Health First Colorado covers ABA for members age 20 and younger through the Pediatric Behavioral Therapies (PBT) EPSDT benefit — and it breaks the usual state-Medicaid mold twice. First, no autism diagnosis is required: ASD is one of several qualifying conditions (developmental delay, intellectual disability or another developmental or behavioral condition also count, and under-3s may qualify as At Risk for Delay), so intake should never turn a family away for lacking an ASD evaluation. Second, ABA is a statewide fee-for-service carve-out: Colorado's four Regional Accountable Entities administer the capitated behavioral health benefit, but PBT is not in that capitation — every PAR goes to the state's UM vendor Acentra, and every claim goes to the state fiscal agent, regardless of the member's RAE. The trade-off is authorization rigor: everything, including the initial assessment, is prior-authorized, and 97156 parent-training does not exist as a billable code here.
Under ACC Phase III (launched July 1, 2025), Colorado runs four Regional Accountable Entities — RMHP (Region 1), Northeast Health Partners (Region 2), Colorado Community Health Alliance (Region 3), and Colorado Access (Region 4) — that administer the capitated behavioral health benefit, plus the Elevate (Denver Health) physical-health MCO. PBT/ABA sits outside all of it: it is a fee-for-service EPSDT state-plan benefit, with PARs submitted to HCPF's statewide UM vendor Acentra (formerly Kepro) and claims paid by the state fiscal agent (Gainwell). Policy Memo PM 25-005 states it plainly — PBT is "reimbursed by Health First Colorado as fee-for-service." For intake, that means the member's RAE or MCO assignment is irrelevant to ABA: one PAR process, one fee schedule, one claims pipeline, statewide. Do not route ABA authorizations to a RAE, and do not expect a RAE to answer ABA UM questions.[5][8][2]
Colorado's Criteria for Behavioral Therapies (February 2023) require only ONE of three things: (1) a diagnosed condition for which behavioral therapy is evidence-based or evidence-informed — "including" ASD, but explicitly not limited to it; (2) an inability to adequately participate in home, school, or community activities because of a behavior or skill deficit, supported by a standardized assessment of maladaptive behaviors; or (3) a safety risk to self or others — self-injury, aggression, elopement, property destruction, stereotypy. Coverage runs on EPSDT medical necessity for members age 20 and younger. This is a genuine intake differentiator: a family waiting months for a diagnostic evaluation can still qualify through the functional-interference or safety pathway.[3][4][2]
The recency rule that does apply: the clinical documentation must include a signed comprehensive diagnostic evaluation performed within the previous twelve months by a qualified health care professional (the client's physician, nurse practitioner, or psychologist) — a 12-month clock on the evaluation, not an autism-diagnosis mandate. The ordering/referral can come from an MD/DO, PA, NP, or Licensed Psychologist (psychologists were added to the referrer list August 12, 2024).[3][4][2]
What changed on 10/12/2026: HCPF’s PBT billing manual added a “Member Eligibility” list whose items all apply. It requires a member under 21 enrolled in Health First Colorado who has “a documented qualifying diagnosis such as a neurodevelopmental condition … including but not limited to Autism Spectrum Disorder, developmental delay, intellectual disability, or another developmental or behavioral condition” or who is “under three (3) years of age and … At Risk for Delay.” The member also needs “a documented recommendation for PBT services resulting from a Diagnostic Evaluation” and an impairment that keeps the child from age-appropriate activities, or behavior that puts them or others at risk or interferes with learning, communication or community access. On top of that come a reasonable expectation of measurable improvement, a Treatment Plan, needs that are “not solely educational in nature,” and an approved PAR. Read together with the 2023 Criteria, autism is still not required, but the functional and safety routes now sit alongside a qualifying diagnosis rather than replacing it. From December 1, 2026, PARs “will be reviewed using the applicable InterQual® criteria,” which replace the state-developed PBT criteria but do not change benefit, rule or documentation requirements.[3][4][2]
The PBT Billing Manual is blunt: "All PBT services must be pre-approved in a Prior Authorization Request (PAR) process" — including the 97151 assessment, which many states leave auth-free. PARs go to Acentra through the Atrezzo portal (ColoradoPAR.com) and must include the ordering practitioner's prescription or Plan of Care with a diagnosis (ICD-10 preferred), a standardized norm-referenced adaptive-behavior assessment (the state does not mandate a specific instrument — provider's choice, completed by the PBT provider), the referral, treatment history, and measurable goals; supporting assessment and progress notes must be no more than 60 days old at submission. Approved PARs run up to six months, so reauthorization is a twice-a-year event: each new PAR needs documented meaningful, measurable, functional improvement "confirmed through data, documented in charts and graphs, durable over time," plus a signed revised treatment plan showing generalization outside the treatment setting. Documentation must meet CASP minimum requirements, and denials have four paths — PAR Reconsideration (second review by a different physician), a new PAR with added information, peer-to-peer, or member appeal to the Office of Administrative Courts.[2][5]
PM 25-005 (effective April 15, 2025) added operational teeth worth designing intake around: Health First Colorado will no longer cover 40 hours/week of clinic-based PBT when the child has access to school hours, unless the district shows the child can't be served in a classroom — school IEP hour counts must be submitted with EPSDT requests, so capture the school picture at intake. Credential floors are explicit: RBT minimum for 97153, BCBA (or equivalent) minimum for 97155, and all PBT providers had to re-enroll as Provider Type 83 (clinic) or 84 (individual) by September 1, 2025. EVV (Electronic Visit Verification) is mandatory for PBT delivered in home or community settings — an operational burden many states don't impose on ABA — and the memo warns of recoupment on documentation failures (nap time and other-provider co-treatment time are not billable).[2][5]
Code set: the PBT manual’s “Allowable Procedure Coding” table lists 97153, 97154, 97155, 97158, 97151 and 97151 TJ, and nothing else. There is no 97152, 97156, 97157, 0362T or 0373T, and no HCPCS H-code (H0031, H0032, H2014, H2019) is a PBT code. Units go on the PAR per procedure code, and the modifiers on the PAR and the claim must match.[2][5]
Colorado's fee schedule has three quirks intake and billing must both know. First, 97151 pays a FLAT amount per assessment — $866.88 on the July 1, 2026 schedule (v1.4; it was $882.78 before the October 2025 cut), billable once per 365 days — rather than per 15-minute unit (97151-TJ pays $39.61/unit on the same schedule, down from $40.24, set at 2 units per 365 days). Second, 97156 does not exist here: the family adaptive behavior treatment guidance code is absent from the PBT allowable-code table (97151, 97151-TJ, 97153, 97154, 97155, 97158 only) and has no rate — caregiver training is instead a required element woven into the treatment plan, not separately billable revenue. Third, rates were cut mid-year: Special Provider Bulletin B2500528 (September 2025, under Executive Order D 2025 014's budget shortfall) reduced PBT rates for dates of service on or after October 1, 2025 — 97153 $18.17 → $17.20 and 97155 $26.62 → $25.80 per 15-minute unit, with the group codes hit hardest: 97154 $11.51 → $8.81 (-23%) and 97158 $17.83 → $9.34 (-48%). There are no credential-tier modifiers — a single rate per code (TJ modifier only on 97151). As of this review, no restoration has landed: HCPF's July 1, 2026 fee schedule carries the identical post-cut PBT rates, unchanged from January and April 2026 — and HCPF’s 6/29/2026 Provider News (Issue 147) announced a new 2.0% across-the-board rate reduction under HB 26-1410 for dates of service from July 1, 2026. That reduction does not show in the PBT rows: the July 1, 2026 schedule (v1.4) lists the same PBT rates as January 2026 ($866.88 for 97151, $17.20 for 97153, $8.81 for 97154, $25.80 for 97155, $9.34 for 97158), so the 2.0% cut was not applied to PBT. HCPF’s news page no longer carries a written exemption notice, so confirm with HCPF before relying on the rates holding. Build revenue models on the post-October-2025 numbers, and treat group-based service lines with caution.[6][7][2][14][22][17][1]
Colorado turned technician credentialing into a billing condition in late 2025. Emergency rule MSB 25-09-04-A created Section 8.281 (emergency effective October 10, 2025; finally adopted December 12, 2025) after federal audit findings that uncredentialed technicians had been reimbursed — preliminary estimates put the potential repayment to CMS as high as $59 million. The rule requires billing providers to ensure every technician they supervise holds an active credential: an RBT (high school diploma, 40-hour BACB-specification training, passed competency exam, ongoing supervision per BACB requirements) or the QABA alternative, an ABAT (age 18+, high school diploma, 40 hours of approved coursework plus 15+ supervised hours, a 5% quarterly supervision requirement, passed competency exam). One honesty note on timing: the compliance deadline is currently suspended — HCPF's December 22, 2025 notice withdrew the December 12 deadline (which had itself replaced August 31) and promised a new date, while urging providers to reach full compliance now. Colorado has no state registry or license for technicians, so the requirement rides directly on the national certifications — and the BACB's own application already requires a criminal background check plus an abuse-registry check within 180 days of applying (the BACB does not require fingerprinting). For hiring pipelines, HB26-1425 (signed June 2, 2026) adds a one-time 45-day pre-certification billing window: Medicaid must reimburse for a not-yet-certified technician for at least 45 days while certification is pursued, but only after the tech clears a name-based judicial record check, completes all certification training, and completes abuse-and-neglect reporting training — the 45-day clock starts when those are done, the agency must submit quarterly technician rosters, and reimbursement requests must stop if certification isn't in hand by day 45. The law also protects titles: only techs holding a current, valid credential may be called "Registered Behavior Technician."[9][10][11][12][13]
Background screening now runs on three layers. Agency layer: Section 8.281.4 requires billing providers to complete ANNUAL background checks on every service provider they supervise — an ongoing employer obligation, not a hire-once event. Enrollment layer: HCPF's standard 42 CFR 455.434 screening imposes fingerprint-based checks on provider types designated high categorical risk and on any person with a 5%+ ownership or control interest in such a provider (the CY2026 federal institutional application fee is $750) — HCPF’s provider-enrollment page (checked 10/18/2026) now lists the provider types it designates high categorical risk: doulas, DME suppliers, home health agencies, hospices, lactation providers, skilled nursing facilities, state-plan personal care agencies, certain opioid treatment providers, some HCBS services and NEMT. Behavioral Therapy Clinics (Type 83) and Behavioral Therapists (Type 84) are not on that list, so enrollment-level fingerprinting should not apply to a PBT agency. The page says that only high-risk providers and their owners must comply. Facility layer, center-based programs only: HB26-1425 makes ABA clinics CDHS-licensed day treatment facilities — license applications are due on or before August 1, 2026, and operating unlicensed becomes illegal August 1, 2027 — and the CDHS regime requires fingerprint-based CBI-plus-FBI checks on every applicant, owner, employee, newly hired employee, licensee, and adult 18+ residing in the clinic, screened against the C.R.S. 26-6-905(8) disqualifying offenses, plus a TRAILS check for confirmed child abuse or neglect findings; every new hire triggers a fresh investigation (with a portability exception for commonly owned clinics on a central records system). ABA delivered in homes, schools, or community settings is exempt from clinic licensure (C.R.S. 26-6-904(1)(e)), so this regime binds center-based operations only.[9][10][11][12][13]
On the supervisor side, Colorado has no behavior analyst license in force today — Medicaid qualifies billing providers through the Behavioral Therapy Provider Attestation (rev. September 2025), whose four tiers run from licensed doctoral clinicians down to BCBA/QASP certification, and Section 8.281.4 requires an approved attestation plus a clean record (no sanctions or discipline from the applicable licensing board or credentialing body), with asynchronous supervision explicitly non-covered. Under HB26-1425's Medicaid provisions, a reimbursable RBT must work under the supervision of a licensed psychologist, BCBA, BCBA-D, or BCaBA, and Section 8.281 imports the BACB floor — supervision on a minimum of 5% of service hours each calendar month — as a Medicaid condition. The licensure horizon: on July 1, 2028, mandatory state licensure arrives under a new Colorado Behavior Analyst Licensing Board in DORA — Licensed Behavior Analysts (BCBA, BCBA-D, or QBA certification plus a fingerprint-based CBI/FBI check at the applicant's cost) and Licensed Assistant Behavior Analysts (BCaBA or QASP-S, practicing only under LBA supervision) — with unlicensed practice a class 2 misdemeanor. The supervision ratio is left to board rulemaking (no numeric caseload cap in statute yet), so build the 2028 conversion into your credentialing roadmap now.[9][10][11][12][13]
There is no plan network to get into. Pediatric Behavioral Therapies are carved out to fee-for-service, so a provider enrolls once with Health First Colorado and bills the state for any eligible member, whatever their RAE. The PBT billing manual (revised July 15, 2026) sets the route: "Organizations with a Tax ID must enroll as Provider Type 83 - Behavioral Therapy Clinic," and the clinicians who may affiliate with that clinic are doctoral psychologists (Provider Type 37), licensed behavioral health clinicians (Type 38) and behavioral therapists (Type 84). Providers still enrolled as Type 25 for PBT "must disenroll and start a new application for type 83." Claims carry both a rendering and a billing NPI.[2][9]
Before billing, Section 8.281 requires the agency to keep its technicians certified (RBT, or ABAT with 5% quarterly supervision) and background-checked annually, and every service still needs an approved PAR from Acentra. The manual does not describe any enrollment cap or moratorium for Type 83; confirm current enrollment status with HCPF provider enrollment if you are applying now.[2][9]
Colorado does not license behavior analysts yet. HB26-1425 creates a Colorado Behavior Analyst Licensing Board in DORA, and “on and after July 1, 2028, an individual is prohibited from engaging in or offering the practice of applied behavior analysis unless the individual is licensed by the board”; unlicensed practice after that date is a class 2 misdemeanor. Until then there is no Colorado behavior analyst license to hold, and BACB certification is the operative credential.[19][23]
Health First Colorado enrolls out-of-state providers “under the same rules and regulations applied to Colorado providers,” but pays for out-of-state services only in listed situations: residents of recognized Colorado border localities, members living in other states under special circumstances such as foster care, emergencies, care needed because returning to Colorado would endanger the member’s health, and “Services that are unavailable in Colorado” (the last two prior authorized). The manual does not address an out-of-state therapist delivering PBT by telemedicine to a member located in Colorado, so ask HCPF provider enrollment before relying on it.[19][23]
Health First Colorado’s filing limit is 365 days: “Effective June 1, 2018, timely filing for Health First Colorado claim submission is 365 days from the date of service,” and a claim past that needs a timely filing waiver. An approved PAR is not a waiver — waiting for prior authorization or for the Department “is not an acceptable reason for late filing.” Once the original period has run out, a claim stays alive only if each re-bill or adjustment is received within 60 days of the last action, with the previous ICN entered on the claim. Medicare-denied services must be filed within 365 days of the date of service or 120 days of the Medicare denial, whichever is longer.[23][2]
Disputes run in two steps. After exhausting the fiscal agent’s re-bill and adjustment routes, a provider files a Request for Reconsideration with the fiscal agent, within 60 days of the last action if initial timely filing has expired; if that fails, the provider may file a written appeal with the Office of Administrative Courts.[23][2]
Secondary claims get no extension when commercial insurance is slow. Health First Colorado pays last, but HCPF tells providers: “Providers should not delay Health First Colorado claims submission where there is potential TPL. The Health First Colorado program requires that claims be submitted within 365 days from the date of service.” Claims should not reach the fiscal agent “later than 365 days from the date of service” while a third party is still processing them. Enter the third-party payment or denial on the claim and keep the EOB on file; attach it only to a paper claim. If the other insurer pays after Health First Colorado has, refund the Health First Colorado payment.[23][2]
Payment cycle: “Each Friday, the weekly payment cycle prepares claims for payment, processes the payment, updates the provider’s Accounts Receivable (AR), if applicable, posts Electronic Funds Transfer (EFT) the next week and produces a RA.” Apart from holiday delays of one or two days, payment arrives at the start of the following week. When EFT is interrupted, HCPF pays by paper State warrant.[23][2]
Taxonomy: neither the PBT billing manual nor the General Provider Information Manual requires a taxonomy code on the PBT claim. What they require are the rendering and billing NPIs, the PAR number, and a valid OPR NPI in field 17b.[23][2]
The questions that decide whether a family can start with Health First Colorado (Colorado Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
Age 20 and younger. The Pediatric Behavioral Therapies benefit is available to members who "are 20 years old and younger" and meet EPSDT medical-necessity criteria; Section 8.281.3.A sets the same line as "under the age of 21." There is no lower bound — children under three qualify on being "at risk for delay" from biological or environmental factors, without a named diagnosed condition.[2][9]
Twelve months, on the evaluation rather than on a diagnosis. The clinical documentation must include "a signed comprehensive diagnostic evaluation performed within the previous twelve (12) months by a qualified health care professional... who prescribes and/or recommends behavioral therapy services," together with the name, date and significant results of the completed and signed screening questionnaire. Separately, any assessment or progress notes submitted with a PAR "must not be more than 60 days prior to submission of PAR request."[3][2]
No autism diagnosis is required at all. The 2023 Criteria open the benefit on any one of three pathways, while the PBT manual revised 10/12/2026 lists a documented developmental or behavioral diagnosis (ASD, developmental delay, intellectual disability or another condition), or At Risk for Delay under 3, among its eligibility requirements. The three 2023 pathways are (a diagnosed condition for which behavioral therapy is evidence-based or evidence-informed, "including autism spectrum disorder"; inability to adequately participate in home, school or community activities; or a safety risk to self or others). Where an evaluation is performed, the Criteria name "a qualified health care professional such as the client's physician, nurse practitioner, or psychologist," and Section 8.281.2.E adds that a diagnostic evaluation "may be performed by a psychologist, developmental pediatrician, neurologist, or other credentialed clinician."[3][9][2]
No single instrument is mandated, but the rule names the expected ones: standardized diagnostic tools "such as the Autism Diagnostic Observation Schedule (ADOS-2), Autism Diagnostic Interview-Revised (ADI-R)"; developmental, cognitive and adaptive functioning measures "(e.g., Vineland, cognitive/IQ testing)"; and a review of medical, educational and psychosocial history. The functional-interference pathway additionally requires "a standardized assessment of maladaptive behaviors," and the PAR requires a standardized norm-referenced adaptive-behavior assessment completed by the PBT provider — instrument choice is the provider's.[9][3][2]
Required, and from a short list. "All Outpatient therapy services must have a written order/prescription/referral by any of the following: Physician (M.D. or D.O.); Physician Assistant; Nurse Practitioner; Licensed Psychologist." Licensed Psychologist was added on 8/12/2024 to match the criteria and the federal ordering/prescribing/referring rules. What the order must contain: the PAR must include a "legibly written and signed ordering practitioner prescription or approved Plan of Care" with the diagnosis (preferably ICD-10), the reason for therapy, sessions per week, total duration, treatment history, measurable goals and medical-necessity documentation. How families usually get one: the Criteria expect "a signed comprehensive diagnostic evaluation performed within the previous twelve (12) months by a qualified health care professional such as the client's physician, nurse practitioner, or psychologist who prescribes and/or recommends behavioral therapy services." So the diagnosing evaluation, or a separate signed prescription from one of the listed practitioners, serves as the order. The ordering practitioner must be enrolled. HCPF's OPR notice says federal rules require "the National Provider Identifier (NPI) of the individual practitioner who ordered the service, and that practitioner must be enrolled in the state Medicaid program (42 CFR §§455.410 and 455.440)." Since the 6/4/2026 manual revision, CMS-1500 field 17 is "Required" and "Must contain a valid OPR NPI in Field 17.b." The manual sets no separate expiry on the order itself and HCPF publishes no order template. The order travels with each PAR, so it has to be in hand before the first service: "Do not render or bill for services until the PAR has been processed."[2][24][3]
Covered, on any modality. "Pediatric Behavioral Therapists are covered under the telemedicine policy," and "Home Health Agency services and therapies, Hospice, and Pediatric Behavioral Treatment may be provided via any telemedicine modality" — unlike outpatient PT/OT/speech, which must have interactive audio-visual. Every PBT code is on the allowable-telemedicine list: 97151, 97153, 97154, 97155 and 97158. POS 02 is on the PBT allowed-place-of-service table, and the telemedicine billing page directs every rendering provider to bill “Place of Service code 02 or 10 and the appropriate modifiers FQ, FR, 93 or 95” — 95 for real-time audio-video, 93 or FQ for audio-only, FR when a supervising practitioner is present by two-way audio-video. GT is not the PBT modifier: Colorado limits GT to a listed set of provider types (physicians, clinics, psychologists, FQHCs, RHCs and similar), which does not include the Type 83/84 PBT enrollments. Two conditions travel with it: "the use of telecommunications equipment for delivery of services does not change prior authorization requirements," and before the first telemedicine treatment the provider must furnish the member (or legal representative) signed written disclosure statements, after which the initial face-to-face requirement may be waived.[2][18]
Health First Colorado (Acentra, ColoradoPAR): since January 2026 the standard PAR turnaround is seven (7) calendar days and expedited PARs are decided within three (3) calendar days — "PARs submitted as Expedited: no pends or requests for information will be allowed," so the expedited file must be complete at submission. On standard PARs, pends for additional information were cut "from 10 business days to seven (7) calendar days," only one pend is allowed ("all information requested in the initial pend must be supplied, or the PAR will result in a technical denial"), and "All PARs, including pends, must be processed within 21 calendar days of initial submission." For renewals: PARs are approved "for up to a six (6)-month period," every PBT service (97151 assessment included) must be approved "prior to rendering the services," and assessment or progress notes must be no more than 60 days old when the PAR is submitted — so build the next PAR inside that 60-day window and before the current one ends.[25][2][26]
Health First Colorado pays last: it "is called the payer of last resort because Federal regulations require that all available health insurance benefits be used before Health First Colorado considers payment," and "claims for members with health insurance resources are denied when the claim does not show insurance payment or denial information." Report the TPL payment or denial and the TPL EOB date on each claim (the EOB itself need not be attached every time); keep the commercial EOBs for seven years. A member with commercial managed-care coverage "must obtain MCO benefit services from the MCO" (the manual: "Health First Colorado claims for members who have commercial managed care coverage are denied"), so work inside the commercial plan's network and rules; and invalid primary denials ("No denial reason identified," "Duplicate claim," "Insufficient information for processing," "Claim in process") do not open the Medicaid claim. When a commercial benefit limit is exhausted, claims beyond it still go to the TPL first. The PAR is still needed: "Approval of a PAR does not guarantee Health First Colorado payment" and payment also requires "third party resources payment pursued" — the PBT manual gives no exemption from the PAR when Medicaid is secondary. Unreported coverage found later leads to retraction of paid claims. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid.[23][2][27][28][29]
Coverage decides whether Health First Colorado (Colorado Medicaid) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Three layers, and one of them is a number. Code-level: "A Registered Behavior Technician (RBT) is the minimum qualification required to administer ABA services... under CPT code 97153," and "a Board-Certified Behavior Analyst (BCBA), or equivalent, is the minimum qualification required to administer services under CPT code 97155." Rule-level: Section 8.281.4.A.6 requires billing providers to ensure RBTs "receive ongoing supervision per the requirements of the BACB" and that ABATs "adhere to a 5% quarterly supervision requirement," plus annual background checks on every service provider they supervise and no sanctions from the applicable board. Exclusion-level: "asynchronous supervision or reviews" are expressly non-covered, as are "services not delivered or supervised by a qualified provider." Neither the PBT billing manual nor its co-treatment matrix caps how many technicians one BCBA may supervise.[5][9][2]
Colorado's published ceilings are per-year, not per-day. "Code 97151 is a flat rate, and one (1) unit is to be billed once every 365 days. Code 97151TJ is set at two (2) units that can be billed once every 365 days." Section 8.281.6 limits initial pediatric therapy assessments and periodic reassessments to one session per provider every 12 calendar months each, with additional sessions only where the Department authorises them as medically necessary. No per-day unit ceiling is published for 97153 or 97155 — the operative ceilings are the units approved on the PAR and PM 25-005's rule that 40 hours a week of clinic-based PBT is no longer covered when the child has access to school hours unless the district shows the child cannot be served in a classroom.[5][9]
The service provider signs, personally, before the claim goes out. "Each entry in a medical record must be signed and dated by the individual providing the service or good. Stamped signatures are not acceptable. Printed or displayed electronic records must note that signatures and dates have been applied electronically (10 CCR 2505-10 § 8.130.2.G)," and "providers are required to ensure that all required signatures are obtained before any claims are submitted for payment." Session notes "are required to contain detailed descriptions of therapy sessions... basic patient information, a narrative summary of the treatment provided, and a detailed summary of behavior targets, intervention types, and other relevant data," and ABA documentation must meet CASP minimum requirements. On the claim form itself, initials, typed or computer-printed names and "signature on file" are all unacceptable in field 31.[5][2]
Five POS codes are allowed: 02 telemedicine, 03 school, 11 office, 12 home and 99 other/community-based (the rule permits a "Community" location and 99 is the closest code). EVV is mandatory for PBT delivered in the home or the community, capturing member ID, the individual providing the service, start and end times, the service, the date and the location. School is payable — POS 03 has been allowed for all fee-for-service benefits since May 3, 2024, and PM 25-005 confirms "Health First Colorado covers medically necessary PBT services in a school setting" — but community providers must follow school-district policy, and therapies provided under a member's IEP and billed to the School Health Services Program "are not separately reimbursable." Section 8.281.5.B adds the clinical test: services "must be delivered in a clinically appropriate setting for the behavior being treated." One tension worth knowing before a PAR: the February 2023 Criteria's exclusion list still names "school-based services" among non-covered items.[2][5][9][3]
Both NPIs, and the enrollment has to match. "PBT services must be billed using the 837 Professional (837P) transaction or CMS 1500 form, which requires using rendering and billing National Provider IDs (NPIs)." Organisations with a Tax ID enrol as Provider Type 83 (Behavioral Therapy Clinic); the individuals who may affiliate to it are Provider Type 37 (doctoral psychologist), 38 (licensed behavioral health clinician) and 84 (behavioral therapist), and all three must be affiliated with the Type 83. Providers formerly enrolled as Type 24/25 had to convert by September 1, 2025. The ordering practitioner's OPR NPI goes in field 17b, and field 32 carries the service facility.[2][5]
Colorado publishes no rule on billing 97153 and 97155 for the same clock time. What it does publish is cross-discipline co-treatment: co-treatment between two outpatient therapists is covered only where "a valid clinical rationale for providing co-treatment must be present" and "each provider must have an approved plan of care which includes co-treatment," with notes describing the additional services, identifying the co-treatment providers and justifying the arrangement. The hard edge is the billing rule: "time while members are napping is not covered or billable time. Time while the other modality is treating is also not billable," and claims for either are subject to recoupment. The billing manual's co-treatment matrix says the same thing from the other side — "providers will only bill for the time interacting with the member, and not the total time in the room." The 10/12/2026 manual revision adds the rule for any co-treatment: it is reimbursable only when each service is separately medically necessary, addresses distinct or coordinated goals, “requires the active participation of each rendering provider” and is documented as not duplicative. Providers must record the actual time of each service and the total billable time, and “may not separately round each activity, intervention, or portion of the session to a 15-minute unit.” The matrix cell for one Pediatric Behavioral Therapist alongside another reads “Allowable with clear reason for safety or medical necessity in PAR and with approval only.” That is the closest published rule to two PBT providers billing the same session, so justify any overlap of 97155 with 97153 in the PAR.[5][2]
Ask the plan: ColoradoPAR (Acentra/Atrezzo) and the HCPF PBT policy contact named on PM 25-005 — ask specifically whether 97155 is payable alongside 97153 when the analyst is directing the technician with the member present.
No. Pediatric Behavioral Therapies bills only 97151 (and 97151 TJ), 97153, 97154, 97155 and 97158, the codes in the PBT manual’s allowable procedure table. No HCPCS H-code is on it, and 97152, 97156 and 97157 are not billable either.
No. ASD is one qualifying condition among several. The PBT billing manual (revised 10/12/2026) accepts a documented neurodevelopmental, developmental or behavioral diagnosis, such as autism, developmental delay or intellectual disability, or At Risk for Delay for a child under 3. It also needs a Diagnostic Evaluation recommending PBT and a functional impact or safety risk. The 2023 Criteria also let functional interference or safety risk qualify a child on their own, and InterQual replaces those criteria for PARs from 12/1/2026. A signed comprehensive evaluation within the past 12 months is still required.
No — PBT/ABA is a fee-for-service carve-out. Regardless of RAE region (RMHP, NHP, CCHA, or Colorado Access) or the Elevate MCO, all PARs go to the state UM vendor Acentra through the Atrezzo portal (ColoradoPAR.com), and claims go to the state fiscal agent.
Yes — unlike many states, ALL PBT services must be pre-approved in a PAR, including the 97151 assessment. Approved PARs run up to 6 months, so plan for reauthorization twice a year with charts-and-graphs progress data.
