DECEMBER 2023
At Colorado Access, caring for you and your success is our top priority as you serve our members. This monthly Provider Update serves as a highlight of important information and resources to help you as a contracted provider with us.
Get Higher Reimbursements for Providing Behavioral Health Services in Non-English Languages
The PHE ends May 11, 2023. The renewal process for the more than 1.75 million people covered by either Health First Colorado (Colorado’s Medicaid program) or Child Health Plan Plus (CHP+) starts in May. The Colorado Department of Health Care Policy and Financing (HCPF) estimates that 30% of enrolled people will not need to take any action to remain covered, while the other 70% will need to submit eligibility verification.
HCPF also estimates that more than 325,000 people will no longer qualify for Health First Colorado and CHP+ coverage. People who no longer qualify can apply for insurance through the state’s official marketplace, Connect for Health Colorado, online or by calling their customer service line at 855-752-6749.
As more updates become available, we will continue to share what this means for you and for our members.
We are excited to introduce a new program that allows you to earn enhanced reimbursements for providing behavioral health services in non-English languages. Eligible outpatient providers can now bill a 10% increased rate on direct outpatient behavioral health services offered in a member's identified language. Federally qualified health centers, community mental health centers, and inpatient hospitals do not qualify for this incentive.
This incentive is the first of its kind, and it recognizes the additional effort, training, and expertise needed to deliver culturally and linguistically appropriate care.
This program is exclusive to us, Colorado Access, and does not apply to any other Regional Accountable Entity (RAE) services that use an interpreter.
Talk to your assigned provider network manager or find out who to contact here to learn more.
Provider Revalidation
On November 12, 2023, the flexibility that suspended provider disenrollment after the revalidation date during the COVID-19 Public Health Emergency (PHE) ended. You have a grace period to finish the revalidation process if you have revalidation dates from October 1, 2020, to November 11, 2023. If you have a revalidation date after November 11, 2023, you need to complete revalidation on time.
You can see updated revalidation dates online at hcpf.colorado.gov/revalidation. A "Provider Revalidation Dates Spreadsheet" is in the "Revalidation Resources" section.
You must disenroll if you have an expired NPI that is not in use.
If you do not complete the revalidation process by your revalidation due date, you risk:
Having your claims denied
Take-backs
Being disenrolled
Revalidation is facilitated exclusively through the Department of Health Care Policy and Financing (HCPF) Provider Web Portal. After you log in, click the "Revalidation" link (under the "Provider" section). This link will only be available within six months of your revalidation date. It will take you to the “Provider Revalidation: Welcome” panel. To begin the revalidation process, click “Continue.”
If you need help to use the portal:
Get help online:
Call Gainwell at 844-235-2387
Updated Provider Forms
To help make data intake more streamlined and accurate, we recently updated four provider forms: the physical health clinical staff update form, the behavioral health clinical staff update form, the provider notification of termination form, and the clinic closure form. The updated forms can be found on our website for your immediate use.
411 Notification to Providers
We are required by the Department of Health Care Policy and Financing (HCPF) to perform the RAE Encounter Data Validation Review (411 audit) annually to ensure that you maintain complete and accurate clinical records for our members. This is essential for meeting patient needs, complying with federal and state laws, and supporting claims billed.
HCPF includes 411 chart records for each region in the review. Each region is audited across multiple behavioral health services against the coding requirements for the Uniform Services Coding Standards (USCS) Manual (now the State Behavioral Health Services Billing Manual). HCPF randomly selects providers to participate.
The 2024 411 audit will review paid behavioral health encounters from inpatient, residential, and outpatient psychotherapy services with dates of service from July 1, 2022 through June 30, 2023, with paid dates between July 1, 2022 and September 30, 2023. HCPF has not yet released the audit sample.
Coding and Documentation
We regularly audit provider documentation to ensure that all participating providers delivering behavioral health and substance use disorder (SUD) services meet compliance, quality documentation, and coding standards. Audit criteria is based on regulations, billing manuals, industry best practices, and other sources that support appropriate billing and documentation.
Here are answers to audit criteria that are frequently missed and commonly asked questions:
Texting is not an approved mode of service delivery. Services provided by text messages are not billable.
Clinical supervision sessions are not billable.
While it may be best practice to document canceled or missed sessions, they are not billable. Contact with a patient to reschedule a session is also not billable.
When using Place of Service (POS) 10 (telehealth provided when member is located in their home), documentation must specify they are at home either with the actual POS code, or a description of the code. Anything that is not explicitly identified as “home” should default to 2.
