---
title: "Health First Colorado (Colorado Medicaid) ABA coverage: the intake guide."
url: "https://carelu.com/payers/colorado-medicaid"
markdown_url: "https://carelu.com/payers/colorado-medicaid.md"
state: CO (Colorado)
payer: Health First Colorado (Colorado Medicaid)
kind: State Medicaid program
description: "How Health First Colorado covers ABA under the Pediatric Behavioral Therapies EPSDT benefit — no autism diagnosis required, the statewide FFS carve-out (RAEs don't administer ABA), Acentra/Atrezzo PARs on every code, the missing 97156, and the October 2025 rate cuts."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Health First Colorado (Colorado Medicaid) ABA coverage: the intake guide.

_Payer Guide · Health First Colorado · Last updated September 2026 · 15 primary sources_

> No autism-dx gate; FFS carve-out (RAEs don't run ABA); PAR on everything; no 97156.

Health First Colorado covers ABA for members age 20 and younger through the Pediatric Behavioral Therapies (PBT) EPSDT benefit — and it breaks the usual state-Medicaid mold twice. First, no autism diagnosis is required: the coverage criteria open the benefit on any of three pathways (a qualifying condition including but not limited to ASD, a functional interference with home/school/community life, or a safety risk), so intake should never turn a family away for lacking an ASD evaluation. Second, ABA is a statewide fee-for-service carve-out: Colorado's four Regional Accountable Entities administer the capitated behavioral health benefit, but PBT is not in that capitation — every PAR goes to the state's UM vendor Acentra, and every claim goes to the state fiscal agent, regardless of the member's RAE. The trade-off is authorization rigor: everything, including the initial assessment, is prior-authorized, and 97156 parent-training does not exist as a billable code here.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — ALL PBT services need a Prior Authorization Request (PAR) via Acentra's Atrezzo portal (ColoradoPAR.com), including the 97151 assessment [1][4]
- **Prior auth for treatment**: Required — same Acentra PAR process; approvals valid up to 6 months, reauth needs charts-and-graphs progress data [1][4]
- **Autism diagnosis required?**: NO — no autism diagnosis required; any of three criteria (qualifying condition, functional interference, or safety risk) opens the benefit [2][1]

## At a glance

- **Covers ABA?:** Yes — age 20 and younger, via EPSDT (Pediatric Behavioral Therapies benefit)
- **Autism dx required?:** NO — three qualifying pathways; ASD is one option, not a gate
- **Prior auth:** Required on ALL services incl. the 97151 assessment — PAR via Acentra (Atrezzo portal)
- **Auth period:** Up to 6 months per PAR; reauth needs charts-and-graphs progress data
- **Diagnosis recency:** Signed comprehensive diagnostic evaluation within the previous 12 months
- **Rates (DOS 10/1/2025+):** 97153 $17.20 · 97155 $25.80 per 15-min unit; 97151 flat per assessment
- **97156:** NOT COVERED — no billable parent/caregiver guidance code in Colorado
- **Staff screening:** RBT/ABAT certification is a billing condition (Section 8.281; deadline suspended — comply now) + annual background checks

## The carve-out: RAEs don't touch ABA

Under ACC Phase III (launched July 1, 2025), Colorado runs four Regional Accountable Entities — RMHP (Region 1), Northeast Health Partners (Region 2), Colorado Community Health Alliance (Region 3), and Colorado Access (Region 4) — that administer the capitated behavioral health benefit, plus the Elevate (Denver Health) physical-health MCO. PBT/ABA sits outside all of it: it is a fee-for-service EPSDT state-plan benefit, with PARs submitted to HCPF's statewide UM vendor Acentra (formerly Kepro) and claims paid by the state fiscal agent (Gainwell). Policy Memo PM 25-005 states it plainly — PBT is "reimbursed by Health First Colorado as fee-for-service." For intake, that means the member's RAE or MCO assignment is irrelevant to ABA: one PAR process, one fee schedule, one claims pipeline, statewide. Do not route ABA authorizations to a RAE, and do not expect a RAE to answer ABA UM questions. [4][7][1]

## No autism diagnosis required — the three pathways

Colorado's Criteria for Behavioral Therapies (February 2023) require only ONE of three things: (1) a diagnosed condition for which behavioral therapy is evidence-based or evidence-informed — "including" ASD, but explicitly not limited to it; (2) an inability to adequately participate in home, school, or community activities because of a behavior or skill deficit, supported by a standardized assessment of maladaptive behaviors; or (3) a safety risk to self or others — self-injury, aggression, elopement, property destruction, stereotypy. Coverage runs on EPSDT medical necessity for members age 20 and younger. This is a genuine intake differentiator: a family waiting months for a diagnostic evaluation can still qualify through the functional-interference or safety pathway. [2][3]

The recency rule that does apply: the clinical documentation must include a signed comprehensive diagnostic evaluation performed within the previous twelve months by a qualified health care professional (the client's physician, nurse practitioner, or psychologist) — a 12-month clock on the evaluation, not an autism-diagnosis mandate. The ordering/referral can come from an MD/DO, PA, NP, or Licensed Psychologist (psychologists were added to the referrer list August 12, 2024). [2][3]

