Outpatient Behavioral Health Fee-for-Service

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General Policies

  • 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.

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General Billing Information

Refer to the General Provider Information manual for general billing information.

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Benefit Policies

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.

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Mental Health Services

Eligible Providers

 

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.

 

  1. Physician
    1. Doctor of Osteopathy and Medicine
    2. Psychiatrist
  2. Psychologist, Psy.D/Ph.D
  3. Masters Level Clinician
    1. Licensed Professional Counselor (LPC)
    2. Licensed Marriage and Family Therapist (LMFT)
    3. Licensed Clinical Social Worker (LCSW)
    4. Advanced Practice Nurse
  4. Physician Assistant
  5. Community Mental Health Center (CMHC)
  6. Federally Qualified Health Center (FQHC)
  7. Rural Health Clinic (RHC)
  8. Hospital

 

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Covered Benefits and Limitations

 

The following services are covered:

 

  1. Individual Psychotherapy - Therapeutic contact with one (1) member of more than 30 minutes, but no more than two (2) hours.
  2. Individual Brief Psychotherapy - Therapeutic contact with one (1) member of up to and including 30 minutes.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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:
    1. Assessment and monitoring
    2. Individual/group/family therapy
    3. Psychological testing
    4. Medical/nursing support
    5. Psychosocial education
    6. Skill development and socialization training focused on improving functional and behavioral deficits
    7. Medication management
    8. Expressive and activity therapies
  8. 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.

 

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Mental Health Services Procedure Code Table

 

Service 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

 

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Outpatient Substance Use Disorder Services

Eligible Providers

 

The following providers are eligible to provide Outpatient Substance Use Disorder (SUD) services to Health First Colorado members.

 

  1. Licensed Health Practitioners who are also:
    1. 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
    2. Certified Addiction Counselors (CAC II or CAC III) or Licensed Addiction Counselors (LAC) by the Department of Regulatory Agencies (DORA); or
    3. National Certified Addiction Counselors II (NCAC II) or Master Addiction Counselors (MAC) by the National Association of Alcohol and Drug Abuse Counselors (NAADAC); or
    4. Certified in addiction psychiatry by the American Board of Psychiatry and Neurology certified in Addiction Psychiatry (ABPN).
  2. 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.

 

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Methadone Clinics

 

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.

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Treatment Planning

 

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.

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Covered Benefits and Limitations

 

LIMITATIONS

 

  1. Members are not required to obtain a referral from their Primary Care Physician (PCP) or Primary Care Medical Provider (PCMP) to receive these services.
  2. Members must have a treatment plan that is approved by a licensed practitioner listed above.
  3. Outpatient Fee-for-Service Substance Use Disorder Treatment services may only be rendered by providers outlined above.
  4. Services are covered only when the client has been diagnosed with at least one of the following:
    1. Alcohol use or induced disorder
    2. Amphetamine use or induced disorder
    3. Cannabis use or induced disorder
    4. Cocaine use or induced disorder
    5. Hallucinogen use or induced disorder
    6. Inhalant use or induced disorder
    7. Opioid use or induced disorder
    8. Phencyclidine use or induced disorder
    9. Sedative Hypnotic or Anxiolytic use or induced disorder
    10. Tobacco use disorder

 

COVERED SERVICES

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.

  1. Course of treatment and changes in level of care must be based on best practices as defined by the current ASAM Patient Placement Criteria.
  2. Re-assessments must be spaced appropriately throughout the course of treatment to ensure the treatment plan is effectively managing the client's changing needs.
  3. Each complete assessment corresponds to one unit of service.
  4. 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).

  1. Individual and family therapy is limited to one client per session.
  2. Individual and family therapy are billed at 15 minutes per unit.
    1. A session is considered a single encounter with the client that can encompass multiple timed units.
  3. Family therapy must be directly related to the client's treatment for substance use disorder or dependence.
  4. Individual therapy and family therapy sessions are allowed on the same date of service.

 

Group Therapy
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.

  1. Group therapy must include more than one patient.
  2. 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).
  3. 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.

  1. 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.
  2. 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.
    1. If the client does not return for the counseling of their urinalysis results, the collection of the sample cannot be claimed.
  3. 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.
  4. The counseling portion of the service may be conducted during a session of individual or family therapy.
  5. Multiple urine collections per date of service are not additionally reimbursed.
  6. Alcohol / drug screening and counseling is limited to one unit per date of service.
    1. 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.

  1. The client does not need to be physically present for this service to be performed if it is done on the client's behalf.
  2. 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.
  3. 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.

 

Social / Ambulatory Detoxification
Facilities licensed by the Office of Behavioral Health (OBH) to provide detoxification services are the only provider eligible to render social / ambulatory detoxification services.

  1. Social / ambulatory detoxification services:
    1. Include supervision, observation, and support from qualified personnel for clients exhibiting intoxication or withdrawal symptoms.
    2. Are provided when there is minimal risk of severe withdrawal (including seizures and delirium tremens) and when any co-occurring mental health or medical conditions can be safely managed in an ambulatory setting.
  2. A session is defined as the continuous treatment time from the first day to the last day of social/ambulatory detoxification.
    1. Each session may last a maximum of three days.
  3. Room and board is not a covered social / ambulatory detoxification service. Claims billed for room and board will not be reimbursed.
  4. Social / ambulatory detoxification is divided into four distinct services—physical assessment of detoxification progress, evaluation of level of motivation, safety assessment, and provision of daily living needs—with corresponding procedure codes, which may be provided and billed on the same date of service if medically necessary, as defined in rule at 10 CCR 2505-10 Section 8.076.1.8.

 

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.

  1. 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.
    1. 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.
    2. 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.
    3. 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.

 

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Substance Use Disorder Procedure Code Table

 

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
Detox: safety assessment S3005 15 minute 1 units per day HF Yes
Detox: assessment of detoxification progression and monitoring T1007 15 minute 3 units per day HF Yes
Detox: provision of daily needs T1019 15 minute 3 units per day HF Yes
Detox: level of motivation assessment T1023 15 minute 3 units per day HF Yes
Medication Assisted Treatment: administration, acquisition, and dispensing of Methadone H0020 Untimed 1 unit per day HF Yes

 

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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.

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Additional Covered Services Procedure Code Table

 

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

 

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Non-Covered Behavioral Health FFS Services

  1. 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.
  2. Services provided by email, telephone, text message, facsimile transmission, and online research.
  3. Room and board services.
  4. Educational, vocational and job training services.
  5. Habilitation services.
  6. Services to inmates in public institutions (i.e. correctional facilities) as defined in 42 CFR § 435.1009.
  7. Services to individuals residing in institutions for mental diseases as defined in 42 CFR § 435.1009.
  8. Recreational and social activities.
  9. Day treatment program services.
  10. Peer advocate services.
  11. Residential treatment, excluding Residential Treatment Facilities.
  12. Court-ordered DUI services.
  13. Reimbursement for contractual arrangements between the provider and a third party.

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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.

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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:

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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?
$ Charges
Not required  
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.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.

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.
11 Office
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)
Not Required
Family Planning (unshaded area)
Not Required
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 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
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.

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CMS 1500 Behavioral Health Claim Example

Behavioral Health Fee-for-service Claim Example

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.

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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
12/30/19 Converted to web page HCPF