For example, a note can either state “POS 10” or “telehealth – client in home.”
For outpatient services:
A comprehensive, evidence-based assessment is completed and signed within seven business days from the date of service.
A treatment plan is completed and signed within 14 business days of the assessment.
Treatment plans should establish and note discharge criteria.
Progress summaries should note the plan for the next contact or follow-up with the patient and/or any care coordination.
Please reference the State Behavioral Health Services Billing Manual to learn more about coding and documentation standards. If you have additional questions, please email your provider network services representative at [email protected].
Behavioral Health Foster Care Request for Proposals
We are seeking a behavioral health provider to partner with on foster youth programming. Applications are currently open. One provider will be awarded $300,000 to administer behavioral health-focused screenings or assessments to children in the foster care system in Adams, Arapahoe, Douglas, and Elbert counties. To view the Request for Proposal and submit an application, click here. Applications are due by Friday, January 19, 2024.
2024 Survey
DataStat administers the annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey on behalf of the state of Colorado. The anonymous survey is available in both English and Spanish and provides valuable insights for enhancing the member experience with us and our network providers.
Member outreach will take place from mid-December 2023 to late May 2024, with online, phone, and mail-in options to complete the survey. A statewide initiative aims to boost response rates in 2024 by emphasizing the survey’s role in driving improvements. If you are asked about the survey, please inform members about its significance and stress the value of their input.
To read past CAHPS reports, click here. To learn more about the survey, click here.
Responsibility to Review Delegate Provider Web Portal Accounts
If you are registered as an “Individual Within a Group,” you must have your own Provider Web Portal username and password to revalidate separately from your affiliated group. Here is a guide that can help if you have forgotten your username or password.
You can set up support staff or third-party vendors as delegates to perform certain functions, like verifying claim status or retrieving remittance advice, on your behalf. You can review the status of delegate accounts and the functions they’re authorized to access in the Provider Web Portal. You should keep this updated in accordance with their current job duties and employment status. Only delegates with a valid, current business reason should have access to the Provider Web Portal. The administrative account is the only one that gives a user full access to all functionality in the Provider Web Portal.
A delegate account with an outdated status presents a security risk to program integrity. Existing accounts will be deactivated after 90 days of inactivity. New accounts will be deactivated after 60 days of inactivity. Please log in to the Provider Web Portal regularly to prevent deactivation.
Behavioral Health Administration Benefits
Before providing Title XIX (TXIX) services, please review the patient's eligibility and ensure they have TXIX benefits through Health First Colorado (Colorado's Medicaid program). Members who have behavioral health administrative benefits (BHAB) but not TXIX are not eligible for any service under TXIX.
State-funded BHAB allows the BHA service organization (managed services organization) and the community mental health centers (CMHCs) to service members who are eligible for the tested services Behavioral Health Means (X1) and Behavioral Health Non-Means (X2). These services provide a limited behavioral health safety net benefit that covers the 14 critical behavioral health-related services in every region of the state.
If you have any questions, please contact the Provider Services Call Center.
More resources:
Upcoming Enrollment Requirement
Claims with services requiring Ordering, Prescribing, or Referring (OPR) providers will post Explanation of Benefits (EOB) 1997 if the OPR provider was not enrolled with Health First Colorado by mid-November 2023. EOB 1997: "The referring, ordering provider, and attending type is invalid for the service. The service is not within the scope of the provider type."
This is not a claim denial. Claims submitted for services or items that require an OPR can be found in the relevant billing manual on the Billing Manuals web page.
If you have any questions, please contact the Provider Services Call Center.
Billing Members Copays or Deductibles
You cannot bill members for copays or deductibles assessed by third-party resources. You cannot bill members for the difference between commercial health insurance payments and their billed charges when Health First Colorado does not make additional payments. The member's commercial health insurance must be billed first, and lower-of-pricing is used to calculate reimbursement from Health First Colorado. Learn more here and here.
Annual Supervision Attestation
Licensed clinicians looking to supervise unlicensed and pre-licensed practitioners under the Colorado Medicaid Standards for Unlicensed Practitioners policy guidelines must submit an attestation to each contracted Regional Accountable Entity (RAE) to engage in supervision practices.
As a contracted provider with us, you will now automatically receive an email from us annually during the month of your original attestation that will link you to our learning management system, where you will re-attest. Organizations, groups, and facilities only need to submit one attestation for their entity.
The policy and attestation form can be found here.
