Outpatient Behavioral Health Fee-for-Service
- General Policies
- Billing Information
- Benefit Policies
- Mental Health Services
- Outpatient Substance Use Disorder Services
- Additional Covered Services
- Non-Covered Behavioral Health FFS Services
- Special Provision: EPSDT Services Can Exceed Policy Limitations For Members Age 20 And Younger
- Procedure/HCPCS Codes Overview
- Paper Claim Reference Table
- Timely Filing
- Outpatient Behavioral Health Fee-For-Service Manual Revisions 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.
- Beginning July 2018 members have up to 6 short-term behavioral health visits per fiscal year covered in the primary care setting, billed FFS to the fiscal agent DXC. Refer to the ACC Phase Two web page for exact details on this policy.
- 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.
- 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 a 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 the RAE. Providers must contact the RAE which serves their region to begin the enrollment process. Details are available at the Department's Regional Accountable Entity web page.
- Providers who are denied RAE enrollment may not bill DXC fee-for-service (FFS) as an alternative reimbursement route. If the provider is denied RAE enrollment this means that 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.
- A number of services, such as office administered drugs (e.g. Suboxone) are covered Health First Colorado benefits but are not covered by the RAE. These services must always be billed to DXC FFS. Reference the coverage diagram below.
- 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.
General Billing Information
Refer to the General Provider Information manual for general billing information.
Outpatient Behavioral Health Services are a group of services designed to provide medically necessary behavioral health services to certain Health First Colorado members in order to restore these individuals to their highest possible functioning level. Services may be provided by any willing, qualified provider as described below. Services are provided on an outpatient basis and not during an inpatient hospital stay.
Behavioral Health is split into two (2) benefit categories: Mental Health services and Substance Use Disorder (SUD) services.
Mental Health Services
Only the following enrolled provider types and qualifications are eligible to render Mental Health services to Health First Colorado members. Specific procedures may require different provider or qualifications, as listed.
- Doctor of Osteopathy and Medicine
- Psychologist, Psy.D/Ph.D
- Masters Level Clinician
- Licensed Professional Counselor (LPC)
- Licensed Marriage and Family Therapist (LMFT)
- Licensed Clinical Social Worker (LCSW)
- Advanced Practice Nurse
- Physician Assistant
- Community Mental Health Center (CMHC)
- Federally Qualified Health Center (FQHC)
- Rural Health Clinic (RHC)
The following services are covered:
- Individual Psychotherapy - Therapeutic contact with one (1) member of more than 30 minutes, but no more than two (2) hours.
- Individual Brief Psychotherapy - Therapeutic contact with one (1) member of up to and including 30 minutes.
- Family Psychotherapy - Therapeutic contact of up to and including two (2) hours with one (1) member, typically a child/youth, with one (1) or more of the member's family members and/or caregivers present and included in the therapeutic process and communications.
- Group Psychotherapy - Therapeutic contact with more than one (1) member of up to and including two (2) hours. Not all members in the group session need be Health First Colorado enrolled.
- Behavioral Health Assessment - An initial or ongoing diagnostic evaluation of a member to determine the presence or absence of a behavioral health diagnosis, to identify behavioral health issues that impact health and functioning, and to develop an individual service/care plan.
- Pharmacological Management - Monitoring of medications prescribed and consultation provided to members by a physician or other medical practitioner authorized to prescribe medications as defined by State law, including associated laboratory services as indicated.