## PAR mechanics: everything is prior-authorized

The PBT Billing Manual is blunt: "All PBT services must be pre-approved in a Prior Authorization Request (PAR) process" — including the 97151 assessment, which many states leave auth-free. PARs go to Acentra through the Atrezzo portal (ColoradoPAR.com) and must include the ordering practitioner's prescription or Plan of Care with a diagnosis (ICD-10 preferred), a standardized norm-referenced adaptive-behavior assessment (the state does not mandate a specific instrument — provider's choice, completed by the PBT provider), the referral, treatment history, and measurable goals; supporting assessment and progress notes must be no more than 60 days old at submission. Approved PARs run up to six months, so reauthorization is a twice-a-year event: each new PAR needs documented meaningful, measurable, functional improvement "confirmed through data, documented in charts and graphs, durable over time," plus a signed revised treatment plan showing generalization outside the treatment setting. Documentation must meet CASP minimum requirements, and denials have four paths — PAR Reconsideration (second review by a different physician), a new PAR with added information, peer-to-peer, or member appeal to the Office of Administrative Courts. [1][4]

PM 25-005 (effective April 15, 2025) added operational teeth worth designing intake around: Health First Colorado will no longer cover 40 hours/week of clinic-based PBT when the child has access to school hours, unless the district shows the child can't be served in a classroom — school IEP hour counts must be submitted with EPSDT requests, so capture the school picture at intake. Credential floors are explicit: RBT minimum for 97153, BCBA (or equivalent) minimum for 97155, and all PBT providers had to re-enroll as Provider Type 83 (clinic) or 84 (individual) by September 1, 2025. EVV (Electronic Visit Verification) is mandatory for PBT delivered in home or community settings — an operational burden many states don't impose on ABA — and the memo warns of recoupment on documentation failures (nap time and other-provider co-treatment time are not billable). [1][4]

## Rates: a flat assessment, a missing code, and a mid-year cut

Colorado's fee schedule has three quirks intake and billing must both know. First, 97151 pays a FLAT amount per assessment — $882.78 on the July 2025 schedule, billable once per 365 days — rather than per 15-minute unit (97151-TJ pays $40.24/unit, set at 2 units per 365 days). Second, 97156 does not exist here: the family adaptive behavior treatment guidance code is absent from the PBT allowable-code table (97151, 97151-TJ, 97153, 97154, 97155, 97158 only) and has no rate — caregiver training is instead a required element woven into the treatment plan, not separately billable revenue. Third, rates were cut mid-year: Special Provider Bulletin B2500528 (September 2025, under Executive Order D 2025 014's budget shortfall) reduced PBT rates for dates of service on or after October 1, 2025 — 97153 $18.17 → $17.20 and 97155 $26.62 → $25.80 per 15-minute unit, with the group codes hit hardest: 97154 $11.51 → $8.81 (-23%) and 97158 $17.83 → $9.34 (-48%). There are no credential-tier modifiers — a single rate per code (TJ modifier only on 97151). As of this review, no restoration has landed: HCPF's July 1, 2026 fee schedule carries the identical post-cut PBT rates, unchanged from January and April 2026 — and while a new 2.0% across-the-board Health First Colorado rate cut took effect July 1, 2026 under HB 26-1410's FY2026-27 budget, HCPF's own provider-news page confirms Pediatric Behavioral Therapy is explicitly exempted from that additional cut. Build revenue models on the post-October-2025 numbers, and treat group-based service lines with caution. [5][6][1][13][14]

## Staffing & credentialing: who you can hire, and what they must clear

Colorado turned technician credentialing into a billing condition in late 2025. Emergency rule MSB 25-09-04-A created Section 8.281 (emergency effective October 10, 2025; finally adopted December 12, 2025) after federal audit findings that uncredentialed technicians had been reimbursed — preliminary estimates put the potential repayment to CMS as high as $59 million. The rule requires billing providers to ensure every technician they supervise holds an active credential: an RBT (high school diploma, 40-hour BACB-specification training, passed competency exam, ongoing supervision per BACB requirements) or the QABA alternative, an ABAT (age 18+, high school diploma, 40 hours of approved coursework plus 15+ supervised hours, a 5% quarterly supervision requirement, passed competency exam). One honesty note on timing: the compliance deadline is currently suspended — HCPF's December 22, 2025 notice withdrew the December 12 deadline (which had itself replaced August 31) and promised a new date, while urging providers to reach full compliance now. Colorado has no state registry or license for technicians, so the requirement rides directly on the national certifications — and the BACB's own application already requires a criminal background check plus an abuse-registry check within 180 days of applying (the BACB does not require fingerprinting). For hiring pipelines, HB26-1425 (signed June 2, 2026) adds a one-time 45-day pre-certification billing window: Medicaid must reimburse for a not-yet-certified technician for at least 45 days while certification is pursued, but only after the tech clears a name-based judicial record check, completes all certification training, and completes abuse-and-neglect reporting training — the 45-day clock starts when those are done, the agency must submit quarterly technician rosters, and reimbursement requests must stop if certification isn't in hand by day 45. The law also protects titles: only techs holding a current, valid credential may be called "Registered Behavior Technician." [8][9][10][11][12]

