CO · guidance
CO HCPF Fee-for-Service Behavioral Health Benefit — General Billing Information
GeneralBillingInformation
RefertotheGeneralProviderInformationManualforgeneralbillinginformation.
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HealthFirstColoradocanonlyreimburseforservicesthatareconsideredMedicallyNecessary.Accordingto10CCR2505-10section8.076.1.8,aserviceisconsideredmedicallynecessarywhenit:
Will,orisreasonablyexpectedtoprevent,diagnose,cure,correct,reduce,oramelioratethepainandsuffering,orthephysical,mental,cognitive,ordevelopmentaleffectsofanillness,condition,injury,ordisability.Thismayincludeacourseoftreatmentthatincludesmereobservationornotreatmentatall.Formembersunderage21,persection8.280.4E,thisincludesareasonableexpectationthattheservicewillassistthemembertoachieveormaintainmaximumfunctionalcapacityinperformingone(1)ormoreActivitiesofDailyLiving.
IsprovidedinaccordancewithgenerallyacceptedprofessionalstandardsforhealthcareintheUnitedStates;
Isclinicallyappropriateintermsoftype,frequency,extent,site,andduration;
Isnotprimarilyfortheeconomicbenefitoftheproviderorprimarilyfortheconvenienceofthemember,caretaker,orprovider;
Isdeliveredinthemostappropriatesetting(s)requiredbythemember'scondition;
Isnotexperimentalorinvestigational;and
Isnotmorecostlythanotherequallyeffectivetreatmentoptions.
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FederalMedicaidlaw,42U.S.C.§1396d(r),requiresstateMedicaidprogramstoprovideEPSDTbenefitsformembersunder21yearsofage.ThismeansHealthFirstColoradoisrequiredtocoveranyserviceformembersage20oryoungerthatismedicallynecessary“tocorrectorameliorateadefect,physicalormentalillness,oraconditionidentifiedbyscreening,”whetherornottheserviceiscoveredundertheColoradoStateMedicaidPlan.“Ameliorate”meansto“makemoretolerable”or,inotherwords,toimproveormaintainthemember’shealthinthebestconditionpossible,compensateforahealthproblem,preventitfromworsening,orpreventthedevelopmentofadditionalhealthproblems.Eveniftheservicewillnotcurethemember’scondition,itmustbecoveredifitismedicallynecessarytoimproveormaintainthemember’soverallhealth.
EPSDTdoesnotrequirethestateHealthFirstColoradoagencytoprovideanyservice,product,orprocedurethatis:
Unsafe,ineffective,orexperimental/investigational.
Notmedicalinnatureornotgenerallyrecognizedasanacceptedmethodofmedicalpracticeortreatment.
Servicelimitationsonscope,amount,duration,frequency,and/orotherspecificcriteriadescribedintheabovescreeningpoliciesmaybeexceededormaynotapplyaslongastheproviderdocumentationshowshowtheservice,product,orprocedurewillcorrect,improveormaintaintherecipient'shealth,compensateforahealthproblem,preventitfromworsening,orpreventthedevelopmentofadditionalhealthproblems.
Providersmaybesubjecttopost-paymentreviewtoassuretheuseofavalidated,standardizedscreeningtoolandmedicaljustificationforscreensinexcessofthestatedbenefitlimits.
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Provenance
- Source
- hcpf.colorado.gov
- Retrieved
- 2026-07-26
- Edition
- 2026-07-26
- Content hash
999c416cf81c6536838c9e3901b2ba412de673d84cf5ccc80886dc155ae3b557
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