- Outpatient Day Treatment – Therapeutic contact with a member in a structured program of therapeutic activities lasting more than four (4) hours but less than 24 hours per day. When provided in an outpatient hospital program, may be called “partial hospitalization". Services include:
- Assessment and monitoring
- Individual/group/family therapy
- Psychological testing
- Medical/nursing support
- Psychosocial education
- Skill development and socialization training focused on improving functional and behavioral deficits
- Medication management
- Expressive and activity therapies
- Emergency / Crisis Services – Services provided during a mental health emergency which involve unscheduled, immediate, or special interventions in response to a crisis situation with a member, including associated laboratory services, as indicated.
|Service||Procedure Code||Code description||RAE Covered|
|Individual Psychotherapy||90832||Psychotherapy, 30 minutes with member and/or family member||Yes|
|Individual Psychotherapy||90833||Psychotherapy, 30 mins, with member or family member, when performed with an E&M service listed separately||Yes|
|Individual Psychotherapy||90834||Psychotherapy, 45 minutes with member and/or family member||Yes|
|Individual Psychotherapy||90836||Psychotherapy, 45 mins, with member or family member, when performed with an E&M service listed separately||Yes|
|Individual Psychotherapy||90837||Psychotherapy, 60 minutes with member and/or family member||Yes|
|Individual Psychotherapy||90838||Psychotherapy, 60 mins, with member or family member, when performed with an E&M service listed separately||Yes|
|Individual Brief Psychotherapy||90832||Psychotherapy, 30 minutes with member and/or family member||Yes|
|Individual Brief Psychotherapy||90833||Psychotherapy, 30 mins, with member or family member, when performed with an E&M service listed separately||Yes|
|Family Psychotherapy||90832||Psychotherapy, 30 minutes with member and/or family member||Yes|
|Family Psychotherapy||90833||Psychotherapy, 30 mins, with member or family member, when performed with an E&M service listed separately||Yes|
|Family Psychotherapy||90834||Psychotherapy, 45 minutes with member and/or family member||Yes|
|Family Psychotherapy||90836||Psychotherapy, 45 mins, with member or family member, when performed with an E&M service listed separately||Yes|
|Family Psychotherapy||90837||Psychotherapy, 60 minutes with member and/or family member||Yes|
|Family Psychotherapy||90838||Psychotherapy, 60 mins, with member or family member, when performed with an E&M service listed separately||Yes|
|Family Psychotherapy||90846||Family psychotherapy (w/o pt)||Yes|
|Family Psychotherapy||90847||Family psychotherapy (conjoint)||Yes|
|Family Psychotherapy||90849||Multiple-family group psychotherapy||Yes|
|Group Psychotherapy||90853||Group psychotherapy (not multi-family)||Yes|
|Psychiatric diagnostic evaluation||90791||Psychiatric diagnostic evaluation||Yes|
|Psychiatric diagnostic evaluation||90792||Psychiatric diagnostic evaluation with medical services||Yes|
|Cognitive Capability Assessment||96101||Psycho testing by psych/phys, per hour||Yes|
|Cognitive Capability Assessment||96102||Psycho testing by technician, per hour||Yes|
|Cognitive Capability Assessment||96103||Psycho testing admin by comp||Yes|
|Cognitive Capability Assessment||96105||Assessment of aphasia, per hour||No|
|Cognitive Capability Assessment||96110||Developmental test limited, per instrument used||No|
|Cognitive Capability Assessment||96111||Developmental test extended, with interpretation and report||No|
|Cognitive Capability Assessment||96116||Neurobehavioral status exam, per hour||Yes|
|Cognitive Capability Assessment||96118||Neuropsych test by psych/phys, per hour||Yes|
|Cognitive Capability Assessment||96119||Neuropsych testing by technician, per hour||Yes|
|Cognitive Capability Assessment||96125||Cognitive test by healthcare professional, per hour||No|
|Cognitive Capability Assessment||96127||Brief emotional or behavioral assessment, per standardized instrument||No|
|Health and Behavior Assessment||96150||Assess hlth/behave init||No|
|Health and Behavior Assessment||96151||Assess hlth/behave subseq||No|
|Biopsychosocial Assessment/Intervention||96152||Intervene hlth/behave indiv||No|
|Biopsychosocial Assessment/Intervention||96153||Intervene hlth/behave group||No|
|Biopsychosocial Assessment/Intervention||96154||Interv hlth/behav fam w/pt||No|
|Biopsychosocial Assessment/Intervention||96155||Interv hlth/behav fam no pt||No|
|Pharmacological Management||90863||Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (list separately in addition to the code for primary procedure)||Yes|
|Emergency/Crisis Services||90839||Psychotherapy for crisis; first 60 minutes||Yes|
|Emergency/Crisis Services||90840||Psychotherapy for crisis; each additional 30 minutes (list separately in addition to code for primary service)||Yes|
Outpatient Substance Use Disorder Services
The following providers are eligible to provide Outpatient Substance Use Disorder (SUD) services to Health First Colorado members.
