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BHI PROVIDER
MANUAL
FY15 Edition
Behavioral Healthcare Inc.
Provider Manual
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Table of Contents
Section I - General Information .................................................................................................................................3
Welcome To Behavioral Healthcare, Inc. .................................................................................................................3
Locations and Contact Information ..........................................................................................................................4
Policies and Procedures............................................................................................................................................5
Change of Status or Address Notification .................................................................................................................6
Section II – Provider Credentialing ...........................................................................................................................7
Credentialling ...........................................................................................................................................................7
Re-Credentialing .......................................................................................................................................................9
Provider Rights ....................................................................................................................................................... 10
Provider Satisfaction Survey ................................................................................................................................... 10
Section III – Utilization Management ...................................................................................................................... 11
Verifying Eligibility ................................................................................................................................................. 11
Plan Benefits ........................................................................................................................................................... 11
Authorizations ......................................................................................................................................................... 14
Medical Necessity Criteria ...................................................................................................................................... 17
Clinical Denials and Appeals .................................................................................................................................. 18
Section IV – Claims ................................................................................................................................................... 20
General Claims Information ................................................................................................................................... 20
Member Billing........................................................................................................................................................ 21
Coordination of Benefits ......................................................................................................................................... 21
Provider Claims Appeal Process ............................................................................................................................ 22
Section V – Clinical Expectations ............................................................................................................................. 27
Access to Care Standards ........................................................................................................................................ 27
Documentation Standards ....................................................................................................................................... 28
Section VI – Quality Improvement and Corporate Compliance ........................................................................... 31
Clinical Practice Guidelines ................................................................................................................................... 31
Provider Audits ....................................................................................................................................................... 31
Fraud, Waste, and Abuse ........................................................................................................................................ 32
Quality of Care Concerns ....................................................................................................................................... 32
Critical Incident Reporting ..................................................................................................................................... 33
Quality Improvement and Corporate Compliance Resources ................................................................................. 33
Section VII – Member and Family Affairs .............................................................................................................. 34
Member Choice ....................................................................................................................................................... 34
Member Rights and Responsibilities ....................................................................................................................... 34
Designated Client Representative (DCR) ............................................................................................................... 36
Advance Directives.................................................................................................................................................. 36
Grievances .............................................................................................................................................................. 37
Second Opinions...................................................................................................................................................... 38
Preventative Physical and Behavioral Health Programs ........................................................................................ 38
Section VIII – Care Management ............................................................................................................................ 39
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Section I - General Information
Welcome To Behavioral Healthcare, Inc.
Welcome to the Behavioral Healthcare, Inc. (BHI) network of participating providers! BHI is the
state designated Behavioral Healthcare Organization (BHO) for Medicaid recipients in
Arapahoe, Douglas, and Adams Counties, including the City of Aurora. This manual is an
extension of the provider contract and is a resource about BHI's continuum of mental health
services. It will also provide you with the guidelines for doing business with BHI, including
policies and procedures.
BHI is a company founded in 1994 by Arapahoe Douglas Mental Health Network, Aurora
Mental Health Center, and Community Reach Center. These community mental health centers
have over 100 years combined experience in providing a complete range of mental health
services. The BHI provider network has over 500 caring professionals to meet member needs.
BHI arranges for the provision of and access to varying levels of service through a broad range
of providers, consisting of appropriately licensed and/or certified practitioners, facilities, and
programs. BHI is committed to the “Recovery Model” as a philosophy of integrated treatment
for individuals and their families with severe and chronic mental illness and co-morbidity. BHI
offers an array of therapeutic, educational, peer-led, and illness management programs to our
members to assist them in their recovery toward optimal functioning in their homes and
communities.
As a BHI network provider, BHI will work with you to coordinate the continuum of mental
health services your clients may need. Please read the following pages carefully. The information
included in this manual will provide you with a better understanding of what to expect from your
network affiliation with BHI. If you have any questions about the information contained in this
manual, our staff welcomes your call.
BHI is committed to managing a behavioral health network that is accessible and attentive to
providers’ concerns and needs. We continuously monitor and endeavor to improve our
performance in this regard. Updates to this provider manual facilitate a better understanding of
the requirements for network providers. This manual is updated frequently as substantive
changes are made to information, processes, etc. You can find the most current version of this
manual on the BHI website at bhicares.org.
Training
BHI offers providers training on a variety of subjects, including: Introduction to BHI and BHOs,
Medicaid eligibility and benefits acquisition, access to care standards, member transition issues,
grievances and appeals, cultural competency, clinical documentation, and substance use
disorders. To find out when the next trainings are being offered, check the Provider Bulletin or
call BHI at 720-490-4400.
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BHI Mission Statement
To provide a continuum of behavioral health services that demonstrates a commitment to
superior quality and respect for members and families.
BHI Vision Statement
BHI strives to promote recovery by focusing on the unique needs, strengths, and hopes of
members and families.
Locations and Contact Information
Administrative Office
155 Inverness Drive West
Suite 201
Englewood, Colorado 80112
Telephone:
(720) 490-4400
Toll Free:
1(877) 349-7379
TTY:
1(855) 364-1799
Fax:
(720) 490-4395
Center Point Drop In Center
2200 West Berry Street
Littleton, CO 80120
Telephone:
(303) 789-9640
Community Connections Drop In Center
10004 East Colfax Avenue
Aurora, CO 80010
Telephone:
(303) 739-9631
The Rainbow Center Drop In Center
2140 East 88th Avenue
Thornton, CO 80229
Telephone:
(303) 287-2902
Leadership Staff:
Shelly Spalding, Chief Executive Officer
Dr. Ron Morley, Chief Medical Officer
Jennifer Lacov, Chief Financial Officer
Brian Hemmert, Director of Quality Improvement & Utilization Management
Scott Utash, Director of Member & Family Affairs
Teresa Summers, Director of Provider Relations
Jeff George, Director of Technology Services
Laura Hill, Director of Integrated Care & Wellness
Beth Tarasenko, Corporate Compliance Officer
Nathan Wagner Jr., Director of Human Resources
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Policies and Procedures
Pursuant to the terms of the provider contract, participating providers shall comply with the BHI
policies and procedures. Please see the BHI website for full copies of the policies and
procedures.
Confidentiality and Security
It is the policy of BHI, and BHI expects the same of providers, to adhere to the Health Insurance
Portability and Accountability Act (HIPAA), Health Information Technology for Economic and
Clinical Health (HITECH) Act, and 42 CFR Part 2 in order to guard against unauthorized or
inadvertent disclosure of confidential information at provider's offices and sites of care. All
treatment records shall be kept in locked file cabinets at the provider’s office when not actively
being used. Records must be returned to the file cabinets each evening. In instances of a breach
of unsecured Protected Health Information (PHI) by provider, provider shall be responsible for
reporting the breach to BHI via the Critical Incident form found on BHI’s website. Current
authorization forms must be signed by the member or appropriate representative and be kept in
their treatment record. BHI privacy policies and forms can be found on the BHI website.
Non-Discrimination Policy
BHI does not exclude, deny benefits to, or otherwise discriminate against any person on the
grounds of race, color, nation of origin, gender, sex, religion, creed, sexual orientation, disability,
or age. This includes all programs and activities offered by BHI or through a contractor or other
entity with whom we arrange to carry out our programs or activities.
Communication with Persons with Limited English Proficiency (LEP)
BHI has protocols in place to ensure that persons with limited English proficiency (or sensoryimpaired/speech impaired) have meaningful access to and equal opportunity to participate fully
in BHI services and other member benefits. For more information, please reference ADM-119
Communication with Persons with Limited English Proficiency on the BHI website.
Interpreter Services
All non-English speaking members may receive interpreter or translation services free of charge.
Members can access this service by calling BHI directly at (720) 490-4400. BHI uses Cyracom
as its oral interpreter service. If a member is non-English speaking, he/she may submit a
grievance or appeal using our interpreter services. To file a written/oral grievance or appeal in a
language the member can understand, the member can contact BHI at (720) 490-4400.
BHI will translate its written materials/information into any dominant non-English language that
is within our service area. In addition, BHI will make available our written information in
alternate formats such as audio tape or large print. A member may request this information by
contacting us at (720) 490-4400. Any translated or alternate format materials will be sent to the
member within 30 days of the request.
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Culturally Sensitive Service Delivery
Cultural competency goes beyond racial bounds to include gender, sexual orientation, abilities,
and age. It celebrates the strengths that people with different backgrounds bring to services and
programs. BHI is committed to creating an environment that respects and values the
perspectives, beliefs, and differences of all employees, members, and providers. We work toward
improving cultural diversity and competency to increase the quality of service provided to all of
our members. As a BHI contracted provider, it is your responsibility to ensure that members
receive effective, understandable, and respectful care that is provided in a manner compatible
with the members’ cultural health beliefs, practices, and preferred language. The members’
Individualized Service Plan must address these requests and needs.
Change of Status or Address Notification
Network providers can help keep files current by notifying BHI's Director of Provider Relations
of change of status or address. Information can be submitted by calling (720) 490-4413 or faxing
the BHI Provider Information Form to (720) 490-4395, or by mailing the BHI Provider
Information Form to Behavioral Healthcare, Inc. 155 Inverness Drive West, Suite 201,
Englewood, Colorado 80112, Attn. Provider Relations. Failure to notify BHI of changes may
result in delay in payment of claims or change in network status to include suspension or
termination from the network.
