needed, covered, and appropriate. 

Through a competitive process, the UM vendor was selected to administer the fee-for-service UM program for outpatient benefits, services and supplies, out-of-state inpatient services, and the Inpatient Hospital Review Program, under the umbrella of the ColoradoPAR program. The QRTP and PRTF benefits fall under the ColoradoPAR program.

What tool and information will be used to determine whether PRTF or QRTP services are medically necessary and who is involved in the decision-making?

Medical necessity for initial treatment in a QRTP or PRTF will be determined by the Enhanced Standardized Assessment (ESA). An ESA must occur within 14 days of placement in a QRTP or PRTF. If the ESA supports that level of care, initial treatment is approved for 30 days. Continuing stay reviews, for periods of treatment beyond that 30 days, will utilize all available clinical information to determine ongoing medical necessity. The Statewide Standardized Utilization Management (SSUM) Guidelines for Youth Under 21 Years Old are the guidelines for the UM vendor to determine the medically necessary treatment setting and interventions based on a youth’s severity of illness and intensity of service need.

Who is on the Independent Team at the PRTF provider that certifies the member’s need for treatment while the ESA is being completed?

Independent Team means a team certifying the need for Psychiatric Residential Treatment Facility (PRTF) services that is independent of the referring party and includes a physician who has competence in the diagnosis and treatment of behavioral health and knowledge of the client’s condition.

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 behavioral health 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 so that the services shall no longer be needed.
   

What tool and information will be used for the continuing stay review, who is involved in the decision-making, and how often is the review completed?

The UM vendor will complete both the initial and continuing stay review using the Statewide Standardized Utilization Management (SSUM) Guidelines for Youth Under 21 Years Old to determine that the member meets medical necessity criteria for the QRTP or PRTF level of care.

If an ESA recommends PRTF and the youth has to go out of state, will that recommendation meet Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements?

Yes. If Medicaid (through EPSDT) is being asked to pay for the out-of-state care, a recommendation showing the youth needs that level of care is required. An ESA can be used as that recommendation.

Where can I find information about what to do if I get a denial letter?

 When a Health First Colorado member receives a partial or full denial on a prior authorization for services requested on their behalf by their health care provider, both the provider and the member or their guardian/representative will receive the notice of the determination through letters. The letter to the provider outlines the adverse determination process and includes the option for and instructions on how to submit a reconsideration or peer-to-peer consultation request through the UM vendor's provider portal. The letter to the member includes instructions on how to appeal the decision. More information about appeals can be found on the Health First Colorado website. 

Questions Regarding Youth in County Custody

How do these changes impact members who are seeking QRTP or PRTF services while in county custody?

Medicaid can only fund medically necessary care. If the county wishes to initiate or continue a placement in QRTP or PRTF that is not medically necessary, the county will do so without Medicaid as a source of funding.

Are prior authorization and stay reviews handled differently for members in county custody?

HCPF is the payor for QRTP and PRTF services when the member is in child welfare custody, or has a diagnosis that excludes QRTP/PRTF services from RAE coverage. When HCPF is the payor for QRTP/PRTF, the member must receive an ESA within 14 days of placement. When the ESA supports the level of care where the member is receiving services, the services will be authorized for 30 days. The UM vendor will review and approve or deny any stays beyond the initial 30 days. Continuing stay reviews will occur every 30 days thereafter.

For members not in child welfare custody the RAE is responsible for authorizing QRTP or PRTF services when requested. The RAE can approve QRTP or PRTF level of care without an ESA if it has sufficient information to determine the requested level of care is medically necessary. If the RAE has insufficient information to approve QRTP or PRTF services, the member must undergo an ESA before the RAE can deny a request for QRTP or PRTF services. The RAE is the final arbiter of medical necessity and may agree or disagree with the recommendation of the ESA. Each RAE will conduct continuing stay reviews at the discretion and cadence of the RAE.

Details of the work flow and submitting information will differ between Acentra and RAEs, but the clinical components and authorization decisions should be similar.