- Licensed Health Practitioners who are also:
- Certified in addiction medicine by the American Society of Addiction Medicine (ASAM), the American Board of Addiction Medicine (ABAM), or the American Board of Preventive Medicine (ABPM); or
- Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction Counselors (LAC) by the Department of Regulatory Agencies (DORA); or
- National Certified Addiction Counselors II (NCAC II) or Master Addiction Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors (NAADAC); or
- Certified in addiction psychiatry by the American Board of Psychiatry and Neurology certified in Addiction Psychiatry (ABPN).
- Licensed Clinicians.
Licensed Clinician means a provider who is a clinical social worker licensed pursuant to CRS 12-43-404, marriage and family therapist licensed pursuant to CRS 12-43-504, professional counselor licensed pursuant to CRS 12-43-603, addiction counselor licensed pursuant to CRS 12-43-804, or psychologist (Psy.D/Ph.D) licensed pursuant to CRS 12-43-304.
Licensed Health Practitioner means an advanced practice nurse licensed pursuant to CRS 12-38-111.5, physician/psychiatrist licensed pursuant to CRS 12-36-101, or physician assistant licensed pursuant to CRS 12-36-107.4.
The rendering provider's NPI must be indicated on the claim in the rendering/performing field.
Methadone Clinics must enroll as medical clinics Provider Type – 16 with the Health First Colorado fiscal agent, DXC. See enrollment requirements for details.
Individual rendering providers must have their own NPI number and enrollment.
Even though Suboxone is provided by Methadone Clinics it is not considered a SUD benefit. Rather, it is considered a physical health benefit. Other ancillary medical services provided by Methadone Clinics (physical health assessments, blood draws, etc.) are also considered physical health services. Therefore, these physical health services are never billed to the RAE. They are always billed to DXC.
Laboratory services require CLIA certification.
An approved treatment plan must be in place for each client prior to the client receiving services. An initial assessment is required to establish a treatment plan. Treatment plans require approval from a licensed provider (above list) with the authority to approve treatment plans within their scope of practice.
All rendered services must be medically necessary, as defined in Rule Section 8.076.1.8, and must be detailed in the client's treatment plan and progress notes. Initial substance use disorder assessments are exempt from inclusion in the approved treatment plan.
Approved treatment plans must identify treatment goals and must explain how the proposed treatment services will achieve those stated goals.
Approved treatment plans must identify the treatment services planned for use over the course of treatment. The amount, frequency, and duration of these treatment services must be included in the approved treatment plan.
- Members are not required to obtain a referral from their Primary Care Physician (PCP) or Primary Care Medical Provider (PCMP) to receive these services.
- Members must have a treatment plan that is approved by a licensed practitioner listed above.
- Outpatient Fee-for-Service Substance Use Disorder Treatment services may only be rendered by providers outlined above.
- Services are covered only when the client has been diagnosed with at least one of the following:
- Alcohol use or induced disorder
- Amphetamine use or induced disorder
- Cannabis use or induced disorder
- Cocaine use or induced disorder
- Hallucinogen use or induced disorder
- Inhalant use or induced disorder
- Opioid use or induced disorder
- Phencyclidine use or induced disorder
- Sedative Hypnotic or Anxiolytic use or induced disorder
- Tobacco use disorder
Substance Use Disorder Assessment
A substance use disorder assessment is an evaluation designed to determine the most appropriate level of care based on criteria established by the American Society of Addiction Medicine (ASAM), the extent of drug or alcohol use, abuse, or dependence and related problems, and the comprehensive treatment needs of a client with a substance use disorder diagnosis.