Rule Change for Marriage and Family Therapists and Mental Health Counselors
The Centers for Medicare & Medicaid Services (CMS) has announced a rule change that now allows marriage and family therapists and mental health counselors – including eligible addiction, alcohol, or drug counselors who meet qualification requirements for mental health counselors – to enroll for the first time in Medicare.
Newly-eligible practitioners were able to enroll in Medicare starting November 1, 2023, and can start billing Medicare as of January 1, 2024. If this applies to you, you must currently use Modifier HO on claims submitted directly to Medicaid without a Medicare denial, but this will only be allowed after April 1, 2024, in situations where enrolled Medicare providers are supervising unlicensed behavioral health providers and submitting claims as the rendering provider.
Behavioral Health Modifier Changes
On January 1, 2024, HCPF will be changing modifiers that impact billing; the first-position modifier will no longer be added to claims, with a few exceptions. The first-position modifiers that will no longer be required on a claim are:
HE (State Plan)
B3: HK (Residential), U4 (CM), TM (ACT), HM (Respite), HJ (Voc), TT (Recovery, HT (Prev/EI) HQ (Clubhouse/Drop in, and HF (SUD)
The only codes in the SBHS Manual that will require a first-position modifier (currently a second-position modifier) are:
New Code for Behavioral Health Drop-In Services
As of January 1, 2024, behavioral health drop-in center services will be billed with Healthcare Common Procedure Coding System (HCPCS) code H0046. The service is currently covered by code H0023 with a specific modifier to distinguish it from other services. Code H0046 will not need a modifier.
HCPCS code H0023 will be used exclusively for behavioral health outreach and will no longer require modifiers to distinguish it from drop-in services.
Code H0046 is identical in structure and utilization to code H0023. This includes minimum and maximum time, relative unit value, and reimbursement rates. There will be no changes to benefits
Autism Spectrum Disorder
Starting January 1, 2024, psychotherapy services for a primary diagnosis of autism spectrum disorder (ASD) will be covered under the RAEs. Hereis a list of psychotherapy codes that will be covered by the RAEs for a primary diagnosis of ASD beginning January 1, 2024:
Neurological and Psychological Testing Policy Change
You will be able to submit claims for neurological and psychological testing to Gainwell Technologies or the MCE as determined by the diagnosis identified at the point of referral effective January 1, 2024. The scope of testing needed is determined through a review of available member history and existing clinical documentation when a referral for testing is received. You can identify the primary payer (MCE or FFS) based on the primary condition being assessed or dismissed.
You will need to submit claims to the fiscal agent for reimbursement if the referring diagnosis is covered under the FFS benefit. You can do this by adding modifier code SC if the testing yields a diagnosis which is part of the Capitated Behavioral Health Benefit (responsibility of the MCE). Modifier code SC indicates that it is an exception to the allowed diagnosis for FFS.
You should first get prior authorization according to the MCE’s policy if the referring diagnosis is part of the Capitated Behavioral Health Benefit (responsibility of the MCE). You should still submit the claim to the MCE if the concluding diagnosis is a non-covered MCE diagnosis.
This policy will be included in the January 1, 2024 State Behavioral Health Services Billing Manual.
Institute of Mental Disease (IMD) Campus Policy
As of January 1, 2024, policy guidance will be published for campus settings with multiple residential behavioral health components to navigate IMD criteria. Refer to this policy to avoid triggering an IMD designation. Learn more here.
New Specialty Types for Substance Use Disorder (SUD)
Certain specialty types will be created in line with BHA rule approval under Provider Type 64 (SUD Continuum) to align with new BHA endorsements for outpatient SUD services effective January 1, 2024. You should update enrollments with the revised license documentation as the appropriate endorsement is secured.
American Society of Addiction Medicine (ASAM) Level 1.0 Outpatient substance use treatment that is less than nine hours a week and is appropriate for less severe disorders or as a step-down from more intensive services.
ASAM level 1WM Ambulatory Withdrawal Management without Extended On-Site Monitoring:
Mild withdrawal with daily or less-than-daily outpatient supervision
Likely to complete withdrawal management and continue treatment or recovery
ASAM level 2WM Ambulatory Withdrawal Management with Extended On-Site Monitoring:
Moderate withdrawal with all-day withdrawal management support and supervision
Supportive family or living situation at night
Likely to complete withdrawal management
ASAM Level 2.1 Intensive Outpatient Program (IOP) clinical services, including counseling and psychoeducation
IOP services are usually between nine and 19 hours per week.