Background screening now runs on three layers. Agency layer: Section 8.281.4 requires billing providers to complete ANNUAL background checks on every service provider they supervise — an ongoing employer obligation, not a hire-once event. Enrollment layer: HCPF's standard 42 CFR 455.434 screening imposes fingerprint-based checks on provider types designated high categorical risk and on any person with a 5%+ ownership or control interest in such a provider (the CY2026 federal institutional application fee is $750) — HCPF doesn't publish the risk category assigned to PBT Provider Types 83/84, so confirm whether enrollment-level fingerprinting applies with provider enrollment directly. Facility layer, center-based programs only: HB26-1425 makes ABA clinics CDHS-licensed day treatment facilities — license applications are due on or before August 1, 2026, and operating unlicensed becomes illegal August 1, 2027 — and the CDHS regime requires fingerprint-based CBI-plus-FBI checks on every applicant, owner, employee, newly hired employee, licensee, and adult 18+ residing in the clinic, screened against the C.R.S. 26-6-905(8) disqualifying offenses, plus a TRAILS check for confirmed child abuse or neglect findings; every new hire triggers a fresh investigation (with a portability exception for commonly owned clinics on a central records system). ABA delivered in homes, schools, or community settings is exempt from clinic licensure (C.R.S. 26-6-904(1)(e)), so this regime binds center-based operations only. [8][9][10][11][12]

On the supervisor side, Colorado has no behavior analyst license in force today — Medicaid qualifies billing providers through the Behavioral Therapy Provider Attestation (rev. September 2025), whose four tiers run from licensed doctoral clinicians down to BCBA/QASP certification, and Section 8.281.4 requires an approved attestation plus a clean record (no sanctions or discipline from the applicable licensing board or credentialing body), with asynchronous supervision explicitly non-covered. Under HB26-1425's Medicaid provisions, a reimbursable RBT must work under the supervision of a licensed psychologist, BCBA, BCBA-D, or BCaBA, and Section 8.281 imports the BACB floor — supervision on a minimum of 5% of service hours each calendar month — as a Medicaid condition. The licensure horizon: on July 1, 2028, mandatory state licensure arrives under a new Colorado Behavior Analyst Licensing Board in DORA — Licensed Behavior Analysts (BCBA, BCBA-D, or QBA certification plus a fingerprint-based CBI/FBI check at the applicant's cost) and Licensed Assistant Behavior Analysts (BCaBA or QASP-S, practicing only under LBA supervision) — with unlicensed practice a class 2 misdemeanor. The supervision ratio is left to board rulemaking (no numeric caseload cap in statute yet), so build the 2028 conversion into your credentialing roadmap now. [8][9][10][11][12]

## Intake gates

The questions that decide whether a family can start with Health First Colorado (Colorado Medicaid), and what they have to bring.

- **Age limit**: Age 20 and younger. The Pediatric Behavioral Therapies benefit is available to members who "are 20 years old and younger" and meet EPSDT medical-necessity criteria; Section 8.281.3.A sets the same line as "under the age of 21." There is no lower bound — children under three qualify on being "at risk for delay" from biological or environmental factors, without a named diagnosed condition. [1][8]
- **Diagnosis recency**: Twelve months, on the evaluation rather than on a diagnosis. The clinical documentation must include "a signed comprehensive diagnostic evaluation performed within the previous twelve (12) months by a qualified health care professional... who prescribes and/or recommends behavioral therapy services," together with the name, date and significant results of the completed and signed screening questionnaire. Separately, any assessment or progress notes submitted with a PAR "must not be more than 60 days prior to submission of PAR request." [2][1]
- **Who may diagnose**: No autism diagnosis is required at all — the benefit opens on any one of three pathways (a diagnosed condition for which behavioral therapy is evidence-based or evidence-informed, "including autism spectrum disorder"; inability to adequately participate in home, school or community activities; or a safety risk to self or others). Where an evaluation is performed, the Criteria name "a qualified health care professional such as the client's physician, nurse practitioner, or psychologist," and Section 8.281.2.E adds that a diagnostic evaluation "may be performed by a psychologist, developmental pediatrician, neurologist, or other credentialed clinician." [2][8]
- **Diagnostic tools required**: No single instrument is mandated, but the rule names the expected ones: standardized diagnostic tools "such as the Autism Diagnostic Observation Schedule (ADOS-2), Autism Diagnostic Interview-Revised (ADI-R)"; developmental, cognitive and adaptive functioning measures "(e.g., Vineland, cognitive/IQ testing)"; and a review of medical, educational and psychosocial history. The functional-interference pathway additionally requires "a standardized assessment of maladaptive behaviors," and the PAR requires a standardized norm-referenced adaptive-behavior assessment completed by the PBT provider — instrument choice is the provider's. [8][2][1]
- **Referral required?**: Required, and from a short list. "All Outpatient therapy services must have a written order/prescription/referral by any of the following: Physician (M.D. or D.O.); Physician Assistant; Nurse Practitioner; Licensed Psychologist" — Licensed Psychologist was added 8/12/2024 to align with the criteria and the federal ordering/prescribing/referring rules. The PAR must include the "legibly written and signed ordering practitioner prescription or approved Plan of Care" carrying the diagnosis (preferably ICD-10), reason for therapy, sessions per week, total duration, treatment history, measurable goals and medical-necessity documentation; and the claim must carry a valid OPR NPI in CMS-1500 field 17b, per 42 CFR § 455.440. [1]
- **Telehealth**: Covered, on any modality. "Pediatric Behavioral Therapists are covered under the telemedicine policy," and "Home Health Agency services and therapies, Hospice, and Pediatric Behavioral Treatment may be provided via any telemedicine modality" — unlike outpatient PT/OT/speech, which must have interactive audio-visual. Every PBT code is on the allowable-telemedicine list: 97151, 97153, 97154, 97155 and 97158. POS 02 is on the PBT allowed-place-of-service table and the telemedicine manual directs POS 02 or 10. Two conditions travel with it: "the use of telecommunications equipment for delivery of services does not change prior authorization requirements," and before the first telemedicine treatment the provider must furnish the member (or legal representative) signed written disclosure statements, after which the initial face-to-face requirement may be waived. [1][15]
- **Prior-auth decision time**: Health First Colorado (Acentra, ColoradoPAR): since January 2026 the standard PAR turnaround is seven (7) calendar days and expedited PARs are decided within three (3) calendar days — "PARs submitted as Expedited: no pends or requests for information will be allowed," so the expedited file must be complete at submission. On standard PARs, pends for additional information were cut "from 10 business days to seven (7) calendar days," only one pend is allowed ("all information requested in the initial pend must be supplied, or the PAR will result in a technical denial"), and "All PARs, including pends, must be processed within 21 calendar days of initial submission." For renewals: PARs are approved "for up to a six (6)-month period," every PBT service (97151 assessment included) must be approved "prior to rendering the services," and assessment or progress notes must be no more than 60 days old when the PAR is submitted — so build the next PAR inside that 60-day window and before the current one ends. [16][1][17]
- **Other insurance (who pays first)**: Health First Colorado pays last: it "is called the payer of last resort because Federal regulations require that all available health insurance benefits be used before Health First Colorado considers payment," and "claims for members with health insurance resources are denied when the claim does not show insurance payment or denial information." Report the TPL payment or denial and the TPL EOB date on each claim (the EOB itself need not be attached every time); keep the commercial EOBs for seven years. A member with commercial managed-care coverage "must obtain MCO benefit services from the MCO" (the manual: "Health First Colorado claims for members who have commercial managed care coverage are denied"), so work inside the commercial plan's network and rules; and invalid primary denials ("No denial reason identified," "Duplicate claim," "Insufficient information for processing," "Claim in process") do not open the Medicaid claim. When a commercial benefit limit is exhausted, claims beyond it still go to the TPL first. The PAR is still needed: "Approval of a PAR does not guarantee Health First Colorado payment" and payment also requires "third party resources payment pursued" — the PBT manual gives no exemption from the PAR when Medicaid is secondary. Unreported coverage found later leads to retraction of paid claims. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid. [18][1][19][20][21]

## Delivery and billing rules

Coverage decides whether Health First Colorado (Colorado Medicaid) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Three layers, and one of them is a number. Code-level: "A Registered Behavior Technician (RBT) is the minimum qualification required to administer ABA services... under CPT code 97153," and "a Board-Certified Behavior Analyst (BCBA), or equivalent, is the minimum qualification required to administer services under CPT code 97155." Rule-level: Section 8.281.4.A.6 requires billing providers to ensure RBTs "receive ongoing supervision per the requirements of the BACB" and that ABATs "adhere to a 5% quarterly supervision requirement," plus annual background checks on every service provider they supervise and no sanctions from the applicable board. Exclusion-level: "asynchronous supervision or reviews" are expressly non-covered, as are "services not delivered or supervised by a qualified provider." [4][8]
- **Daily limits / MUEs**: Colorado's published ceilings are per-year, not per-day. "Code 97151 is a flat rate, and one (1) unit is to be billed once every 365 days. Code 97151TJ is set at two (2) units that can be billed once every 365 days." Section 8.281.6 limits initial pediatric therapy assessments and periodic reassessments to one session per provider every 12 calendar months each, with additional sessions only where the Department authorises them as medically necessary. No per-day unit ceiling is published for 97153 or 97155 — the operative ceilings are the units approved on the PAR and PM 25-005's rule that 40 hours a week of clinic-based PBT is no longer covered when the child has access to school hours unless the district shows the child cannot be served in a classroom. [4][8]
- **Session-note signature**: The service provider signs, personally, before the claim goes out. "Each entry in a medical record must be signed and dated by the individual providing the service or good. Stamped signatures are not acceptable. Printed or displayed electronic records must note that signatures and dates have been applied electronically (10 CCR 2505-10 § 8.130.2.G)," and "providers are required to ensure that all required signatures are obtained before any claims are submitted for payment." Session notes "are required to contain detailed descriptions of therapy sessions... basic patient information, a narrative summary of the treatment provided, and a detailed summary of behavior targets, intervention types, and other relevant data," and ABA documentation must meet CASP minimum requirements. On the claim form itself, initials, typed or computer-printed names and "signature on file" are all unacceptable in field 31. [4][1]
- **Place of service**: Five POS codes are allowed: 02 telemedicine, 03 school, 11 office, 12 home and 99 other/community-based (the rule permits a "Community" location and 99 is the closest code). EVV is mandatory for PBT delivered in the home or the community, capturing member ID, the individual providing the service, start and end times, the service, the date and the location. School is payable — POS 03 has been allowed for all fee-for-service benefits since May 3, 2024, and PM 25-005 confirms "Health First Colorado covers medically necessary PBT services in a school setting" — but community providers must follow school-district policy, and therapies provided under a member's IEP and billed to the School Health Services Program "are not separately reimbursable." Section 8.281.5.B adds the clinical test: services "must be delivered in a clinically appropriate setting for the behavior being treated." One tension worth knowing before a PAR: the February 2023 Criteria's exclusion list still names "school-based services" among non-covered items. [1][4][8][2]
- **Bill as provider**: Both NPIs, and the enrollment has to match. "PBT services must be billed using the 837 Professional (837P) transaction or CMS 1500 form, which requires using rendering and billing National Provider IDs (NPIs)." Organisations with a Tax ID enrol as Provider Type 83 (Behavioral Therapy Clinic); the individuals who may affiliate to it are Provider Type 37 (doctoral psychologist), 38 (licensed behavioral health clinician) and 84 (behavioral therapist), and all three must be affiliated with the Type 83. Providers formerly enrolled as Type 24/25 had to convert by September 1, 2025. The ordering practitioner's OPR NPI goes in field 17b, and field 32 carries the service facility. [1][4]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Colorado publishes no rule on billing 97153 and 97155 for the same clock time. What it does publish is cross-discipline co-treatment: co-treatment between two outpatient therapists is covered only where "a valid clinical rationale for providing co-treatment must be present" and "each provider must have an approved plan of care which includes co-treatment," with notes describing the additional services, identifying the co-treatment providers and justifying the arrangement. The hard edge is the billing rule: "time while members are napping is not covered or billable time. Time while the other modality is treating is also not billable," and claims for either are subject to recoupment. The billing manual's co-treatment matrix says the same thing from the other side — "providers will only bill for the time interacting with the member, and not the total time in the room." [4][1]
  - Ask the plan: ColoradoPAR (Acentra/Atrezzo) and the HCPF PBT policy contact named on PM 25-005 — ask specifically whether 97155 is payable alongside 97153 when the analyst is directing the technician with the member present.

## What intake should collect for Health First Colorado (Colorado Medicaid)

- **Which of the three pathways applies:** ASD diagnosis, functional interference (with a standardized assessment), or safety risk — no autism dx needed, so screen for all three instead of gating on diagnosis.
- **Comprehensive evaluation within 12 months:** A signed diagnostic evaluation by the child's physician, NP, or psychologist — the 12-month recency clock is the real document gate.
- **Referral source:** MD/DO, PA, NP, or Licensed Psychologist — the prescription/Plan of Care anchors the PAR.
- **School enrollment and IEP hours:** PM 25-005 requires school hour counts with EPSDT requests; 40 hrs/week clinic-based PBT won't be approved when school is available.
- **Home/community service settings:** EVV is mandatory outside the clinic — capture where sessions will happen so operations can stand up visit verification.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Health First Colorado (Colorado Medicaid) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00071
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none — ABA/PBT is a statewide FFS carve-out; RAEs do not administer or pay ABA. Claims go to the state fiscal agent (Gainwell) on the medical FFS line.
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No
- **Where the 271 carries MCO enrollment:** Managed-care (ACC/RAE) enrollment is carried in Subscriber loop 2110C/MSG (pipe-delimited qualifier/value pairs — MCSTARTRSN$XX = Managed-Care Start Reason code+description, MCD$XXXXXXXX = the related entity's Colorado Medicaid ID) plus related-entity loop 2120C (entity NPI in 2120C/NM109, name in NM1). "ACC" = Accountable Care Collaborative (Colorado's RAE program; the v2.2 guide does not use the literal term "RAE").
- **Eligibility span granularity:** Real-time / near-real-time (271 returned "within 30 minutes or less") and batch; the response is keyed to the date span requested in the 270 (no explicit monthly-vs-daily span rule is stated in the guide). CRITICAL: the 271 carries NO ABA/PBT/benefit-level carve-out flag — a member's RAE (ACC) attribution is visible, but ABA's FFS carve-out is NOT derivable from the 271. It must be applied from benefit policy: all PARs go to Acentra and claims to Gainwell FFS regardless of the RAE shown.

