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Health First Colorado covers physical and occupational therapy services provided in an outpatient setting. Services take place in the office, hospital, home, and other settings. Physical and occupational therapy (PT/OT) is also available through the Home Health Program and in the school as part of the School Health Services Program.
All enrolled members are eligible to receive these services.
Reference the billing and policy manual for complete details.
A variety of CPT billing codes are available for billing. These include but are not limited to:
As a Health First Colorado (Colorado's Medicaid Program) provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance – it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.
The enrollment process is online and begins on the Become a Provider page.
Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.
Professional outpatient PT/OT services are reimbursed according to the current Health First Colorado Fee Schedule. Reimbursement rates will vary by CPT code reported. The fee schedule shows the maximum allowed reimbursement for each CPT code. Submitted claims will be reimbursed according to 'lesser-of' pricing logic. This means that the line item will reimburse either at submitted charges or the fee schedule rate, whichever is lesser.
Hospital providers of physical and occupational therapy are subject to EAPG reimbursement methodology.
Providers must first enroll into the program to submit claims. Once they are enrolled, providers may submit claims directly by logging into the Provider Web Portal. Claims may be submitted by billing agencies on behalf of the provider.
Resources for enrollment and billing may be found at Provider Resources.
Members with an approved IFSP for PT/OT services still have their services covered by Health First Colorado. Coverage policy and limitations are not different for members with an approved IFSP. An approved IFSP may serve as an 'order for services', in lieu of a physician order.
Health First Colorado must be billed first for the member's PT/OT services as part of an IFSP. Early Intervention funding is only available for services not covered by Health First Colorado.
"Rehabilitative" means therapy that treats acute injuries and illnesses which are non-chronic conditions. Rehabilitative is therefore short-term in nature.
"Habilitative" means therapy that treats chronic conditions with the purpose of helping the member retain or improve skills and functioning that are affected by the chronic condition. Habilitative therapy may therefore be long-term in nature.
All Medicaid Rules, Regulations, and Statutes apply to the administration of the Colorado Medical Assistance Program at large, which providers are required to follow. The following are specifically called out as the ones governing the outpatient PT/OT benefit:
