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Health First Colorado covers services provided by licensed speech therapists. Services take place in the office, hospital, home, and other settings. Speech therapy is also available through the Home Health Program and in the school as part of the School Health Services Program.
Enrolled members ages 20 and under and adult clients in limited circumstances qualify for medically necessary services.
Reference the billing and policy manual for complete details.
A variety of CPT billing codes are available for billing by speech therapists. 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 speech therapy 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 speech 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 speech therapy 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 speech therapy 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.
Can adults who are not on the Alternative Benefit Plan (ABP) receive CPT 92609 for habilitative reasons?
Yes. This is the only exception to the coverage policy which requires adults to have the ABP to receive habilitative speech therapy.
All adults may access 92609 for rehabilitative and habilitative services. The outpatient speech therapy policy manual details this this under the ‘Treatment’ section on augmentative and alternative communication therapy.
30-day retro-active prior authorization requests allowed until 4/30/2019
The Department and eQHealth Solutions have reviewed outpatient Speech Therapy Prior Authorization Request (PARs), and have determined that all speech therapy providers will have until 4/30/2019 to submit prior authorization requests which are retroactive back to the date of request and/or 4/1/2019. This means the 'begin date' of the treatment may be for a date which is before the 'submission date' of the request. These PARs will not be denied for untimely submission, however they will still be reviewed for compliance with Department policy and rule, and medical necessity. Outpatient speech therapy claims will be denied for dates of service on/after 4/1/2019 if there is not an approved PAR on file for those services.
Which CPT codes will require a PAR?
CPT codes 92507, 92508, 92526, and 92609 will require a PAR.
Will there be units of service available that do not require a Prior Authorization, like outpatient PT/OT?
No. All speech therapy procedure codes which require Prior Authorization will not have units of service available without a Prior Authorization. Evaluation procedure codes 92521, 92522, 92523, 92524, 92597, 92605, 92607, 92608, and 92618 will not require Prior Authorization.
Will current patients require a PAR beginning in April 2019, or will only new patients?
All claims for outpatient speech therapy will require a PAR to be reimbursed. Therefore, all patients, whether new or current, will require a PAR.
Can PARs be submitted prior to April 2019?
Yes. Providers have between 2-1-19 and 3-31-2019 to submit PARs ahead of the PAR requirement go-live date of 4-1-2019.
Will members be able to have active Prior Authorizations from more than one speech therapy provider concurrently?
Yes, so long as each PAR addresses different treatment goals. PARs for treatment which duplicates treatment of a currently active PAR will be denied. Providers must submit documentation that clearly supports the specific goals their therapy will be addressing.
What is the maximum allowed duration for an outpatient speech therapy Prior Authorization?
How does the requirement for a 90-day review of the Plan of Care align with the Prior Authorization time span?
While the time span for treatment allowed by a PAR may exceed 90 days, the requirements found in the outpatient speech therapy billing and policy manual regarding the Plan of Care are still in effect. EQHealth will check that the documentation is current during the review process.
Will Prior Authorization be required if the member has primary insurance coverage (commercial/Medicare)?
If Colorado Medicaid is the secondary payer then Prior Authorization is not required if the primary insurer has made payment on the claim. If the primary insurer will not cover the benefit then a PAR from EQHealth is required.
Will retroactive prior authorization requests be approved?
For children ages 0-3 who are under the direction of the Early Intervention program, retro-authorization requests will be approved for a window of 30 calendar days from the date on which the provider submits the PAR, even if this does not encompass the start-date of the IFSP. Dates requested on the PAR must be within the dates on the IFSP.
However, claims will not be reimbursed until there is an approved PAR on file for the services requested.
For members ages 4+ all PARs must be approved prior to the delivery of covered treatment.
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 speech therapy benefit:
The Department is soliciting public feedback on changes to the outpatient speech therapy rule found at 10 CCR 2505-10 8.200.3.D.2.
A copy of the proposed changes can be found here. Comments will be accepted through September 30, 2018.
Please send comments to Alex Weichselbaum at Alex.Weichselbaum@state.co.us.