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — ALL PBT services need a Prior Authorization Request (PAR) via Acentra (Atrezzo / ColoradoPAR.com); approvals valid up to 6 months, reauth needs charts-and-graphs progress data. | Flat per assessment (billed once per 365 days); the 97151-TJ per-15-min variant is capped at 2 units per 365 days per 365 days | home, clinic, school, community, telehealth (modality; POS numbers not published in retrievable sources) | — | TJ (97151 per-15-min variant only), No credential-tier modifiers — single rate per code |
| 97152 | No — not on the Colorado PBT allowable-code table | N/A | N/A per N/A | — | N/A | — |
| 97153 | Yes | Required — ALL PBT services need a Prior Authorization Request (PAR) via Acentra (Atrezzo / ColoradoPAR.com); approvals valid up to 6 months, reauth needs charts-and-graphs progress data. | Per approved PAR (up to a 6-month authorization period) per per PAR (up to 6 months) | home, clinic, school, community, telehealth (modality; POS numbers not published in retrievable sources) | — | TJ (97151 per-15-min variant only), No credential-tier modifiers — single rate per code |
| 97154 | Yes | Required — ALL PBT services need a Prior Authorization Request (PAR) via Acentra (Atrezzo / ColoradoPAR.com); approvals valid up to 6 months, reauth needs charts-and-graphs progress data. | Per approved PAR (up to a 6-month authorization period) per per PAR (up to 6 months) | home, clinic, school, community, telehealth (modality; POS numbers not published in retrievable sources) | — | TJ (97151 per-15-min variant only), No credential-tier modifiers — single rate per code |
| 97155 | Yes | Required — ALL PBT services need a Prior Authorization Request (PAR) via Acentra (Atrezzo / ColoradoPAR.com); approvals valid up to 6 months, reauth needs charts-and-graphs progress data. | Per approved PAR (up to a 6-month authorization period) per per PAR (up to 6 months) | home, clinic, school, community, telehealth (modality; POS numbers not published in retrievable sources) | — | TJ (97151 per-15-min variant only), No credential-tier modifiers — single rate per code |
| 97156 | No — not on the Colorado PBT allowable-code table | N/A | N/A per N/A | — | N/A | — |
| 97157 | No — not on the Colorado PBT allowable-code table | N/A | N/A per N/A | — | N/A | — |
| 97158 | Yes | Required — ALL PBT services need a Prior Authorization Request (PAR) via Acentra (Atrezzo / ColoradoPAR.com); approvals valid up to 6 months, reauth needs charts-and-graphs progress data. | Per approved PAR (up to a 6-month authorization period) per per PAR (up to 6 months) | home, clinic, school, community, telehealth (modality; POS numbers not published in retrievable sources) | — | TJ (97151 per-15-min variant only), No credential-tier modifiers — single rate per code |
| 0362T | No — not on the Colorado PBT allowable-code table | N/A | N/A per N/A | — | N/A | — |
| 0373T | No — not on the Colorado PBT allowable-code table | N/A | N/A per N/A | — | N/A | — |

Code notes:

- **97151:** Behavior-identification assessment. Pays a FLAT amount per assessment ($866.88 for DOS on/after 10/1/2025, down from $882.78 on the 7/1/2025 schedule — see rates), NOT per 15-min unit, once per 365 days; the 97151-TJ modifier variant pays per 15-min unit (2 units/365 days). PAR required despite being an assessment — unlike many states.
- **97152:** Not on the Colorado PBT allowable-code table — CONFIRMED absent from two fetched primary sources this pass: the PBT Billing Manual's "Allowable Procedure Coding" table (97153, 97154, 97155, 97158, 97151, 97151-TJ verbatim) and the FY25-26 v1.4 fee schedule (order jumps 97151 -> 97153). Colorado uses only the professional 97151 assessment.
- **97153:** Technician-delivered direct treatment — RBT/ABAT certification is a billing condition (minimum credential for 97153). Per-15-min unit rate cut for DOS on/after 10/1/2025 (see rates).
- **97154:** Group adaptive behavior treatment. Rate cut hardest in Bulletin B2500528 ($11.51 -> $8.81, -23%, DOS on/after 10/1/2025) — treat group service lines with caution (see rates).
- **97155:** Protocol modification — BCBA (or equivalent) minimum credential. Per-15-min unit rate cut for DOS on/after 10/1/2025 (see rates).
- **97156:** NOT COVERED in Colorado — 97156 (family/caregiver adaptive-behavior guidance) is absent from the PBT allowable-code table and has no rate. Caregiver training is a required element woven into the treatment plan, not separately billable revenue. This is a Colorado-specific intake fact worth surfacing before a family expects parent-training billing.
- **97157, 0373T:** Not on the Colorado PBT allowable-code table — confirmed absent from the PBT Billing Manual allowable-coding table and the v1.4 fee schedule.
- **97158:** Group adaptive behavior treatment with protocol modification. Rate cut hardest of all in Bulletin B2500528 ($17.83 -> $9.34, -48%, DOS on/after 10/1/2025) — see rates.
- **0362T:** Not on the Colorado PBT allowable-code table (Colorado bills the Category-I CPT set, not the legacy Category-III codes) — confirmed absent from the PBT Billing Manual allowable-coding table and the v1.4 fee schedule.