Please notify BHI of new practice affiliations, changes in address or licensure, and facility or
program involvement. Remember to include the following information:
 Your name and name(s) of practice, facility, program
 Tax identification number and billing information
 Street address(s), city, state, and zip
 Telephone number(s)
 Copies of new or updated licenses or authorizations
 Copies of cover sheets for updated liability coverage (Provider Information Form)
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Section II – Provider Credentialing
All practitioners must be credentialed by BHI prior to providing services to BHI members. This
is a quality expectation of BHI and the National Commission for Quality Assurance (NCQA).
The BHI Director of Provider Relations is responsible for monitoring all aspects of the provider
network. This includes, but is not limited to provider credentialing, status changes and updates,
geographic and specialty access, and provider relations activities.
Credentialling
The credentialing application process is initiated by a telephone call to the BHI Director of
Provider Relations at (720) 490-4413. The Director of Provider Relations will evaluate to see if
the provider meets the geographic and specialty access needs of the BHI Provider Network. If
the Director of Provider Relations finds that the provider meets the BHI needs, then the provider
will be sent an application. On receipt, the provider’s application will be evaluated according to
BHI's credentialing policy, in accordance with NCQA standards.
For more information about provider credentialing, please reference the BHI policy CRED-403
Provider Credentialing and Re-Credentialing on the BHI website. At credentialing or at any time,
BHI may conduct a structured site visit of network providers’ offices. This survey includes an
evaluation against BHI's standards and evaluation of the provider's clinical record-keeping
practices to ensure conformity with BHI's standards. Upon completion of credentialing, the
provider is sent a contract to be signed and returned to BHI.
Procedures to Maintain Confidentiality
Information obtained during the credentialing/re-credentialing process and Credentialing
Committee meeting minutes are treated as confidential. Colorado law protects quality issues
addressed under peer review. Such records and findings are maintained in a separate quality file.
The Credentialing Committee
BHI utilizes a Credentialing Committee to make recommendations regarding credentialing and
re-credentialing decisions. The Committee membership includes various levels of licensed
individuals and providers from the BHI network, the Director of Quality Improvement and
Utilization Management, the Director of Provider Relations, and the Chief Medical Officer.
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Credentialed providers must notify BHI within 24 hours upon the occurrence of any of the
following:
 Revocation, suspension, restriction, termination, or relinquishment of any of the licenses,
authorizations, or accreditations whether voluntary or involuntary
 Any legal action pending for professional negligence or alleged malpractice
 Any indictment, arrest, or conviction for felony charges or for any criminal charge
 Any lapse or material change in professional liability insurance coverage
 Revocation, suspension, restriction, termination or relinquishment of medical staff
membership or clinical privileges at any healthcare facility
 Any alleged professional misconduct or ethical violations reported to state licensing
boards, professional organizations or the National Practitioners Data Bank
Failure to report any of the above within the specified period will result in immediate suspension
from the network, with possible termination.
Appeal Process
The provider will be notified of the right to appeal the credentialing decision to the Director of
Provider Relations within seven (7) days of receipt of the decision. Corrective actions and
credentialing decisions, which are reviewed by the Credentialing Committee and/or the Provider
Advisory Council, with a recommendation for approval or disapproval, include:
 Termination - the provider will be notified in writing of BHI’s decision to terminate
within seven (7) days of the decision. The BHI Provider Termination Letter Template
advises the provider to contact the Director of Provider Relations in writing within thirty
(30) days of notification to initiate an appeal.
 The provider has the right to appeal the decision to the committee within thirty (30) days
of the decision.
 Not more than one appellate review will be considered.
Provider Appeal Rights
 BHI will provide written notification when a professional review action has been brought
against a provider, reasons for the action, and a summary of the appeal rights and process.
 Providers are allowed to request a hearing within 30 days after notification.
 Providers are allowed to representation by an attorney or other person of their choice.
 BHI will appoint a hearing officer or a panel of individuals (Provider Advisory Council)
to review the appeal.
 BHI will provide written notification of the appeal decision that contains specific reasons
for that decision.
The provider will be given the opportunity to present evidence in person or by phone to the BHI
Provider Advisory Council. The Provider Advisory Council will make the final decision. BHI
will notify the appropriate authorities for behaviors violating the law or ethical standards or
practice.
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Re-Credentialing
BHI re-credentials providers every three years, per NCQA guidelines. Network providers are
sent a re-credentialing application that must be completed in its entirety, signed, and returned to
the outside Credentialing Verification Organization (CVO) as soon as possible. If a provider
chooses not to re-credential, the Director of Provider Relations needs to be notified (see below).
Credentialing information that is subject to change will be re-verified from primary sources by
the CVO during the re-credentialing process. The provider must also attest to any limits on
his/her ability to perform essential functions of the position and attest to absence of current
illegal drug use (in accordance with applicable legal requirements such as the Americans with
Disabilities Act).
Leaving the Network
If a Provider decides to terminate its contract with BHI, BHI will allow members to continue to
receive treatment for a chronic or acute behavioral health condition through the current period of
active treatment or for 90 days, whichever is less. This applies when a provider terminates a
contract for reasons other than professional review actions or when a provider within a group
practice decides to discontinue employment with the group but the group continues its contract
with BHI, except when the member has been assigned to the group practice and other qualified
providers are available to that member. BHI will work with providers who are no longer under
contract to develop a reasonable transition plan for each member.
In order for a member to continue with a terminated provider, the provider must agree to the
following conditions:
1. Continue the member’s treatment for an appropriate period (based on transition plan
goals)
2. To share information regarding the treatment plan of the member(s) with BHI
3.
To continue to follow BHI Utilization Management policies and procedures
If a provider does not agree to the following terms, the provider must give BHI a list of members
(and contact information) who are currently receiving services with the provider. If continuing
with the same provider or facility is not an option for the member, BHI will assist the member in
finding another provider to continue treatment as soon as possible after BHI receives the
notification of termination.
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Provider Rights
Rights of a BHI Provider include:
 Providers maintain the right to review the information submitted in the support of their
credentialing application.
 Providers will be notified of any information obtained during the organization’s
credentialing process that varies substantially from the information provided to the
organization by the practitioner.
 The provider maintains the right to correct erroneous information.
 The information collected during the credentialing process will be kept confidential,
except as otherwise required by law.
 Providers maintain the right, upon request, to be informed of the status of their
credentialing or re-credentialing application.
 Right to receive notification of their privileges under the credentialing program.
 Providers have the right to practice within the lawful scope of their licensure including
advising and/or advocating on behalf of members regarding treatments that may be selfadministered and the risks, benefits, and consequences of treatment or non-treatment.
Provider Satisfaction Survey
BHI conducts an annual provider satisfaction survey to gather data from contracted providers
regarding their opinions of the administrative and clinical processes of BHI. This data is
aggregated and trended to provide BHI with valuable information regarding opportunities for
improvement in business operations. Providers will receive the survey from the Quality
Improvement department via mail, email, or fax.
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Section III – Utilization Management
The Utilization Management (UM) Program maintains a system of comprehensive and effective
management of a member’s care through monitoring access to services from the point of entry
through discharge. Utilization review activities are applied across all levels of care and
contracted providers are required to adhere to utilization management policies and procedures.
The UM program supports member recovery by ensuring consistent access to the most effective
and least restrictive medically necessary behavioral health services.
The BHI UM department works in collaboration with the BHI Office of Member and Family
Affairs to ensure member rights, requests, grievances, and appeals are responded to in an
appropriate and timely manner. The UM Director works in collaboration with the BHI Quality
Assurance Committee, the BHI Quality Improvement (QI) Department, and all providers within
the BHI Provider Network to collect data for program evaluation and outcome measures.
Verifying Eligibility
When a member requests services by visiting a provider site, providers must verify Medicaid
eligibility and BHO enrollment with BHI at the time services are rendered. Providers should
photocopy the member’s current Medicaid card and verify that BHI is designated for behavioral
health services. We strongly recommend that providers continue to verify eligibility on an
ongoing basis, as eligibility status is subject to change. Member eligibility can be verified in the
following ways:
 Call BHI at 720-490-4400 or toll free 1-800-920-7934.
 Use the State’s Web portal system at http://www.colorado.gov/hcpf and obtain a screen
print of the eligibility status for documentation.
Plan Benefits
In-Network Service Benefits
Services of the benefit plan are available through in-network providers who are contracted for
specific services. All providers must be credentialed and contracted to participate in BHI's
Network. Benefits are in effect only when the provider adheres to BHI's referral and utilization
management procedures. The types of behavioral health benefits for Medicaid members are
listed below. Please reference the USCS manual on the BHI website for the exact procedure
codes included in the behavioral health Medicaid benefit package.
Assessment Services
Psychological Testing
Prevention/Early Intervention Services
Inpatient Services
Social Ambulatory Detoxification
Evaluation and Management
Crisis/Emergency Services
Partial Hospitalization
Outpatient Substance Use Disorder Services
In-Home/Home-Based Services
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Psychotherapy (individual, family, group)
Peer Support/Recovery Services
Residential Services
Sub-Acute Treatment Services
Respite Care
Case Management
Day Treatment
Intensive Outpatient Services
Rehabilitation Services
Drop-In Center/Clubhouse Services
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Out-of-Network Benefits
There are no benefits available for out-of-network services. Services provided for psychiatric
emergencies are the only benefit allowed by out-of-network providers, unless otherwise specified
in a Single Case Agreements pre-arranged through the BHI Director of Provider Relations.