- Course of treatment and changes in level of care must be based on best practices as defined by the current ASAM Patient Placement Criteria.
- Re-assessments must be spaced appropriately throughout the course of treatment to ensure the treatment plan is effectively managing the client's changing needs.
- Each complete assessment corresponds to one unit of service.
- An assessment may involve more than one session and may span multiple days. If the assessment spans multiple days, the final day of the assessment is reported as the date of service.
Individual and Family Therapy
Individual and family therapy is the planned treatment of a client's problem(s) as identified by an assessment and listed in the treatment/service plan. The intended outcome is the management and reduction, or resolution of the identified problem(s).
- Individual and family therapy is limited to one client per session.
- Individual and family therapy are billed at 15 minutes per unit.
- A session is considered a single encounter with the client that can encompass multiple timed units.
- Family therapy must be directly related to the client's treatment for substance use disorder or dependence.
- Individual therapy and family therapy sessions are allowed on the same date of service.
Group therapy refers to therapeutic substance use disorder counseling and treatment services, administered through groups of people who have similar needs, such as progression of disease, stage of recovery, and readiness for change.
- Group therapy must include more than one patient.
- A session of group therapy may last up to three hours and is billed in units of one hour each (e.g., a three-hour group session would consist of three units).
- A unit of service may be billed separately for each client participating in the group therapy session.
Alcohol / Drug Screening and Counseling
Alcohol / drug screening and counseling is the collection of urine followed by a counseling session with the client to review and discuss the results of the screening.
- The analysis of the urine specimen (urinalysis) may only be billed by a provider with the appropriate CLIA certification for the test performed. Urinalysis is not part of the Outpatient Fee-For-Service SUD benefit.
- Substance use disorder providers will only be reimbursed for collecting the urine specimen and providing a counseling session to review and discuss the results of the urinalysis. Claims submitted for the collection of the urine sample without the subsequent counseling of urinalysis results will not be reimbursed.
- If the client does not return for the counseling of their urinalysis results, the collection of the sample cannot be claimed.
- Substance use disorder counseling services to discuss and counsel the client on the test results must be provided by an eligible rendering provider, as outlined in this manual.
- The counseling portion of the service may be conducted during a session of individual or family therapy.
- Multiple urine collections per date of service are not additionally reimbursed.
- Alcohol / drug screening and counseling is limited to one unit per date of service.
- A unit of service is the single collection and subsequent counseling session.
Targeted Case Management
Targeted case management refers to coordination and planning services provided with, or on behalf of, a client with a substance use disorder diagnosis.
- The client does not need to be physically present for this service to be performed if it is done on the client's behalf.
- Targeted case management services are limited to service planning, advocacy, and linkage to other appropriate medical services related to substance use disorder diagnosis, monitoring, and care coordination.
- A unit of service equals one 15-minute increment of targeted case management and consists of at least one documented contact with a client or person acting on behalf of a client, identified during the case planning process.
SUD Residential and Inpatient Services
For information about these services, please see the Provider Manual for Residential and Inpatient SUD Services.
Medication-Assisted Treatment (MAT)
Medication Assisted Treatment (MAT) is a benefit for opioid addiction that includes a medication approved by the U.S. Food and Drug Administration (FDA) for opioid addiction detoxification or maintenance treatment.
- When methadone is administered for MAT, the reimbursement for the medication's acquisition is bundled with the reimbursement for administration and dispensing under a single billing code. When other medications are used for MAT (e.g. Suboxone), the reimbursement for the medication is billed separately from the administration and dispensing using physician administered drug billing codes.
- Only licensed physicians, physician assistants, or nurse practitioners are eligible to administer MAT. All providers must comply with the Office of Behavioral Health's Opioid Medication Assisted Treatment program requirements set forth at 2 C.C.R. 502-1 21.320.
- Take-home dosing is permitted in accordance with Office of Behavioral Health rules at 2 CCR 502-1 21.320.8. Therefore, one unit of MAT must be reported for each date of service the client ingests the dose of methadone.