### Medicaid rates

Source: FY2025-26 Health First Colorado Fee Schedule (July 2025 v1.4) + Special Provider Bulletins B2500528 & B2500530 (rate reductions eff. 10/1/2025) — all retrieved via Wayback archive this pass (live hcpf.colorado.gov 403s). Single flat statewide rate per code, no credential-tier modifiers (TJ modifier only on 97151). WATCHLIST (IMPORTANT): the FY25-26 1.6% increase was REPEALED effective 10/1/2025 (these cuts stand — NOT restored), and a further across-the-board -2.0% reduction PLUS a "reset of pediatric behavioral rates" is approved effective 7/1/2026 (FY2026-27, HB26-1410). As of 2026-07-23 the current DOS-on/after-7/1/2026 rates are therefore likely BELOW the figures below, but the 7/1/2026 fee schedule could not be located this pass (no archived copy) — treat the values here as the last CONFIRMED (10/1/2025) set and re-pull 01_CO_Fee Schedule 07012026. Effective 2025-10-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $866.88 flat per assessment (DOS on/after 10/1/2025; = 32 units x $27.09/unit at an 8-hr increment) — was $882.78 on the 7/1/2025 schedule; once per 365 days (frequency per the PBT Billing Manual PAR section) | per assessment | — |
| 97153 | $17.20 per 15-min unit (cut from $18.17, DOS on/after 10/1/2025) | 15min | — |
| 97154 | $8.81 per 15-min unit (cut from $11.51, -23%, DOS on/after 10/1/2025) | 15min | — |
| 97155 | $25.80 per 15-min unit (cut from $26.62, DOS on/after 10/1/2025) | 15min | — |
| 97158 | $9.34 per 15-min unit (cut from $17.83, -48%, DOS on/after 10/1/2025) | 15min | — |
| 97151-TJ | $40.24 per 15-min unit (2 units per 365 days; not reduced in the 10/1/2025 bulletins) | 15min | — |

### Contacts

- **Provider services phone:** (720) 689-6340 — Acentra Customer Service Line (ColoradoPAR UM/PAR questions, which includes PBT/ABA)
- **Portal:** [Atrezzo (Acentra provider portal, via ColoradoPAR.com)](https://coloradopar.com)
- **Fax:** (800) 922-3508 — Acentra Provider Fax Line (toll-free)

Questions to ask on a verification call:

- Will telehealth be authorized for this child's PBT services, and if so what POS setting and modifier should we bill?
- What per-PAR unit or hour caps did this member's approved authorization set for 97153, 97154, 97155, and 97158?
- Are the rates you're quoting the post-10/1/2025 fee schedule, or has the 7/1/2026 rate reset under HB26-1410 already taken effect for this date of service?
- Does this practice's EDI setup return eligibility in real time, or should we expect the batch turnaround the companion guide describes ("within 30 minutes or less")?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://web.archive.org/web/20250211050831/https://hcpf.colorado.gov/sites/hcpf/files/CO_EDI_v5010%20X12_270_271_CompanionGuide%20-%2003062024.pdf (accessed 2026-07-23)
- https://hcpf.colorado.gov/sites/hcpf/files/HCPF%20PM%2025-005%20Pediatric%20Behavioral%20Therapy%20Policy%20Clarification.pdf (accessed 2026-07-23)
- https://web.archive.org/web/20250807084124/https://hcpf.colorado.gov/pbt-manual (accessed 2026-07-23)
- https://web.archive.org/web/20260123111147id_/https://hcpf.colorado.gov/sites/hcpf/files/01_CO_Fee%20Schedule_Health%20First%20Colorado_07012025%20v1.4.pdf (accessed 2026-07-23; source document older than 18 months)
- https://web.archive.org/web/20260217015928/https://hcpf.colorado.gov/sites/hcpf/files/Special%20Provider%20Bulletin%20-%20Rate%20Reductions%20092025_B2500528_0.pdf (accessed 2026-07-23; source document older than 18 months)
- https://web.archive.org/web/20260114194341/https://hcpf.colorado.gov/sites/hcpf/files/Health%20First%20Colorado%20Provider%20Bulletin%20B2500530.pdf (accessed 2026-07-23; source document older than 18 months)
- https://hcpf.colorado.gov/par (accessed 2026-07-23)
- https://atrezzohelp.acentra.com/help-contact/ (accessed 2026-07-23)

## Common questions

### Does Colorado Medicaid require an autism diagnosis for ABA?

No — a genuine differentiator. The Criteria for Behavioral Therapies open the Pediatric Behavioral Therapies benefit on any of three pathways: a qualifying diagnosed condition (including but not limited to ASD), functional interference with home/school/community participation, or a safety risk to self or others. A signed comprehensive evaluation within the past 12 months is still required.