Out-of-Area Care
BHI is responsible for all behavioral health care provided for Adams, Douglas, and Arapahoe
counties for Colorado Medicaid Community Mental Health Services Program and Managed Care
Organization participants. This includes care that is provided outside of Colorado. All out-ofarea care provided outside of a service area but still in Colorado must meet the same criteria and
follow the same policies and procedures as described in this handbook for in-area care. All outof-area care, except emergency care, must be preauthorized. Out-of-area providers must obtain
preauthorization from BHI.
Medical Care
BHI is responsible only for psychiatric authorization/management and reimbursement.
Authorization for any medical care rendered in conjunction with DSM-IV TR conditions must be
obtained through the member's medical plan.
 If the member's medical plan is rendered through a Health Maintenance Organization
(HMO), you must consult the member's Primary Care Physician (PCP) before
ordering/rendering any medical care/test.
 Every effort should be made to obtain the member's consent to release pertinent
information to the PCP and the PCP should then be informed, particularly of prescribed
psychiatric medications.
 Pertinent medical information, particularly medication management, should be
coordinated with the member's PCP.
 Early & Periodic Screening, Diagnosis & Treatment (EPSDT) programs must be
coordinated with Member's PCP by referring members who need screens to their PCP
and obtaining and considering results of the screens in service planning.
Collection of Copayments/Deductibles
Medicaid enrolled members covered in our program are not subject to co-pays or deductibles.
Collection of fees directly from Medicaid members may result in termination as a participating
network provider. This includes providers who bill members for services rendered that were not
paid through claims submissions. Medicaid members cannot be billed for services unless the
service is not a covered benefit of the BHO Medicaid program.
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Benefit FAQs
Prescription Drugs: BHI is not responsible for the cost of prescription drugs, including those
received in the emergency room.
Residential Child Care: BHI will not be responsible for the cost of room, board, or behavioral
health services for children/adolescents in residential childcare facilities or residential treatment
centers unless a specific contract exists with the facility and the service has been preauthorized
by BHI.
Recipient Co-payments: BHI providers cannot assess any charges to members.
Early & Periodic Screening Diagnosis and Treatment (EPSDT): Medicaid providers are required
by the State of Colorado to coordinate with the EPSDT program by obtaining results of screens,
referring members who need screens to their PCP/pediatrician, and considering results of screens
in service planning. This pertains to all members age 1-21.
Substance Use Disorder benefits: BHI covers any outpatient or social ambulatory detoxification
services for members with a primary substance use disorder diagnosis. Residential services,
inpatient services, and medical detoxification are paid through the Medicaid fee-for-service
program.
Benefit Limits: Effective January 1, 2014, there are no benefit limits for services received.
Coordination with External Agencies and Organizations: BHI providers are required, as
necessary, to coordinate a member’s behavioral health services with services provided by other
human services agencies including:
 County social services/human services department
 Child welfare agencies and other agencies providing human services or medical
treatment to Medicaid members in need of or participating in mental health care
 Therapeutic Residential Child Care Facilities (TRCCF)
 Organizations providing services to older adults (nursing and alternative care facilities)
 Schools
 Judicial/legal systems
 Advocacy organizations
 Agencies providing translation/interpretation services
 Agencies providing services to deaf and hard of hearing members
Enrollment Exclusions: Specifically excluded are:
 Qualified Medicare Beneficiaries only (QMB-only)
 Qualified Individuals 1 (QI 1)
 Qualified Working Disabled Individuals (QWDI)
 Special Low Income Medicare Beneficiaries (SLMB)
 Undocumented Immigrants
 Program of All-inclusive Care for the Elderly (PACE)
 Individuals who are inpatient at the Colorado Mental Health Institute at Fort Logan or
Pueblo, which includes those who are:
o Found by a criminal court to be Not Guilty By Reason of Insanity (NGRI)
o Found by a criminal court to be Incompetent to Proceed (ITP)
o Ordered by a criminal court to the Institute for evaluation
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Benefit Exclusions and Limitations
 Treatment of organic mental disability
 Treatment of intellectual disability and developmental disability
 Treatment of autism
 Treatment for medical detoxification
 Treatment for obesity/weight loss not associated with anorexia nervosa or bulimia
 Tests or procedures conducted to rule out medical conditions
 Additional medical care, supplies or services required by individuals who have
associated problems
 Care which is predominantly custodial or child protection in nature
 Speech and occupational therapies
 Treatment for chronic pain unless determined to be of predominantly psychological
origin
 Treatment for conditions such as sexual addiction, compulsive gambling, codependency, or adult children of alcoholics and non-abusing family members where
these are the primary diagnosis being treated
 Structured sexual therapy programs including the use of sexual surrogates
 Nutritionally based therapies
 Treatment by telephone unless preauthorized by BHI
 Health care services, treatment and/or supplies which BHI’s Chief Medical Officer
deems to be experimental, investigational, or primarily for research purposes
 Services such as sleep therapy, employment counseling, training and/or educational
therapy for learning disabilities, or other educational services such as educational testing
will only be considered if preauthorized by BHI
 Services and treatment which are solely focused on personal or professional growth and
development
 Services for children that the school system is required to provide by law
 Academic education
Authorizations
It is important to note that your contractual arrangement with BHI is the Provider Services
Agreement (PSA). The PSA indicates that covered services must be medically necessary,
appropriate, and delivered in an appropriate, timely, least restrictive and cost effective manner.
Services may be provided only for diagnoses covered by the Medicaid behavioral health
program. For a list of covered diagnosis, please reference the website for the Uniform Service
Coding Standards Manual on the BHI website.
Pre-authorization
Certain services require pre-authorization. Providers are expected to contact BHI for
authorization of these services prior to beginning service provision. Routine outpatient services
do not require authorization for contracted network providers. Please reference UM-824
Utilization Review Decisions for more information.
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The following list of services is representative of the services that require prior authorization.
Please note that this list is not exhaustive and that BHI reserves the right to add or delete services
from time to time. We will notify providers when changes are made to this list.
 Inpatient and Acute Treatment Unit (ATU) Services
 Subacute Services (e.g. hospital alternative programs)
 Partial Hospitalization
 Residential
 Day Treatment
 In-home/Home-Based Services
 Intensive Outpatient
 Respite
 Specialized Assessments (e.g. psychological testing)
 Social Detoxification
 Psychological testing
Failure to obtain preauthorization except in cases of emergency services will jeopardize payment
from BHI. It is the provider's responsibility to ensure that preauthorization has been obtained.
Providers cannot bill a Medicaid member for services that are not reimbursed (denied) by BHI
because of failure to obtain prior authorization.
Continued Authorizations
In the event that a member's clinical needs exceed the initial authorization, a provider can request
authorization for additional treatment services. Authorization of additional sessions must be
obtained prior to provision of such treatment; otherwise, reimbursement for treatment will be
jeopardized.
 Providers must submit a written treatment plan and requested documentation to BHI at
the agreed upon timeframe but minimally prior to the last session for review to determine
medical necessity for more sessions.
 The utilization management review process will address relevant clinical issues.
 If further care is requested and determined to be clinically indicted and medically
necessary subsequent authorization will be made.
 If the treatment plan does not meet medical necessity, the utilization review will address
the relevant issues with the provider and refer the case for further review with the Chief
Medical Officer.
Emergency Services
BHI expects network providers to provide a twenty-four (24) hour on-call service to patients.
This can be a shared on-call emergency service.
BHI contracts emergency evaluations twenty-four (24) hours per day, seven days per week to the
Emergency Services teams at the three Community Mental Health Centers (CMHC) in BHI’s
catchment area. Members in crisis are expected to call their therapist (see below for phone
numbers). A telephone response by the network provider, or clinician on-call, is expected within
15 minutes. If a level of care assessment or emergency mental health assessment is needed, the
clinician is expected to call BHI to make these arrangements. Please reference the BHI policy
UM-818 Emergency and Post-stabilization Services for more information.
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Utilization Management Procedures for Inpatient and Subacute Admissions
The BHI UM Department is available seven days a week, 24 hours a day, to review requests for
inpatient and sub-acute care of a BHI member. Once admission occurs, BHI UM department
remains involved for concurrent review and authorization determinations for continued stay as
well as assisting with discharge planning. Hospital liaisons from the CMHCs will assist with
discharge planning. In the event the patient no longer meets medical necessity criteria for
continued stay, further days will be denied and the provider may appeal the denial according to
BHI's appeal procedures. BHI and the discharge planners will remain actively involved until the
member is safely and successfully discharged.
Level of Care Assessment
Any changes in a member's level of care require preauthorization by BHI. Anytime a provider
believes a member requires a different level of care, a provider needs to contact BHI’s utilization
department. In the event that a provider is of the opinion that a member needs to be
psychiatrically hospitalized, the provider must call BHI or one the CMHC’s Emergency Services
Teams with the clinical information, along with the member's phone number and physical
location. They will arrange for an assessment, and give feedback and recommendations to the
member and provider. The CMHC Emergency Services Teams can be contacted at the phone
numbers below:
Arapahoe Douglas Mental Health Network
Aurora Mental Health Network
Community Reach Center
(303) 730-3303
(303) 617-2300
(303) 853-3500
Prior to contacting BHI for referring a member for a level of care assessment, it is expected that
the provider will have had contact with the patient, either in person or on the telephone, and has
assessed the member adequately enough to believe that the patient meets criteria for a higher
level of care.
Authorization Determination Timeframes
All authorization decisions shall be made and communicated to the member/provider as
expeditiously as the member’s condition requires. All BHI decisions related to authorization or
denial of authorization for services requested by clients or providers will be made according to
the following timeframes. Please reference UM-815 Utilization Management Timeframes.
1. For standard, pre-service authorizations, decisions shall be made and communicated to
the member and/or provider within 10 calendar days following the date of the service
request. The standard authorization timeline may be extended up to 14 calendar days if:
a. The member or member representative asks for an extension
b. BHI feels there is a need for additional information and can justify that the
extension is in the member’s best interest. The member does not have to agree
with the timeframe extension for routine or standard authorizations and may file a
grievance if they are in disagreement.
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2.
An urgent, pre-service authorization process will be utilized any time that a provider
indicates or BHI determines that following the standard authorization timeline could
seriously jeopardize the member’s life, health, or the ability to attain, maintain, or regain
maximum function. Authorization decisions for urgent pre-service matters will be made
and communicated to the member/provider as expeditiously as the member’s condition
requires and no later than 3 calendar days (72 hours) after the receipt of the request for
service. BHI will extend the expedited timeline by up to 14 calendar days if:
a. The member or member representative requests an extension
b. BHI feels there is a need for additional information and can justify that the
extension is in the member’s best interest.
3. BHI considers a request made while a member is in the process of receiving inpatient or
subacute care to be an urgent concurrent request. These timeframes also apply if the
member meets criteria for urgent care, even if BHI did not previously authorize the
earlier care. If deemed urgent, BHI will provide the member and/or provider electronic or
written notification regarding the determination within 24 hours.
4. If BHI receives the request for authorization after the member has discharged from the
provider’s care, then BHI considers this a post-service or retrospective review. This type
of review is handled through claims and/or the claims appeal process.
Medical Necessity Criteria
BHI has established Medical Necessity Criteria for all of its providers that serve as the basis for
consistent and clinically appropriate service authorization decisions for all levels of mental
health and co-occurring disorders with mental illness. A copy of the Medical Necessity Criteria
can be found on the BHI website. The Criteria consistently support clinical practice guidelines
and serve as a tool to promote sound and efficient utilization of available resources. BHI Criteria
are consistent with the criteria defined by HCPF Medicaid Managed Care rules and regulations.
Individuals involved in BHI utilization management processes use the following definition of
medical necessity or medically necessary treatment in making authorization determinations:
1. A covered service shall be deemed medically necessary if, in a manner consistent with
nationally accepted standards of medical or clinical practice, the treatment of symptoms
and diagnosis are not rendered in excess of member’s needs.
2. Is found to be reflective of a level of care or service that is safe, where no equally
effective, more conservative, and less costly treatment is available, and meets at least one
of the following criteria:
a. The service will, or is reasonably expected to, prevent or diagnose the onset of an
illness, condition, primary or secondary disability.
b. The service will, or is reasonably expected to, cure, correct, reduce, or ameliorate
the physical, mental, cognitive, or developmental effects of an illness, injury, or
disability.
c. The service will, or is reasonably expected to, reduce or ameliorate the pain or
suffering caused by an illness, injury, or disability.
d. The service will, or is reasonably expected to, assist the individual to achieve or
maintain maximum functional capacity in performing Activities of Daily Living
(ADL).
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BHI Medical Necessity Criteria do not supplant provider judgment. A medical review is
recommended in any circumstance that is unusual or not specifically addressed by the UM or
medical necessity criteria. The Medical Necessity Criteria are disseminated to all providers upon
acceptance into the network and at the time of Criteria revision through the BHI Provider
Bulletin and the BHI website. The Criteria also are available to any interested party, including
members, family members, advocates, and providers through the BHI website or in hard copy
upon request.
Clinical Denials and Appeals
In the case that BHI determines a member does not meet medical necessity criteria for a
requested level of care, the UM department will discuss the member’s needs with the provider
and work collaboratively to agree on an appropriate alternative service or level of care. If an
agreement cannot be reached between BHI’s UM department and the treating provider, the Chief
Medical Officer/designee may request a doctoral or second level review.
If BHI makes an adverse determination, the member (or member representative; for inpatient and
sub-acute requests, the treating provider is often the member representative) is notified. A
written denial notification is issued to the member or member representative within the decision
timeframes. The treating provider has the right to request a conversation with the Chief Medical
Officer or designee who made the decision. This can be arranged by calling the BHI UM
department and requesting a review between physicians/psychiatrists. Please reference UM-810
Notice of Action for more information about Action decisions.
All written or electronic adverse determinations notices include:
1. The facts and reasons for the determination not to authorize the request
2. A statement regarding the clinical rationale based on relevant medical necessity criteria,
guidelines, or protocols used in making the determination
3. Rights and processes for initiating an appeal, including the opportunity for an expedited
appeal, if applicable
4. The timeframes for requesting an appeal
5. The right to request an appeal in writing, via fax, or verbally; if the member/guardian is
filing the appeal verbally, a written appeal must follow
6. The opportunity for the member and/or provider to submit written statements, documents,
records, or other information for consideration as part of the appeal
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Appeals
An Appeal is request for review to change a previous action or adverse determination. Please
reference UM-804 Appeal Process for more information about appeals.
1. A Pre-service Appeal is a request to change an adverse determination for care or service
that the organization must approve, in whole or in part, in advance of the member
obtaining care or services. A member’s request for an appeal of a denial for service
excluded from the organization’s benefits package is a pre-service appeal if the member
has not received the requested services. In this case, the member may not receive
coverage for the requested care or service unless the organization approves it.
2. A Post-service Appeal is a request to change an adverse determination for care or
services that have already been received by the member. These are typically requests for
payment of care or services already rendered. Accordingly, a post-service request would
never result in the need for an expedited review.
3. A Concurrent Appeal is a request to change an adverse determination that terminates a
previously approved course of treatment over a period of time or number of treatments.
4. Expedited Appeal is a request to change a denial for urgent care. A member has the right
to remain in this level of care, however, if the appeal is upheld the member may be
responsible for payment of services.
A member, legal guardian, or DCR can file an Appeal with BHI, orally or in writing. BHI will
treat oral requests for an Appeal as the date of request in order to establish the earliest possible
date for the Appeal. Unless the member is requesting an expedited resolution, all oral requests
for Appeal must be followed with a written request for appeal. Pre-service Appeals are accepted
Monday through Friday 8:00a-5:00p. Expedited Appeals are accepted twenty-four hours a day
seven days a week.
Appeals must be filed within the following timeframes:
1. Pre-service and post-service Appeals: within thirty (30) calendar days of the effective
date of the Action
2. Concurrent Appeals: within ten (10) calendar days prior to the effective date of the
Action
All BHI Appeals are reviewed by a board-certified licensed psychiatrist and may also include
other licensed mental health clinicians or licensed specialty consultants. BHI will resolve each
Appeal, and provide notice as expeditiously as the member’s health condition requires not
exceeding the following:
1. Standard (non-expedited appeals) within ten (10) business days from the date BHI
receives the initial Appeal request
2. Expedited Appeals: within three (3) business days from the date BHI receives the initial
Appeal request
3. Post-service Appeals: BHI treats most post-service appeals through the claims processing
and claims appeal process, as they are typically provider requests for payment. BHI has
thirty (30) calendar days from the date of claim or claim appeal to process the request and
make determination. If the member requests a post-service appeal, they have the same
appeal rights as pre-service appeals and the process is the same; however, the timeframe
for determination is always up to thirty (30) calendar days from the date of request for
determination and resolution.
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Section IV – Claims
General Claims Information
A claim should be submitted for payment subsequent to services being rendered. Providers are
responsible for submitting claims for reimbursement.
Claim Forms
BHI requires providers to submit complete claims for all services rendered to BHI members.
BHI will accept paper claims in CMS 1500 or UB04/CMS 1450 formats. In order to process
claims in a timely, accurate manner, we ask providers to observe standard reporting
requirements. Providers may also reference the following resources when completing claims
submissions:
 CMS 1500 Physician’s Manual
 UB04 Billing Manual
 ICD-9-CM Code Book
 Physicians’ “Current Procedural Terminology” (CPT)
 Health Care Financing Administration Common Procedure Coding System (HCPCS)
Providers must submit all hospital and facility claims on the UB04/CMS 1450. Providers must
file all claims for professional services on the CMS 1500 Universal Billing form.
Claims Submission Requirements
All claims for care must be submitted on an approved claim form and must contain the actual
address, including zip code, where services were provided, regardless of the provider's preferred
billing address.
Claims for services submitted by BHI providers must be received no later than 60 days after the
services were delivered. In cases where BHI is the secondary payer, the network provider is
required to submit claims for services no later than 30 days after all primary payments are made
or finally denied. BHI Provider Relations staff is available to answer any questions you may
have about the claims procedures. Please call (720) 490-4413.
Please send claims or written claims appeals to:
BHI Claims
PO Box 17448
Denver, CO 80217
Time Limit of Payment
Provided all necessary information is received to process the claim, claims shall be paid or
denied within 45 days of the receipt date and within 30 days if submitted electronically.
Primary Diagnosis
The diagnoses covered by The Colorado Medicaid Community Mental Health Services Program
can be found in the USCS Manual, available on the BHI website. If the primary diagnosis is not
on this list, then the provider should bill Colorado Medicaid Fee-For-Service Program. When
submitting a claim, make sure to include the covered diagnosis being treated.
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Inpatient: Upon admission, the facility/institution should maintain in the member’s file the
appropriate registration filled out and signed by the insured/member. At each admission, the
institution is required to obtain an updated registration filled out and signed by the
insured/member. At BHI’s request, copies of signatures must be supplied for auditing purposes
to ensure compliance.
Corrected Billings
Claims submitted, as corrected billings, for the following reasons must have clinical
documentation attached supporting the correction. To expedite handling, please indicate "ReBill" across the top of the claim form.
 Change of diagnosis code--why is diagnosis code being changed?
 Change of date of service--why is date of service being changed?
 Change of service code--why is service code being changed?
 Change of place of service--why is place of service being changed?
Corrected billings received without the documentation will be returned unprocessed.
Clinical Assessment/Concurrent Review Form Copies Not Needed With Claims
Providers do not need to submit copies of their clinical paperwork each time a claim is filed.
Member Billing
According to CRS § 26-4-403, a Medicaid recipient is not liable for the cost of care received
during the time the recipient is Medicaid eligible, provided the care is a benefit of Medicaid and
is determined to be medically necessary. In addition, a provider may not bill the Medicaid
recipient for the difference between provider’s charges and payment by Medicaid, Medicare, or
private insurance. These constraints apply regardless of whether or not Medicaid paid the claim.
A member may have to pay for services rendered if his/her appeal of a denial made by BHI is
upheld through a local appeal or through a State Fair Hearing.
Coordination of Benefits
When submitting a claim for a member with Third Party Liability (TPL), providers must submit
a hard copy of the CMS 1500 or UB04/CMS 1450 along with a copy of the Explanation of
Benefits (EOB), denial notice (including all denial reason wording), benefits exhausted statement
or a copy of the check/voucher used for claim payment from the other insurance/TPL.
If an EOB applies to more than one claim, a copy of the EOB must be attached to each claim
submission. Complete the appropriate TPL data fields/form locators on the claim form submitted
to BHI. Claim TPL data fields/form locators are specific to third party insurance or Medicare;
they cannot be used interchangeably. The claim must be submitted within 30 calendar days from
the TPL’s denial date or processing date.
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Secondary Benefit Calculation “Lower of Logic”
BHI calculates secondary benefits in the following manner:
1. BHI’s benefit allowance is compared to the primary payment.
2. If the primary payment is equal to or greater than the BHI benefit allowance, BHI will
not make payment.
3. If the primary payment is less than the BHI benefit allowance, BHI will pay the
difference between the two amounts. However, payment will not exceed the other
insurance’s (including Medicare) co-insurance, deductible, and/or copayment.
4. BHI will coordinate benefits with a member's primary health insurance carrier. A copy of
the primary carrier's Explanation of Benefits (EOB) or denial should be sent with each
claim submitted.
5. BHI does not automatically pay the other insurance’s (including Medicare) copayments,
coinsurance, and/or deductibles.
NOTE: Providers cannot bill members for the difference between the primary carrier’s health
insurance payments and their billed charges when BHI does not make additional payment.
BHI's referral and utilization management procedures must be observed in order to receive
benefit reimbursement (even if BHI is the secondary insurance carrier).
Provider Claims Appeal Process
For general information: If you have a question regarding why your claim was not paid, you may
call the Colorado Access Claims Department for further clarification at (303) 368-8201.
If you are unsatisfied with a denial on a claim and want the denial reviewed for reversal, the
following information will help you. Provider claims may be denied for several reasons,
including, but not limited to:
 Service required prior authorization
 Member was not eligible on the date of the service (per State information)
 Claim was not filed in a timely manner
 The diagnosis submitted on the claim was not covered under the behavioral health
Medicaid plan
 The service was not medically necessary
All denials are subject to appeal and reconsideration. However, all appeal requests must include
new information that was not provided at the time of the initial claim, including the reason for
appeal. If the claim was denied for timely filing, the provider may attach a copy of an EOB from
a third party to explain the delay in filing.
Providers may submit appeals by mail or facsimile within thirty (30) days of the date of EOB
denial. Written appeals should be submitted to the following address:
BHI Claims
PO Box 17448
Denver, CO 80217
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First level appeals are processed within thirty (30) days of the receipt of the appeal. All appeal
requests must include new information that was not provided at the time of the first level appeal,
including the reason for appeal. If the denial is upheld, an EOB and/or letter will be sent to the
provider with an explanation. If the appeal is overturned, an EOB will accompany the check for
payment to the provider. Appeals submitted without additional information including the reason
for appeal will be returned to the provider.
These procedures do not in any way prohibit the provider from accessing the full array of
regulatory appeal mechanisms available under various rules and regulations. However, as denials
of claims can occur due to error or misunderstanding, providers are encouraged to utilize the BHI
appeal process as a means of resolving these issues at the lowest level.
If providers have questions about the status of claims or appeal, they may contact Colorado
Access/BHI Customer Service at (303) 368-8201.
The following pages explain the various fields of the CMS 1500 and UB04/CMS1405 claim
forms.
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CMS 1500 claim form
CMS 1500
Box #
1
1a
2
3
4
5
6
7
8
9
9a
9b
9c
9d
11
12
13
14
21
23
24a
24b
24d
24e
24f
24g
24j
25
26
28
31
32
32a
33
33a
Instructions
Enter an “X” in the Medicaid box.
Enter the insured’s primary identification number including any letters. Medicaid use Medicaid
number from the patient’s current Medicaid card.
Enter patient’s full name. Do not use nicknames or abbreviated names.
Enter patient’s date of birth in month, day, and year format. Enter an “X” to indicate appropriate
sex.
Enter the insured full name, unless the patient is the insured, then enter the word “Same.”
Enter the patient’s complete address.
Check the appropriate box on the relationship to the insured.
If the insured’s address is the same as the patient’s then enter “Same.”
Enter patient’s status in the appropriate box.
If the patient has other insurance, enter the name of the policyholder here.
Enter the other insured’s policy or group number.
Enter the other insured’s date of birth.
Enter the employer of the other insured.
Enter the plan or program name of the secondary insurance.
Enter the insured’s group number (use Medicaid ID number), date of birth, and check the
appropriate box on other coverage.
Have the insured or appropriate guardian (if under 18 years old) complete the Consent to Release
Information form (copy is provided in the Sample Clinical Forms section of this manual). If form
is, complete and in patients chart, enter “On File.”
Insured must sign box, to send payment for services to the provider. (Medicaid has an automatic
assignment of benefits). If form is, complete and in chart, enter “On File.”
If known, enter the date of onset for services rendered for illness.
Enter the diagnosis in this space.
Enter the corresponding authorization number for the services being billed here.
Enter date of service.
Enter the appropriate Place of Service code
Enter the proper procedure code from your Medicaid contract or the Referral Authorization Letter.
Number 1, 2, 3, or 4 from field 21 it indicate which diagnosis is related to the procedure on each
billing line. Do not enter the ICD-9-CM code.
Enter the charge for the service.
Enter the number of days or units.
Enter the NPI number of the provider that rendered the service.
Enter the Social Security number (SSN) or Federal Employer Identification Number (FEIN) and
mark an “X” in the appropriate box to indicate which is being used.
Enter your patient’s account number.
Enter the total of all charges listed in Section 24 Column F.
Authorized signature or printed name and date of the physician.
Enter the name and address of facility where services were rendered.
The NPI number of the facility where services were rendered.
The provider’s billing name, payment address and telephone number.
The NPI number of the billing provider.
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UB04/CMS 1450 form
UB04/CMS
1450 Box #
1
3a
3b
4
5
6
8a
8b
9a
9b
10
11
12
13
14
15
16
17
18-28
29
31-34
35-36
38
39-41
42
Description
Provider name, address and telephone number
Patient Control Number – Account or bill control number assigned by the
provider
Medical Record Number – Medical record number assigned by the provider
Type of facility (1st digit), bill classification (2nd digit), and frequency (3rd digit).
Refer to the AHA UB04 Uniform Billing Manual for a list of codes.
The Federal Tax ID Number
Beginning and ending service dates of the period included in the bill
The patient’s ID number
The patient’s Last, First and Middle Initial
The patient’s street address
The city in which the patient resides
The patient’s date of birth
The patient’s gender, enter M or F
The date care began (the date of admission or the date care was initiated)
The hour in which the patient was admitted for care. The hour should be entered
in military time (00-24)
The single digit code that describes the reason for admission:
1. Emergency
2. Urgent
3. Elective
The code that best describes the source of the admission:
1. Physician
2. Clinical
3. HMO Plan
4. Transfer from Hospital
5. Transfer from SNF
6. Transfer from other Health Care Facility
7. Emergency Room
8. Court/Law Enforcement
9. Information not available
The hour in which the patient discharged. The hour should be entered in military
time (00-24)
The code that best describes the patient’s status for this billing period:
1. Discharged to home or self care
2. Transferred to another short-term hospital
3. Transferred to a SNF
4. Transferred to an intermediate care facility
5. Transferred to another type of institution
6. Discharged to home under care of an Organized Home Health Services
Organization
7. Left Against Medical Advice
Codes used to identify conditions related to the claims that may affect processing
Accident State
The code and associated date defining a significant event relating to the claim
that may affect processing
The beginning and end dates of the event relating to the claim
Codes used to identify payment variations
Codes that identify a specific accommodation, ancillary service, or billing
calculation. Accommodation days should not be billed on outpatient bill types.
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Required
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Optional
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
25
43
44
45
46
47
50 a, b, c
51 a, b, c
52
53
54
56
57
58
59
60
61
62
63
66
67
67 a-q
69
70 a, b, c
71
72
74
74 a-e
76
77
78-79
80
81 a-d
Revenue codes are to be billed in the following sequence: chronologically for
accommodation dates; in descending order for non-accommodation revenue
codes.
Description of the related revenue code
Accommodation rate for inpatient bills and the HCPCS code for all ancillary
services and outpatient bills.
Date of service in MMDDYY format
Services units provided. If accommodation days are billed, the number of units
billed must be consistent with the Statement Covers Period (Box 6). Service units
should be billed in whole numbers.
Total charges for Field 47 are obtained by multiplying the units of service (Box
46) by the Value of the revenue code (Box 42)
Name of each payer who may have full or partial responsibility for the charges
incurred by the patient and from which the provider might expect some
reimbursement
Identification number, if available, of each payer
Release of Information – Enter Y if the provider has signed written consent from
the patient to release medical /billing information. Otherwise, enter R for
restricted or modified release or N for no release
Assignment of benefits – A code showing whether the provider has a signed
form authorizing the party payer to pay the provider
Amount received toward payment from any payer, including the patient
National Provider Identifier (NPI) number of the billing provider
Other Provider ID – Number assigned to the provider by the payer indicated in
Box 50 a, b, c
Name of the insured who is covered by the payer listed in Box 50
Patient’s Relationship to the Insured
The patient’s member ID number
Insured’s group name
The Insurance Group Number
Prior Authorization Number
Diagnosis and Procedure Code Qualifier (ICD Version Indicator) – Enter “9”
Diagnosis determined after study, using ICD-9-CM codes. The codes should
match those on the prior authorization letter
Other applicable ICD-9-CM diagnosis codes
Admitting Diagnosis Code that represents the significant admitting diagnosis
The diagnosis that represents the reason for the patient’s outpatient visit
Prospective Payment System Code – the code that identifies the DRG
External Cause of Injury
Principal procedure code and date the principal procedure was performed during
this hospital stay.
Other procedure codes performed during the hospital stay
Attending provider’s NPI number, Last and First name
Operating physician’s NPI number, Last and First Name
Other provider’s NPI number, Last and First name
Information when applicable
Codes that do not fit in the other code fields of the form
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No
Yes
Yes
Yes
Yes
No
No
No
N/A
No
Yes
No
No
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes if inpatient
Yes if outpatient
Yes if applicable
No
No
No
Yes
Yes if applicable
Yes if applicable
No
No
26
Section V – Clinical Expectations
Access to Care Standards
All BHI providers are expected to provide services to Medicaid members within the following
guidelines. Please reference BHI policy UM-801 Access and Availability for complete
information about access to care standards and monitoring.
Emergency Care:
An emergency medical condition is defined as a “medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses
an average knowledge of health and medicine, could reasonably expect the absence of immediate
medical attention to result in: A) placing the health of the individual (or for a pregnant woman,
the health of the woman or her unborn child) in serious jeopardy; B) serious impairment to body
functions; or C) serious dysfunction of any body organ or part.”
Emergency care is to be provided within fifteen (15) minutes by phone or within one (1) hour for
a face-to-face evaluation. In life-threatening emergencies, refer your client to go to the closest
emergency facility.
An answering service/machine may direct callers to go to the closest emergency department or
call 911. Any BHI member can also contact the Emergency Services clinicians at one of BHI’s
Community Mental Health Centers at the numbers listed below. These Emergency Services
clinicians are available 24 hours a day, seven (7) days a week.
Arapahoe Douglas Mental Health Network
Aurora Mental Health Network
Community Reach Center
(303) 730-3303
(303) 617-2300
(303) 853-3500
Emergency services do not require prior authorization and are paid through claims processing.
Psychiatric inpatient or sub-acute admissions require prior authorization and must meet medical
necessity criteria. In case of an emergency, the member can go to any hospital emergency room.
Most hospitals in the BHI area will arrange for a specialized face-to-face evaluation performed
by the emergency services teams contracted with BHI for immediate assessment, treatment
planning, and referrals.
Urgent Appointments:
An urgent appointment is defined as a behavioral health condition manifested by acute
symptoms that has the potential to become an emergent health condition in the absence of
treatment. An urgent need may also be any other condition that would place the health or safety
of the Member or another individual in serious jeopardy in the absence of medical or behavioral
health treatment. Urgent appointments shall be available within twenty-four (24) hours of a
request.
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Routine Appointments:
Routine appointments shall be available within seven (7) business days of a request for a routine
appointment. A routine appointment is defined as a behavioral health condition that does not
meet the definition of urgent or emergent. Routine services include but are not limited to an
initial individual intake and assessment appointment. Placing members on waiting lists for initial
routine service requests is not acceptable.
Documentation Standards
Except where disclosure of certain information is expressly prohibited by or contrary to
applicable state and federal laws or regulations, network providers must be prepared to provide
BHI with the following information at the time of review, as necessary and appropriate. BHI
requires that all providers comply with billing and documentation guidelines (including technical
documentation and service content requirements) set forth in the Uniform Services Coding
Standards (USCS) manual. A copy of the manual can be found on the BHI website.
Colorado Client Assessment Record (CCAR)
The CCAR must be completed at time of admission, discharge, once annually, and anytime the
level of care changes. Providers are expected to complete the CCAR using either the BHI ECCAR or the state CCAR Application Portals. BHI will no longer accept faxed copies.
Instructions for accessing the E-CCAR portals can be found on the BHI website.
The Intake/Mental Health Assessment
The intake/mental health assessment should include (a template for a mental health assessment can also
be found on the BHI website):
1.
2.
3.
4.
5.
6.
7.
8.
9.
Member demographics
Presenting concern/chief complaint
Cultural and racial affiliations
Language and reading proficiency
Relevant medical history
History of mental illness and medications
Mental Status Exam
Risk assessment to include suicidal/homicidal ideation, plan, intent, means, psychosis
Substance Abuse history to include type, amount, withdrawal symptoms, method of use,
date/age of initial use, date/age of last use, previous related treatment
10. Progress since admission or last evaluation (for re-assessments)
11. Psychosocial history, including socioeconomic, family, legal, social,
abuse/neglect/domestic violence (as appropriate)
12. Response to previous treatment to include previous treatment history, most recent
treatment, past treatment failures and probable reason for failure, relapse/recidivism,
current level of motivation for treatment
13. Discharge/Disposition plan to include aftercare required upon discharge and barriers to
discharge
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Individualized Treatment/Service Plan
Members have the right to participate in the development of their treatment plans. BHI requires
that all treatment plans be developed using a strength-based model that individualizes treatment
goals for each member. Treatment plans must be updated annually, at minimum. BHI encourages
all providers to update treatment plans every 6 months. A treatment plan template can be found
on the BHI website. While BHI does not require the use of this template, any treatment plan for
BHI members must include the following elements:
 Treatment goals written in the member’s own words
 Measurable objectives based on the member’s identified goals
 Specific, targeted interventions to address the identified goals and objectives
 Member/guardian signature (or documentation of why signature was refused/cannot be
obtained)
 Clinician signature with credentials (licensed supervisor signature required for unlicensed
providers)
 Prescriber signature (only if medications are ordered on the treatment plan)
Clinical Record Documentation Guidelines
BHI requires that the following elements be present in each member’s clinical chart:
1. Each page in the clinical record contains the member's name or identification number.
2. All entries in the clinical record and service plan are signed, with the responsible
clinician's name and professional degree/credentials.
3. All entries are dated, including all member visits, telephone calls, and provider notes or
initials on laboratory reports.
4. The record is legible to someone other than the writer.
5. Personal/ biographical data includes the following: name, address, date of birth, home
telephone, employer or school, work telephone if applicable, marital status, legal status
(voluntary or court-ordered treatment), and emergency contact (name, address, and
telephone number of guardian, significant other, or next of kin).
6. Consent for psychiatric services, or authorization for treatment of a minor (Exception: In
Colorado, minors age 15 or older may enroll in mental health treatment without parental
consent); when custody is shared, signatures of both parents is recommended.
7. A professional disclosure statement that is reviewed and signed by the member
(Exception: CO mandatory disclosure law does not apply to MDs or nurses); the
disclosure statement is clear and explanatory of the practitioner's names, highest degree
and state license, supervisor, and the provider agency or institution
8. Member is notified of specific rights and responsibilities; BHI member rights are
available in this manual, on the website, or upon request.
9. If information has been requested or shared with external sources, a Release of
Information (ROI) is signed and dated by the member or legal guardian.
a. Forms specify that the ROI is valid for no longer than one year and may be
revoked in writing by the member, parent, or legal guardian at any time
b. If there is an emergent situation and there is no ROI, the following information
should be documented: the basis for release of information, the content of the
information released, and the parties to whom the information is released
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EPSDT Screening Form
Colorado Medicaid Community Mental Health Services requires coordination of EPSDT
services between the PCP and the mental health provider. BHI providers are required to
document the following: The PCP has been contacted to determine:
 That the EPSDT has been completed
 That the provider has requested the completion of EPSDT by the PCP if the screening has
not been completed
 That the Medicaid enrollment broker has been called if the Member has no PCP
Discharging from Mental Health Services
For residential, inpatient, and intensive services, providers must create a discharge plan within 48
hours of the member’s admission, or when the member is clinically able to participate
meaningfully in discharge planning. The discharge plan must be signed by the member and/or
guardian and kept in the member record.
Upon completion of the treatment plan (or when BHI, the provider, and member agree to
discontinue treatment), a discharge from services will occur. Providers are responsible for
completing a discharge summary and discharge CCAR. Discharge summaries must include the
following (at minimum):
 A summary of services provided
 The reason for discharge or transfer
 The member’s response to treatment
 The member’s progress in treatment
 Any referrals or follow up, as necessary
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Section VI – Quality Improvement and
Corporate Compliance
The BHI QI Program is responsible for development, implementation, coordination, and
monitoring of clinical and service quality improvement indicators for the BHI program areas of
Utilization Management, Provider and Facility Credentialing, Provider Relations, and Member
and Family Affairs.
It is the policy of BHI that all of its business and other practices shall be conducted at all times in
compliance with all applicable laws and regulations of the United States, the State of Colorado,
all other applicable local laws and ordinances, and the ethical standard/practices of the industry
and BHI.
Clinical Practice Guidelines
BHI develops, implements, monitors, and evaluates clinical practice guidelines, medication
algorithms, and new technology based on current standards of practice. BHI expects that all
providers adhere to all BHI practice guidelines. BHI reviews data regarding compliance with
current guidelines, identifies education opportunities, and makes recommendations for
performance improvement. Please see the BHI website for copies of the practice guidelines.
Provider Audits
The audit process is designed to identify a provider’s compliance with applicable BHI, state
and/or federal regulations governing the healthcare program and payment to the provider. BHI
may request access to and/or copies of treatment records and/or conduct treatment record
reviews:
1. Randomly as part of continuous quality improvement and/or monitoring activities
2. As part of routine quality and/or billing audits
3. As may be required by client, provider, and/or government or regulatory agency contracts
4. As part of periodic reviews conducted pursuant to accreditation requirements to which
BHI is or may be subject to
5. In response to an identified or alleged specific quality of care, professional competency,
or professional conduct issue or concern
6. As may be required by state and/or federal laws, rules, and/or regulations
7. In the course of claims reviews and/or audits
8. As may be necessary to verify compliance with the provider agreement
Based on the results of a provider audit, BHI can implement various requirements for a provider,
including (but not limited to: Corrective Action Plans, recovery of payment, or a probationary
period. For more information about provider audits or recovery of payment, please see the full
policies on the BHI website.
BHI requires that all providers consult the Uniform Service Coding Standards Manual (USCS
Manual) for information about the various requirements for billing the various procedure codes:
place of service requirements, credential requirements, minimum documentation requirements,
etc. The most current USCS Manual can be found in its entirety on the BHI website.
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Fraud, Waste, and Abuse
BHI is dedicated to providing quality healthcare services to members while conducting business
in an ethical manner. BHI supports the efforts of federal and state authorities in identifying
incidents of fraud, waste, and abuse. BHI has mechanisms in place to prevent, detect, report, and
correct incidents of fraud, waste, and abuse in accordance with contractual, regulatory, and
statutory requirements. BHI is required to take appropriate disciplinary and enforcement action
against employees, providers, subcontractors, consultants, members, and agents found to have
committed fraud. We are also required to take appropriate actions to prevent further offenses
through systems and process changes. To report a possible violation, please call the Corporate
Compliance Hotline at (720) 490-4407.
The following definitions are taken from the BHI policy on the recovery of overpayment. Please
see the BHI website for more information and the full policy.
Fraud means an intentional deception or misrepresentation made by a person with the
knowledge that the deception could result in some unauthorized benefit to her/him or some other
person. It includes any act that constitutes fraud under applicable federal or state law.
Waste means the overutilization of services, thoughtless or careless expenditure, mismanagement
of use of Medicaid resources, or other practices that, directly or indirectly, result in unnecessary
costs to the Medicaid program. Waste is generally not considered to be caused by criminally
negligent actions.
Abuse means practices that are inconsistent with sound fiscal, business, or medical practice and
results in an unnecessary cost to the Medicaid Assistance program, an overpayment by the
Medicaid program, or in reimbursement for goods or services that are not medically necessary or
that fail to meet professional recognized standards for health care.
Quality of Care Concerns
A Quality of Care Concern (QOCC) is an issue related to client care that is either reported by
providers or discovered by BHI. Please note that QOCCs are different from grievances, as
grievances are issues raised by members. Please reference the BHI policy QI-207 Quality of
Care Concerns for more information. QOCCs can be related to one of the following categories:
1. Access to care, including delay of care and issues with urgent/emergent care
2. Professional conduct or competence
3. Coordination and continuity of care
4. Medication errors that result in an adverse reaction requiring medical attention
5. Violation of legal or client rights
6. Unexpected client death reported by a BHI mental health center according to their
internal protocol
7. Suicide attempts in a 24-hour care mental health facility requiring medical intervention
8. Assault related injuries requiring medical attention in 24-hour mental health facilities
9. A client under involuntary treatment status missing from a 24-hour mental health facility
10. Failure to report statutory suspected abuse per CRS
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BHI asks for your cooperation with all Quality of Care Concern investigations. If you become
aware of a potential QOCC with another provider, please contact BHI at (720) 490-4400. If you
become the subject of a QOCC investigation, BHI will notify you as to your required response
(submitting medical records, meetings, etc.), as requirements vary depending on the subject of
the QOCC.
Critical Incident Reporting
BHI requires that all providers/agencies/facilities it contracts with or approves to provide services to
report critical incidents involving BHI members to the Quality Improvement Department. A critical
incident is defined as an actual or alleged event or situation that creates a significant risk of substantial or
serious harm to the physical or mental health, safety, or well-being of an individual. This also includes
damage to a facility that impedes the care and treatment of members.
The following categories of critical incidents are reportable:
Breach of Confidentiality
Sexual Contact
Suspected Neglect
Suspected Physical Abuse
Suspected Sexual Abuse
Missing Person
Restraint
Seclusion
Assaultive Behavior
Arrest
Medication Error
Medical condition/injury requiring physician attention
Diverted Drugs
Attempted Suicide
Death
Facility Damage
A full description of reporting requirements and definitions of the above categories can be found in the
QI-705 Critical Incident Reporting on the BHI website. The form to submit critical incidents is also
available online.
Quality Improvement and Corporate Compliance Resources
The following information can be found on the BHI website:
 QI Program Description
 The BHI Annual Quality Report (including the QI Plan and Plan progress)
 Clinical Practice Guidelines
 Corporate Compliance Overview
 Corporate Compliance Plan
 Provider Audit Policy
 Recovery of Payment Policy
 Uniform Service Coding Standards Manual
 Critical Incident Policy and Form
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Section VII – Member and Family Affairs
Member Choice
BHI has a commitment to treat members as partners in the therapeutic relationship. Choice of
providers is essential to fulfilling that commitment. Toward that goal, BHI has an extensive
network of providers. BHI will negotiate a contract or single case agreement with a provider
requested by a member or family member so long as the provider meets minimum BHI
credentialing and quality-of-care requirements and agrees to BHI rates. A Care Coordinator is
assigned to every case to ensure that services are well coordinated, effective, and consistent with
member-stated preferences and identified clinical needs.
If the member chooses to receive care from one of BHI’s main mental health centers, they also
have a choice of providers within the center they select to receive their treatment. At the time of
their initial appointment, a staff member will help them identify any specific preferences they
may have related to location and hours of services, expertise of their provider, a specific
provider, and any cultural considerations. BHI will work hard to provide members with
culturally appropriate services and match them with a provider who meets their needs.
If a member does not have a preference, they will be referred to the clinician who the intake
therapist thinks would be a good fit for their particular needs. In the event that the original choice
is not a good match, the member is entitled to change to another clinician one time at his or her
discretion. Further requests will be reviewed clinically.
If a member is currently receiving mental health services with someone not affiliated with one of
the mental health centers and they desire to continue receiving care from their current provider,
they may request that BHI contract with their current provider to provide their care. If the request
is denied, BHI will attempt to provide the member with a satisfactory alternative. Additionally, if
the member feels their needs cannot be met through one of the mental health centers, they may
seek services through one of the independent network providers. Members are encouraged to
contact BHI to request an external provider. For information about the independent network
providers included in our plan, call BHI at (720) 490-4400.
Member Rights and Responsibilities
BHI strives to maintain a mutually respectful relationship with members. Members will be
treated in a manner that respects their rights and responsibilities. It is important to BHI that both
providers and members are familiar with Member Rights and Responsibilities. Please see the
BHI website (or contact BHI at 720-490-4400) for a printable list of Member Rights and
Responsibilities. Copies of Member Rights and Responsibilities are also available in Spanish.
Please note that all providers should have a copy of the Member Rights and Responsibilities
posted at their agency.
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BHI Member Rights include the following:
1.
To be treated with respect for their dignity and privacy
2.
To be able to ask for information about BHI services and providers, including their mental
health benefits, how to access care, and how to know their rights
3.
To obtain information in a way that is easily understood
4.
To choose any provider in the BHI network
5.
To obtain culturally appropriate and competent services from BHI providers
6.
To obtain services from a provider who speaks their language or to obtain interpretation
services in any language needed
7.
To ask that a specific provider be added to the provider network
8.
To obtain services that are appropriate and accessible when medically necessary, including
care 24 hours a day, (7) seven days a week for emergency conditions
9.
To obtain emergency services from any provider, even those who are not in our network,
without calling BHI first
10. To obtain a routine appointment within (7) seven days, or an urgent appointment within 24
hours of their request
11. To receive medically necessary covered services from a provider who is not in the BHI
network if BHI is otherwise unable to provide them
12. To know about any fees they may be charged
13. To obtain written notice of any decision by BHI to deny or limit requested services and to
appeal that decision
14. To obtain a full explanation from providers about:
a. Their own or their child’s mental health diagnosis and condition
b. Different kinds of treatment that may be available
c. What treatment and/or medication might work best
15. To participate in discussions and make decisions about their care with their provider
16. To obtain a second opinion if they have a question or disagreement about their treatment
17. To be notified promptly of any changes in benefits, services, or providers
18. To refuse or stop treatment, except as provided by law
19. To be free from any form of restraint or seclusion used as a means of convincing them to
do something they may not want to do, or as a punishment
20. To obtain copies of their treatment records and service plans and ask BHI to change their
records if they believe they are incorrect or incomplete
21. To obtain written information on advance medical directives
22. To obtain information about, and help with grievances, appeals and fair hearing procedures
23. To make a grievance (complaint) about their treatment to BHI without fear of retaliation
24. To have an independent advocate help with any questions, problems, or concerns about the
mental health system
25. To express an opinion about BHI’s services to state agencies, legislative bodies, or the
media without their services being affected
26. To exercise their rights without any change in the way BHI or BHI’s providers treat them
27. To have their privacy respected. Personal information can only be released to others when a
member gives permission or when allowed by law
28. To know about the records kept on them while they are in treatment and to know who may
have access to those records
29. To any other rights guaranteed by statute or regulation (the law)
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BHI Member Responsibilities include the following:
1. To pick a provider from the BHI network, or call BHI to see someone that is not in BHI’s
network.
2. To follow the BHI and Medicaid rules described in the BHI Member and Family
Handbook.
3. To follow the steps described in the Member and Family to file a grievance or appeal
with BHI about the services they are receiving.
4. To pay for any services received that is not covered by Medicaid or BHI.
5. To tell us if they have any other insurance, including Medicare.
6. To keep scheduled appointments and call to cancel or reschedule if they cannot make
their appointment.
7. To ask questions when they do not understand or when they want more information.
8. To tell providers any information they need for their care, including whether or not they
are having symptoms.
9. To work with providers to create goals that will help you in their recovery.
10. To follow the treatment plans that they have agreed upon with their providers.
11. To take medications as they are prescribed.
12. To tell their doctor if they are having unpleasant side effects from medications, or if
medications do not seem to be working to help them feel better.
13. To seek out additional support services in the community.
14. To invite the people who will be helpful and supportive to them to be included in
treatment.
15. To understand their rights and the grievance process.
16. To treat their providers as they would expect to be treated.
Designated Client Representative (DCR)
A DCR is someone a member chooses to speak on his/her behalf when he/she has a concern or
appeal about his/her mental health services. It could be a provider, an advocate, a lawyer, a
family member, or any other person the member trusts.
If a member decides to use a DCR, the member must sign a form with the name, address and
phone number of the DCR. This is so we can contact him/her during the investigation or appeal
process. This person will not see a member’s medical records or get information about a
member’s situation unless the member also signs a form to release medical information to his/her
DCR. The DCT form can be found on the BHI website.
Advance Directives
Advance Directives are written instructions recognized under State law relating to the making of
medical treatment decisions and the provision of health care when or if an individual is
incapacitated. It is the policy of BHI to follow applicable State law and Federal Regulations
regarding advance directives and to provide adult members with written information on advance
directives and BHI’s advance directive policy. Please reference the BHI policy OMFA-601
Advance Directives on the BHI website for more information.
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Grievances
If a member is not happy with something other than a service decision, he/she can file a
grievance. A grievance can be about anything other than a decision by BHI to deny, limit, or
change a service that a member or provider requested. This is a member right. A member does
not need to worry that he/she will be treated badly for making a grievance. BHI wants to make
sure that its members are treated fairly and receive the best services possible. This is one way a
member can stand up for himself/herself and his/her rights. It also helps BHI make our services
better for members. For more information about the grievance process, please reference the BHI
policy OMFA-603 Grievance Procedure on the BHI website. Information about grievances must
be posted at each provider office site.
Examples of grievances might include:




The receptionist was rude to a member
A provider would not let a member look at his/her own mental health records
A service plan does not include things the member would like to work on
A member could not get an appointment when needed
How to File a Grievance with BHI
To file a grievance, a member or DCR can contact the BHI Department of Member and Family
Affairs by phone, mail, or by filling out a grievance form (located on the BHI website) and
mailing it to BHI. Members are encouraged to complete a grievance within 30 days from when
the problem occurred. Be sure to include member name, Medicaid identification (ID) number,
address, and phone number.
Other organizations can help members or DCRs with a grievance, including:
 The Ombudsman for Medicaid Managed Care, operated by Maximus. The phone number
is (303) 830-3560 or toll free at 1(877) 435-7123.
 The Department of Health Care Policy and Financing. Their phone number is (303) 8663513 or toll free at 1 (800) 221-3943.
What Happens When A Member Files a Grievance?
1. After BHI receives the grievance, we will send the member a letter within two business
days. The letter will notify the member that BHI received the grievance.
2. We will review the grievance. We may talk with the member or member’s DCR, talk to
the people involved in the situation, and review medical records.
3. Someone who was not involved in the situation the member is concerned about, and who
has the right experience, will review the grievance.
4. We will work with the member or DCR to try to find a solution that works best for the
member.
5. Within 15 business days after we get a grievance, we will send the member a letter
stating the results of the grievance. Alternatively, we will let the member know if we
need more time. The member will receive a letter from BHI after the review is finished.
6. If the member is unhappy with our review, he/she or the DCR can contact the Colorado
Department of Health Care Policy and Financing (HCPF). HCPF will complete another
review that is considered final.
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Second Opinions
It is the right of Medicaid members to receive a second opinion at their request, free of charge.
Members may request a second opinion if they disagree with a provider regarding diagnosis,
treatment recommendations, or other clinical decisions, or if the decision is made to reduce or
deny services. Members may request a second opinion by calling BHI’s Utilization Department
at (720) 490-4400 with their request. The member will be scheduled for the appropriate
assessment. Procedures and reports obtained from any second opinion consultations are
documented and incorporated into the member’s record. Please reference UM-812 Specialty
Consultations and Second Opinions on the BHI website for more information.
Preventative Physical and Behavioral Health Programs
BHI is committed to our members. We want them to lead healthy lives. According to research,
persons with mental illness die on average 25 years earlier than those without a mental illness.
This is due, in part, to ongoing chronic illness. These ongoing illnesses include lung disease,
heart disease, diabetes, and infection. For this reason, BHI recognizes that recovery for
individuals with mental illness requires that we address both physical and mental health needs.
Our programs include: healthy eating, increasing physical activity, addressing mental health
needs, addressing chronic disease, and providing awareness of chronic illness and interventions.
You can find out more about these programs by contacting us. If you would like to make
suggestions or have ideas for preventative health programming, you may also contact us. We
would appreciate your feedback. We are also committed to the Substance Abuse and Mental
Health Services Administration’s (SAMHSA’s) 10 X10 Campaign. The Campaign is a national
call to action to improve life expectancy by 10 years in 10 years for people with mental illnesses.
BHI signed the 10 X 10 pledge in 2008. More information about SAMHSA’s 10 X 10 pledge can
be found on the SAMHSA website.
Prevention is important for improving life expectancy. We offer free preventative health
programs, such as fitness and nutrition classes at our Drop-In Centers. For more information
about our Drop-In Centers or preventative health programs, please see the BHI website or
contact us at (720) 490-4400.
The Community Mental Health Centers in BHI’s catchment area, Arapahoe/Douglas Mental
Health Network (ADMHN), Aurora Mental Health Center (AuMHC), and Community Reach
Center (CRC), offer many different evidence based programs to enhance recovery for our
members.
The program topics offered include many different options such as: Stress Management, Eating
Disorders, Mood Disorders, Learning, and Behavioral Problems in Preschool and School-Age
Children, and Trauma Focused-Cognitive Behavioral Therapy for children and adolescents.
Many of these programs may be accessible to your clients with a referral. Please contact BHI for
more information (720) 490-4400.
These core values guide the ongoing development of BHI’s provider network. This network
represents a comprehensive care delivery system designed specifically for Medicaid. BHI serves
as a vehicle for coordinating behavioral healthcare services among the providers and provider
organizations that serve members enrolled in the plan.
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Section VIII – Care Management
BHI provides care management services for both behavioral health services and physical health
care. Care Management promotes behavioral wellness by addressing, stabilizing, and preventing
decline in its members’ physical health. Care management encourages collaborative care
planning to improve the member’s active participation in treatment in order to facilitate recovery
and wellness. Ongoing communication and coordination of care contributes to better treatment
outcomes and improved quality of life for members.
Care management engages the member, primary care providers in both physical and behavioral
health care, specialty providers, families, and other involved stakeholders to create a partnership
designed to:
 Link members to a Primary Care Provider and/or Specialist
 Develop attainable, objective health goals
 Identify and resolve barriers to treatment goals
 Facilitate communication between members, BHI, and providers
 Assist members in navigating human service and health care systems
 Increase member skills regarding self-management of their illnesses
 Prevent further decline in the member’s health condition
BHI providers are expected to coordinate care among the various caregivers and service
providers involved with a member, and to incorporate those care coordination needs into the
individualized service plan.
For more information about the care management program, please contact the Director of
Quality Improvement & Utilization Management at (720) 490-4400.
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