Pediatric Behavioral Therapies

What is the Pediatric Behavioral Therapies Benefit?

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

How do I find a provider?

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.

What are the codes my provider can use to bill Health First Colorado?

2018 Procedure Code 2018 Procedure Modifier 2018 HCPCS Procedure Code Description New Procedure Coding 2019 Department Service Description 2019 Rate 2019 Unit
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

 $13.37 Per 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 $6.69 Per 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

 $20.85 Per 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 $10.43 Per 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. $307.35 Per Assessment Once per year
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 $36.06 Per 30 minutes

How do I know my behavioral health services will be covered by Health First Colorado?

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. 

How can I determine whether behavioral health services are medically necessary for me? 

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.

What happens once my provider submits my Prior Authorization Request (PAR)? 

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: 

  • PAR Reconsideration: A PAR Reconsideration is similar to a second opinion and must be requested by your provider. Additional documents not submitted with the original PAR may be submitted with the Reconsideration request. A different doctor 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. 

You also have the option to: 

  • Submit a written request for an appeal to the Office of Administrative Courts. For more information, see “My Prior Authorization Request was denied and I want to appeal the decision. How do I appeal the PAR decision?” below. 

My Prior Authorization Request was denied and I want to appeal the decision. How do I appeal the PAR decision? 

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: 

  1. You must request an appeal in writing. This is called a Letter of Appeal. 
  2. Your Letter of Appeal must include: 
  • Your name, address, phone number, and Health First Colorado ID number; 
  • Why you want a hearing; and 
  • A copy of the front page of the Notice of Action (letter notifying you of the PAR decision) you are appealing. 
  1. You may ask for a telephone hearing rather than appearing in person. 
  2. Mail or fax your Letter of Appeal to: 

Office of Administrative Courts 
1525 Sherman Street, 4th Floor 
Denver, CO 80203 
Fax 303-866-5909

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. 

  1. The Office of Administrative Courts will contact you by mail with the date, time, and place of your hearing. 

Can I access the services if my child is on an HCBS Waiver?

Yes.  All EPSDT services are available to all children receiving Health First Colorado. 

If my child is diagnosed with Autism and was receiving services on the Children with Autism Waiver can we receive the services again?

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.

Does my child have to have a diagnosis of Autism to qualify for the services?

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