### Do I submit Colorado ABA authorizations to the member's RAE?

No — PBT/ABA is a fee-for-service carve-out. Regardless of RAE region (RMHP, NHP, CCHA, or Colorado Access) or the Elevate MCO, all PARs go to the state UM vendor Acentra through the Atrezzo portal (ColoradoPAR.com), and claims go to the state fiscal agent.

### Does the ABA assessment need prior authorization in Colorado?

Yes — unlike many states, ALL PBT services must be pre-approved in a PAR, including the 97151 assessment. Approved PARs run up to 6 months, so plan for reauthorization twice a year with charts-and-graphs progress data.

### Can I bill 97156 parent training to Health First Colorado?

No — 97156 is not in the PBT allowable-code table and has no rate on the fee schedule. Caregiver training is a required element of the treatment plan, not a separately billable service.

### What does Colorado Medicaid pay for ABA?

For dates of service on or after 10/1/2025: 97153 pays $17.20 and 97155 pays $25.80 per 15-minute unit (single rate per code, no credential tiers); 97151 pays a flat amount per assessment ($882.78 on the July 2025 schedule, before the October cut), once per 365 days. Group codes 97154/97158 were cut 23-48% in the same bulletin.

## Primary sources

1. [Pediatric Behavioral Therapies Billing Manual (HCPF)](https://hcpf.colorado.gov/pbt-manual)
2. [Health First Colorado Criteria for Behavioral Therapies (Feb 2023)](https://hcpf.colorado.gov/sites/hcpf/files/Health%20First%20Colorado%20Criteria%20for%20Behavioral%20Therapies%20February%202023.pdf)
3. [Pediatric Behavioral Therapies Information for Providers (HCPF)](https://hcpf.colorado.gov/pediatric-behavioral-therapies-information-providers)
4. [HCPF PM 25-005 — Pediatric Behavioral Therapy Policy Clarification](https://hcpf.colorado.gov/sites/hcpf/files/HCPF%20PM%2025-005%20Pediatric%20Behavioral%20Therapy%20Policy%20Clarification.pdf)
5. [FY2025-26 Health First Colorado Fee Schedule (July 2025 v1.4)](https://hcpf.colorado.gov/sites/hcpf/files/01_CO_Fee%20Schedule_Health%20First%20Colorado_07012025%20v1.4.xlsx)
6. [Special Provider Bulletin B2500528 — Rate Reductions (Sep 2025)](https://hcpf.colorado.gov/sites/hcpf/files/Special%20Provider%20Bulletin%20-%20Rate%20Reductions%20092025_B2500528_0.pdf)
7. [HCPF — Accountable Care Collaborative Phase III](https://hcpf.colorado.gov/accphaseIII)
8. [HCPF Emergency Rule MSB 25-09-04-A — Section 8.281 (Oct 2025)](https://hcpf.colorado.gov/sites/hcpf/files/Doc%2009%20MSB%2025-09-04-Av1%20Emergency%20-%20Oct%202025.pdf)
9. [HCPF Compliance Update — RBT Certification Requirement (Dec 22, 2025)](https://hcpf.colorado.gov/sites/hcpf/files/Compliance%20Update%20%E2%80%93%20Registered%20Behavior%20Technician%20(RBT)%20Certification%20Requirement%20-%2012-22-2025.pdf)
10. [HB26-1425 — Applied Behavior Analysis Services (enacted bill text)](https://leg.colorado.gov/bill_files/116474/download)
11. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
12. [HCPF Provider Enrollment (fingerprint background check requirements & CY2026 fee)](https://hcpf.colorado.gov/provider-enrollment)
13. [Health First Colorado Fee Schedule (July 1, 2026 v1.1) — PBT rates unchanged](https://hcpf.colorado.gov/provider-rates-fee-schedule)
14. [HCPF Provider News — PBT exempted from the HB 26-1410 2.0% rate cut (through 7/27/2026)](https://hcpf.colorado.gov/provider-news)
15. [HCPF — Telemedicine Provider Information (allowed procedure codes, POS rules)](https://hcpf.colorado.gov/telemedicine-provider-information)
16. [Health First Colorado Provider Bulletin B2600534 (Feb 2026) — Interoperability changes beginning January 2026](https://hcpf.colorado.gov/sites/hcpf/files/Bulletin%200226_B2600534_0.pdf)
17. [42 CFR 440.230(e) — Medicaid FFS prior-authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-440.230)
18. [HCPF — General Provider Information Manual (Third-Party Liability / Coordination of Benefits)](https://hcpf.colorado.gov/gen-info-manual)
19. [42 CFR 433.139 — Medicaid third-party liability, payment of claims (eCFR)](https://www.ecfr.gov/current/title-42/section-433.139)
20. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
21. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.