No — 97156 is not in the PBT allowable-code table and has no rate on the fee schedule. Caregiver training is a required element of the treatment plan, not a separately billable service.
For dates of service on or after 10/1/2025: 97153 pays $17.20 and 97155 pays $25.80 per 15-minute unit (single rate per code, no credential tiers); 97151 pays a flat $866.88 per assessment (down from $882.78 before the October cut), once per 365 days, and 97151-TJ pays $39.61 per unit. Group codes 97154/97158 were cut 23-48% in the same bulletin. HCPF's July 1, 2026 v1.3 fee schedule carries exactly these PBT rates, so they are the rates in force for FY2026-27.
It depends on the payer. Health First Colorado (Medicaid) does not: its Criteria for Behavioral Therapies open the benefit on a qualifying diagnosed condition (ASD is one, not the only one), functional interference with home, school or community participation, or a safety risk — though a signed comprehensive diagnostic evaluation from the previous 12 months is still required. Commercial plans are the opposite: the state mandate, C.R.S. § 10-16-104(1.4), is a mandate for the treatment of autism spectrum disorders, and the carriers' ABA policies (Aetna, Cigna, UnitedHealthcare/Optum, Anthem) cover ABA for an ASD diagnosis — see each carrier guide's diagnosis field.
Only Medicaid publishes its ABA rates, so only Medicaid can be compared on paper. Health First Colorado pays one statewide rate per code with no credential tiers: 97153 $17.20 and 97155 $25.80 per 15-minute unit, 97151 a flat $866.88 per assessment, group codes 97154 $8.81 and 97158 $9.34, and nothing at all for 97156 (July 1, 2026 v1.3 fee schedule). Commercial ABA rates in Colorado (Aetna, Cigna, UnitedHealthcare/Optum, Anthem) are not published; they are negotiated in each participating-provider agreement, so the answer for a commercial contract is whatever you negotiate, benchmarked against the Medicaid schedule. The non-rate terms differ too: Medicaid prior-authorizes every code including 97151, requires EVV in home and community settings and does not pay parent training, while fully insured commercial plans answer to a mandate with no age limit and no dollar cap and self-funded plans are exempt from it.
Yes. Every PBT code, including 97151 and 97155, is on HCPF's allowable telemedicine list, on any modality, billed with POS 02 or 10. Telemedicine does not change the PAR requirement, and the member must first receive signed written disclosure statements.
Enroll the agency with HCPF as Provider Type 83 (Behavioral Therapy Clinic) and affiliate its psychologists, licensed clinicians and behavioral therapists (Types 37, 38, 84). ABA is fee-for-service, so there are no RAE networks to join for it.
Colorado has no behavior analyst license yet; HB26-1425 makes one mandatory from July 1, 2028. Health First Colorado enrolls out-of-state providers but pays for out-of-state services only in listed cases (border localities, services unavailable in Colorado with PA, and a few others).
Plan on no. The PBT billing manual says providers “must submit, and have approved, PARs for medically necessary services prior to rendering the services,” and PAR approval “does not serve as a timely filing waiver.” We have not verified a retro-PAR route for a member made retroactively eligible; ask Acentra (ColoradoPAR) first.
For commercial plans, yes: C.R.S. 10-16-104(1.4) says “All health benefit plans issued or renewed in this state must provide coverage for the assessment, diagnosis, and treatment of autism spectrum disorders for a child,” and its definition of treatment includes applied behavior analysis by autism services providers. Health First Colorado covers ABA separately, through its Pediatric Behavioral Therapies benefit.
365 days from the date of service. After that, each re-bill or adjustment must be received within 60 days of the last action to keep the claim alive, and an approved PAR is not a timely filing waiver.
An MD/DO, PA, NP or licensed psychologist must write the order, and that practitioner must be enrolled with Health First Colorado. Since June 2026, the PBT manual makes CMS-1500 field 17 required, with the ordering practitioner’s NPI in 17b. The signed prescription or Plan of Care goes with every PAR.
It is proposed, not final. On October 9, 2026, HCPF said it is considering cutting the 97151 authorization period from six months to 60 days, effective November 1, 2026. Comments were due by October 15, 2026.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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