- If the client ingests their dose at the facility, the place of service must be reported as office. If the client ingests their dose at home, the place of service must be reported as home. Records must include documentation to substantiate claims for take-home doses.
|Service||Code||Unit||Unit amount/frequency||Modifier required||RAE Covered|
|Alcohol/drug assessment||H0001||Untimed||1 unit per day||HF||Yes|
|Individual/family counseling and therapy||H0004||15 minute||8 units per day||HF||Yes|
|Group counseling and therapy||H0005||One (1) hour||3 units per day||HF||Yes|
|Targeted case management||H0006||30 minute||4 units per day||HF||Yes|
|Alcohol/drug screening counseling||S9445||Untimed||1 unit per day||HF||Yes|
|Medication Assisted Treatment: administration, acquisition, and dispensing of Methadone||H0020||Untimed||1 unit per day||HF||Yes|
Additional Covered Services
Health First Colorado Fee-For-Service covers additional services which are not covered by the RAE. These services are available to all members. Specific rendering provider requirements may apply to each service.
|Service||Code||Unit||Unit amount/frequency||Allowed Providers|
|Buprenorphine, oral||J0571||One (1) mg||5 / Day||Physician, clinic, non-physician practitioner, osteopath, physician assistant, APN|
|Buprenorphine/naloxone, oral, less than or equal to three (3)mg||J0572||<= three (3) mg||5 / day||Physician, clinic, non-physician practitioner, osteopath, physician assistant, APN|
|Buprenorphine/naloxone, oral, greater than three (3)mg, but less than or equal to six (6)mg||J0573||Three (3)mg-six (6)mg||5 / day||Physician, clinic, non-physician practitioner, osteopath, physician assistant, APN|
|Buprenorphine/naloxone, oral, greater than six (6) mg, but less than or equal to 10 mg||J0574||7-10mg||4 / day||Physician, clinic, non-physician practitioner, osteopath, physician assistant, APN|
|Buprenorphine/naloxone, oral, greater than 10 mg||J0575||>=10mg||3 / day||Physician, clinic, non-physician practitioner, osteopath, physician assistant, APN|
|Office administered injection: Naltrexone, depot form, one (1)mg||J2315||One (1)mg||380 mg / day, limit one (1) injection per month||Physician, clinic, non-physician practitioner, osteopath, physician assistant, APN|
Non-Covered Behavioral Health FFS Services
- Covered diagnosis/procedure services provided to members participating in the Community Behavioral Health Services Program are not covered under the Mental Health fee-for-service benefit.
- Services provided by email, telephone, text message, facsimile transmission, and online research.
- Room and board services.
- Educational, vocational and job training services.
- Habilitation services.
- Services to inmates in public institutions (i.e. correctional facilities) as defined in 42 CFR § 435.1009.
- Mental health services to individuals residing in institutions for mental diseases as defined in 42 CFR § 435.1009 are not covered outside of the RAE
- Recreational and social activities.
- Day treatment program services.
- Peer advocate services.
- Court-ordered DUI services.
- Reimbursement for contractual arrangements between the provider and a third party.
Special Provision: EPSDT Services Can Exceed Policy Limitations For Members Age 20 And Younger
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Health First Colorado) program that requires the state Health First Colorado agency to cover services, products, or procedures for Health First Colorado members ages 20 and younger if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition (health problem) identified through a screening examination (includes any evaluation by a physician or other licensed clinician). EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
EPSDT does not require the state Health First Colorado agency to provide any service, product, or procedure that is:
- Unsafe, ineffective, or experimental/investigational.
- Not medical in nature or not generally recognized as an accepted method of medical practice or treatment.
Service limitations on scope, amount, duration, frequency, and/or other specific criteria described in the above screening policies may be exceeded or may not apply as long as the provider documentation shows how the service, product, or procedure will correct, improve or maintain the recipient's health, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.
Providers may be subject to post payment review to assure the use of a validated, standardized screening tool and medical justification for screens in excess of the stated benefit limits.
