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Behavioral therapy is a treatment that helps change maladaptive behaviors. Professionals use this type of therapy to replace bad habits with good ones.
Behavioral Therapy Criteria
Please check the list of contracted providers. We are adding additional providers each week, so be sure to check back if you don’t immediately find someone close to you.
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
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
All behavioral therapies will need to be authorized prior to the start of treatment. The contracted Medicaid provider will assess your child, put together a treatment plan, and submit a Prior Authorization Request (PAR) to the Department’s Utilization Management (UM) vendor to review for medical necessity. Both you and your provider will receive a letter from the Department’s fiscal agent containing the final PAR determination and your rights to appeal if your PAR is denied.
Your provider will submit the completed forms in an online Prior Authorization Request (PAR). The PAR process verifies that the behavioral health services are medically necessary and right for you. All behavioral health services must be requested through this process.
If the UM vendor approves your PAR, you can then work with your provider to start getting services. Each approved PAR is valid for up to six (6) months. If you need behavioral services for an additional six (6) months, your provider must submit a new PAR.
Your doctor will be able to tell you if your diagnosis, condition, or symptoms make behavioral health services medically necessary for your day-to-day life.
The PAR will be reviewed by licensed clinical reviewers who will assess your behavioral health needs. If the PAR is approved, then your provider will receive notification of the number of hours that behavioral health services may be provided to you. An approved PAR is valid for up to six (6) months, after which a new PAR must be completed and submitted.
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 personal care provider to make sure that all the required documents are included in the PAR submission.
If your PAR is denied or partially denied, you can work with your doctor on these options:
You also have the option to:
You have the right to appeal and ask for a hearing if you do not agree with the PAR decision. You will have an appeal hearing with an Administrative Law Judge. You may represent yourself, or have a lawyer, a relative, a friend, or other spokesperson assist you as your authorized representative.
How to appeal:
Office of Administrative Courts
1525 Sherman Street, 4th Floor
Denver, CO 80203
Your letter of appeal must be received by the Office of Administrative Courts no later than thirty (30) calendar days from the date of your Notice of Action (your denial letter). The date of the Notice of Action is located on the front of the denial letter.
Yes. All EPSDT services are available to all children receiving Health First Colorado.
Only if your child is currently receiving Health First Colorado. If your child is not eligible for Health First Colorado due to income, you could potentially access Health First Colorado under the Children’s Buy In Program.
No. Behavioral therapy is available to all children currently eligible for Health First Colorado when the service is medically necessary. We have established criteria for what qualifies and what does not.
For more information, please contact EPSDT@state.co.us.
Pediatric Behavioral Therapies Information for Providers