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CO HCPF Fee-for-Service Behavioral Health Benefit — General Policies

GeneralPolicies

activein force · 2026-07-26 – presentas-observed

TheFee-For-Service(FFS)BehavioralHealthBenefitisagroupofservicesdesignedtoprovidemedicallynecessarybehavioralhealthservicestocertainHealthFirstColorado(Colorado'sMedicaidprogram)members.ThisBenefitincludesbothMentalHealthservicesandSubstanceUseDisorder(SUD)services.MembersarenotrequiredtoobtainareferralfromtheirPrimaryCarePhysician(PCP)orPrimaryCareMedicalProvider(PCMP)toreceivetheseservices.

RegionalAccountableEntities(RAEs)areresponsibleforcoveringbehavioralhealthservicesfornearlyallHealthFirstColoradomembers.ToverifyifaHealthFirstColoradomember'sbehavioralhealthservicesarecovered,providersmustperformamembereligibilityqueryintheProviderWebPortal.Themembereligibilityquerywilldisplaybothamember’sHealthFirstColoradoeligibilityaswellaswhichRAEamemberisattributedto,whichisresponsibleforcoveringthemember'sbehavioralhealthservices.

MemberswhoareeligiblefortheFFSBehavioralHealthBenefitarelimitedto:

MemberswhodonothaveactiveenrollmentinaRAE.SeeProgramRule8.212forthepolicywhichexemptsHealthFirstColoradomembersfromRAEcoverage.Onlyasmallpercentageofmembersmeetingveryspecificcriteriawillbeexempt.MemberexemptionisdeterminedbytheDepartment.

MembersbeingtreatedforaconditionnoteligibleforreimbursementundertheRAE(suchasAutismSpectrumDisorderorGenderIdentityDisorder).

ProvidersmustreferenceAPPENDIXIintheStateBehavioralHealthServices(SBHS)BillingManualforalistofRAE-coveredservices,andtheDiagnosesSectiontoconfirmRAE-covereddiagnoses.Anumberofservices,suchasofficeadministereddrugs(e.g.Suboxone)arecoveredHealthFirstColoradobenefitsbutarenotcoveredbytheRAE.TheseservicesmustalwaysbebilledFFStotheHealthFirstColoradofiscalagent,GainwellTechnologies.

AprimarycareprovidercanbillFFSuptosix(6)short-termbehavioralhealthvisitsperfiscalyear.VisittheAccountableCareCollaborativePhaseIIwebpagefordetailsontheShort-TermBehavioralHealthServicespolicy.

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Provenance

Source: hcpf.colorado.gov
Retrieved: 2026-07-26
Edition: 2026-07-26
Content hash: bf674a6d802708fc4d5683e66159c77f1984db58646e7e3a9c06ada349ed3c36

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