The Colorado Department of Health Care Policy & Financing (HCPF) administers Health First Colorado, the state’s Medicaid program, which serves more than 1.8 million Coloradans.
It publishes detailed billing manuals, fee schedules, and provider bulletins that change regularly, sometimes multiple times per year. It operates through two primary payment pathways through Regional Accountable Entities (RAEs):
- Fee-for-Service (FFS)
- Managed Care
Understanding which pathway covers your patient is the first step to billing correctly. CPT code billing for Colorado Medicaid is governed by HCPF’s individual service-specific billing manuals, the Colorado Code of Regulations (10 CCR 2505-10), and CMS guidance
This guide distills all of it into a single, actionable resource: current CPT codes, telehealth billing rules, behavioral health codes, and the most common billing mistakes that cost providers thousands of dollars each month.
FFS vs. Managed Care: What Determines Your Billing
Most behavioral health billing services are covered through RAEs, not FFS. Providers must run a member eligibility query in the HCPF Provider Web Portal before every encounter. The query displays both Health First Colorado eligibility and the RAE responsible for covering the member’s services. Billing the wrong payer is one of the leading causes of claim denial.
Provider Enrollment & Eligibility Verification
Before a single claim can be submitted, providers must be enrolled with Health First Colorado and maintain an active National Provider Identifier (NPI) in the HCPF system. Enrollment is managed through the Colorado interChange (MMIS) Provider Web Portal.
Critical Enrollment Requirements
- All Outpatient Physical and Occupational Therapy providers must enter the NPI of the ordering provider on every claim.
- This applies to both CMS 1500 paper claims (field 17b) and electronic submissions (loop 2420, qualifier DK for Ordering, DN for Referring, or DQ for Supervising).
- Missing this NPI results in automatic claim denial.
Fee Schedule & Rate Updates 2025–2026
Colorado Medicaid fee schedules are updated twice per year. The Health First Colorado Fee Schedule is the single authoritative source for CPT code reimbursement rates. Rates are searchable by code at: hcpf.colorado.gov/provider-rates-fee-schedule.
2025–2026 Rate Highlights
A 1.6% across-the-board (ATB) rate increase took effect July 1, 2025, following approval during the 2024 Colorado legislative session. This increase applies to most FFS benefits, including physician services, dental care, and behavioral health, and has been incorporated into the Colorado interChange system.
Sample Behavioral Health Rates (October 2025 – June 2026)
| CPT Code | Service Description | Medicaid Rate |
| 90837 | Psychotherapy, 60 minutes | $134.51 |
| 90834 | Psychotherapy, 45 minutes | $91.09 |
| 90791 | Psychiatric diagnostic evaluation | $159.67 |
Source: https://checkmedicaid.com/colorado-medicaid-fee-schedule/
Claim Submission: Forms, EDI, and Key Fields
Health First Colorado accepts claims via the CMS 1500 paper form or as an 837P electronic transaction through the Provider Web Portal or a clearinghouse. Electronic submission is strongly preferred for faster processing and lower error rates.
Units of Service: Timed vs. Untimed Codes
HCPF follows AMA guidelines, distinguishing “timed” and “untimed” CPT codes. Timed codes specify a direct time increment (e.g., 15-minute increments for PT/OT services). Only time spent directly with the member counts — pre/post-encounter documentation time, drive time, and administrative tasks are excluded. Untimed codes are billed as one unit per session regardless of duration.
Evaluation & Management (E/M) CPT Codes
E/M codes (99202–99215 for office/outpatient visits) are among the most frequently billed codes in Colorado Medicaid. HCPF follows CMS guidelines for E/M service level selection, allowing providers to base the visit level on either Medical Decision Making (MDM) or Total Time on the date of service.
Important change since 2010: Colorado Medicaid no longer recognizes CPT consultation codes (99241–99245 for office/outpatient; 99251–99255 for inpatient). Providers should use the appropriate E/M code reflecting where the visit occurred and the complexity rendered, consistent with Medicare policy.
Adults & Preventive Services
Adults may receive one physical examination per year as a covered benefit. Sports physicals are not a covered service under Health First Colorado. Immunization services follow the HCPF Immunizations Billing Manual, which is separate from the standard E/M billing framework.
EPSDT: Expanded Coverage for Members Under 21
Under federal Medicaid law (42 U.S.C. § 1396d(r)), Health First Colorado must provide Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefits for all members under 21. This means any medically necessary service to correct or ameliorate a defect, physical or mental illness, or condition identified by screening must be covered, even if the service is not listed in Colorado’s standard State Medicaid Plan. Effective January 1, 2024, Autism Spectrum Disorder services for members under 21 fall under this expanded mandate.
Behavioral Health CPT Code Billing
Behavioral health services for nearly all Health First Colorado members are covered through Regional Accountable Entities (RAEs), not FFS. The January 2025 HCPF State Behavioral Health Services (SBHS) Billing Manual is the authoritative source for mental health and substance use disorder (SUD) billing.
Key Behavioral Health CPT Codes
| CPT Code | Description | Billing Unit |
| 90791 | Psychiatric diagnostic evaluation | 1 session |
| 90832 | Psychotherapy, 30 minutes | 1 session |
| 90834 | Psychotherapy, 45 minutes | 1 session |
| 90837 | Psychotherapy, 60 minutes | 1 session |
| 96130 | Psychological testing evaluation, per hour | Timed |
| 96127 | Brief emotional/behavioral assessment | 1 unit per instrument |
| H0049 | Alcohol and/or drug screening | Per encounter |
What is RPM Under Colorado Medicaid?
RPM involves using digital technology to continuously collect a patient’s clinical data in one location and electronically transmit it to a healthcare provider elsewhere. The goal is early detection of health changes to prevent emergency intervention or inpatient hospitalization. SB 24-168 also specifically mandates coverage for continuous glucose monitors (CGMs) and related supplies under both medical and pharmacy benefits.
Prior Authorization & Copayments for RPM
Some RPM services may require prior authorization from Health First Colorado or the member’s managed care plan; verify at the time of service. Most Health First Colorado members have $0 copayments for covered services, including telehealth. Specific RPM copayment policies are governed by HCPF guidance at the time of service.
Conclusion
Colorado Medicaid CPT code billing isn’t just a compliance exercise; it’s a direct driver of your practice’s financial health. With the 1.6% across-the-board rate increase in effect since July 2025, new RPM codes are now reimbursable, and updated telehealth billing requirements are reshaping how remote care is documented. Providers who stay current on HCPF guidance collect more revenue and face fewer audits.
Colorado Medicaid billing rules change frequently, and every missed modifier, incorrect code, or overlooked PAR requirement costs your practice real money. MedHeave specializes in Health First Colorado CPT billing, ensuring your claims are clean, compliant, and paid the first time. Get a free billing audit from MedHeave now!
FAQs
Is Health First Colorado the same as Medicaid?
Yes, Health First Colorado is officially Colorado’s Medicaid program, providing free or low-cost health coverage for eligible low-income children, pregnant women, parents, seniors, and people with disabilities in Colorado.
Is Health First Colorado free?
Health First Colorado (Colorado’s Medicaid program) is free or low-cost public health insurance for Coloradans who qualify.
Is health first a good insurance?
Healthfirst is generally considered a strong insurer for quality in New York, often ranking highly in state Medicaid and Medicare Advantage programs for care quality and member experience.
