Who can access the Pediatric Behavioral Therapies benefit?
Behavioral therapies are a benefit for Health First Colorado (Colorado's Medicaid program) members who meet the following criteria:
- A member is 20 years of age and younger, and
- 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
Providers wishing to serve Health First Colorado members must be enrolled under Health First Colorado’s Provider Type 83, Behavioral Therapy Group. For all providers, the group enrollment (practice, clinic, LLC, etc.) needs to be submitted first. After completing the Provider Type 83, Behavioral Therapy Group application, each 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 are 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 additional documents to Gainwell Technologies 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 HCPF's third party Utilization Management (UM) vendor, Acentra (formerly Kepro), via the online Acentra Portal Atrezzo. For information on PAR submissions, please visit 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 from Acentra. The provider will receive a determination via Atrezzo (Acentra’s PAR portal) once the PAR review is complete. An approved PAR is valid for up to six (6) months, after which a new PAR must be submitted. Both the provider and the Member receive the final PAR determination letter from Gainwell Technologies.
If the PAR is denied or partially denied, 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.
- Request a Peer-to-Peer review.
Members also have the option to:
- Submit a written request for an appeal to the Office of Administrative Courts.
- Appeal instructions are included in denial determination letters.
- Appeal instructions are included in denial determination letters.
Benefits Codes
| 2020 Procedure Code | 2020 Procedure Modifier | 2020 HCPCS Procedure Code Description | New Procedure Coding | 2020 Department Service Description |
|---|---|---|---|---|
| H0046 | Mental Health Services, per 15 minutes | 97153 | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes | |
| New 2019 | 97154 | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to face with two or more patients, each 15 minutes | ||
| H0046 | TJ | Mental Health Services, per 15 minutes | 97155 | Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes |
| New 2019 | 97158 | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes | ||
| T1024 | Evaluation and treatment by an integrated, specialty team, contracted to provide coordinated care to multiple or severely handicapped children, per encounter | 97151 | Behavior identification assessment, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report. Code can be billed only once every 12 months. | |
| T1024 | TJ | Evaluation and treatment by an integrated, specialty team, contracted to provide coordinated care to multiple or severely handicapped children, per encounter | 97151 TJ | Behavior identification re-assessment, limited to 2 units per six months |
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
- Pediatric Behavioral Therapies Benefit Billing Manual
For more information contact:
HCPF_EPSDT@state.co.us