Can the county represent a member in the QRTP and PRTF prior authorization process if the court orders an ESA and gives the county consent to sign releases for the member?

Yes. HCPF and the RAE/MCO can use any clinical information, especially completed ESAs, to make authorization decisions. Including relevant court orders and releases of information alongside clinical information in a prior authorization request will help ensure appropriate communication.

How will youth in county custody access the ESA? Will it go through the Behavioral Health Administration Service Organizations (BHASO) assessment network or the Medicaid assessment network?

ESAs conducted through the BHASO assessment network are completed by Qualified Individuals (QIs) and include the Family and Permanency Team Meeting. This ensures that the ESA meets all requirements for Title IV-E funding under the Family First Prevention Services Act (FFPSA) if QRTP is recommended. Youth in county custody can access ESAs through the Medicaid network, however, those assessments would NOT be FFPSA compliant. 

What is the process for appeals and reconsiderations if a member is in the county’s custody? 

Refer to response above re: Where can I find information about what to do if I get a denial letter? 
The adverse determination letter to the member notifies the member that they may request that their provider submit a reconsideration request on their behalf. It also informs the member of their right to appeal the decision and provides instructions on how to do so. In this scenario, the county agency, who has legal custody of the child, would receive a determination letter and would have the option to request the member's provider submit a reconsideration request or file an appeal on behalf of the member.

How will case workers access information about denials and appeals when a member is in the county’s custody?

The UM vendor uses a provider portal to manage prior authorization requests. Individuals at a provider entity undergo the UM vendor's ColoradoPAR training prior to gaining access to the portal. When a prior authorization determination is made, both the provider entity and the Health First Colorado member or their guardian/representative receive notification through a letter of the determination.

What happens if a transitional placement can’t be found in time when a member’s QRTP or PRTF services are no longer medically necessary?

Once QRTP/PRTF is deemed no longer medically necessary, HCPF/Fee-for-service Medicaid will pay up to 14 days of "transition time" at the QRTP or PRTF level of care, in order to get services/providers/other levels of care in place. Once those 14 days have elapsed, additional time will be approved, on a case-by-case basis, if more time is needed to get medically-necessary services in place. Additional time will be granted on a 7-day cadence. Lack of placement availability (ie: foster home, group home, etc) will not meet medical necessity requirements for extra days of transition time.

Medicaid can only fund medically necessary care. If the county, or the Division of Youth Services (DYS), wishes to initiate or continue placement in QRTP/PRTF that is not medically necessary, the county/DYS will do so without Medicaid as a source of funding.

How can case workers prepare for these changes before the implementation date?

• Ensure all children who are considered for QRTP or PRTF levels of care receive an ESA. 
• For children who are currently placed in a PRTF, who have not received an IA or an ESA, pursue an ESA if they are likely to require PRTF care beyond November 15, 2025. 
• Only utilize the QRTP and PRTF levels of care when it is supported by the ESA recommendation.

What resources are available for case workers who only navigate QRTP or PRTF resources occasionally?

Medicaid resources are listed below. The Colorado Department of Human Services (CDHS) may have additional resources.
 

• Operational Memo: Utilization Management and Assessment Requirements for Qualified Residential Treatment Providers (QRTP) and Psychiatric Residential Treatment Facilities (PRTF)
• Code of Colorado Regulations (8.765) 
• QRTP Billing Manual (for providers billing HCPF directly) 
• PRTF Billing Manual (for providers billing HCPF directly)

Will the court’s role change with the new Enhanced Standardized Assessment (ESA) process? Will there be resources for courts where these cases are rare?

No, the court’s role will not change with the new ESA process.

Additional resources for courts and judicial partners about the ESA process will be shared as they become available. Judicial and legal partners can reach out to Gretchen Russo, Judicial and Legislative Liaison at CDHS, and/or Meredith Villiers, ESA Program Manager at BHA, for additional training and resources.

For more information contact

HCPF_stakeholders@state.co.us