Procedure/HCPCS Codes Overview
The codes used for submitting claims for services provided to Health First Colorado members represent services that are approved by the Centers for Medicare and Medicaid Services (CMS) and services that may be provided by an enrolled Health First Colorado provider.
The Healthcare Common Procedural Coding System (HCPCS) is divided into two principal subsystems, referred to as level I and level II of the HCPCS. Level I of the HCPCS is comprised of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Level II codes are also referred to as alpha-numeric codes because they consist of a single alphabetical letter followed by 4 numeric digits, while CPT codes are identified using 5 numeric digits.
HIPAA requires providers to comply with the coding guidelines of the AMA CPT Procedure Codes and the International Classification of Disease, Clinical Modification Diagnosis Codes. If there is no time designated in the official descriptor, the code represents one unit or session. Providers should regularly consult monthly bulletins in the Provider Services Bulletins section. To receive electronic provider bulletin notifications, an email address can be entered into the Provider web portal in the (MMIS) Provider Data Maintenance area or by filling out a publication preference form. Bulletins include updates on approved procedure codes as well as the maximum allowable units billed per procedure.
The following paper form reference table gives required and/or conditional fields for the paper CMS 1500 claim form for Behavioral Health claims:
CMS 1500 Paper Claim Reference Table
The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.
|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 Health First Colorado 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||Not Required|
|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?||Not Required|
|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||Conditional||Leave blank|
|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: 010119 for January 1, 2019.
Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
|24B. Place of Service||Required||Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
|24C. EMG||Not Required|
|24D. Procedures, Services, or Supplies||Required||Enter the procedure code that specifically describes the service for which payment is requested.|
|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.
|24G. Days or Units||General Instructions||A unit represents the number of times the described procedure or service was rendered.
Except as instructed in this manual or in Health First Colorado bulletins, the billed unit must correspond to procedure code descriptions. The following examples show the relationship between the procedure description and the entry of units.
|24H. EPSDT/Family Plan||Not Required||EPSDT (shaded area)
Family Planning (unshaded area)
|24I. ID Qualifier||Not Required|
|24J. Rendering Provider ID #||Required||In the shaded portion of the field, enter the NPI of the Health First Colorado provider 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. 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.|
CMS 1500 Behavioral Health Claim Example
For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.
Outpatient Behavioral Health Fee-For-Service Manual Revisions Log
|Revision Date||Section/Action||Made by|
|12/1/2016||Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive.||HPE (now DXC)|
|12/27/2016||Updates based on Colorado iC Stage II Provider Billing Manuals Comment Log v0_2.xlsx||HPE (now DXC)|
|/10/2017||Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx||HPE (now DXC)|
|1/19/2017||Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx||HPE (now DXC)|
|1/26/2017||Updates based on Department 1/20/2017 approval email||HPE (now DXC)|
|5/22/2017||Updates based on Fiscal Agent name change from HPE to DXC||DXC|
|5/9/2018||Revision of policies to reflect changes made to 8.746. Revision of SUD eligible providers and SUD benefit limitations. Clarification of Methadone Clinic enrollment details.||HCPF|
|6/25/2018||Updated billing section to point at general manual; replaced multiple instances of BHO with RAE||HCPF|
|7/26/2018||Included information on the 6 short term behavioral health visits in the primary care setting related to ACC 2||HCPF|
|12/21/2018||Clarification to signature requirements||HCPF|
|3/18/2019||Clarification to signature requirements||HCPF|
|7/11/2019||Updated Appendices' links and verbiage||DXC|
|12/30/2019||Converted to web page||HCPF|
|9/14/2020||Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table||HCPF|
Removed section on Social Ambulatory Detox, replaced with direction to SUD Residential and Inpatient Services. Removed HCPCS S3005, T1007, T1019, T1023 from coding table effective 12-31-20. These services are now part of the residential/inpatient provider manual. Removed residential treatment from non-covered services section (effective 1-1-21) and revised IMD language.