Provider Enrollment Application Workshop
Provider Enrollment Application Workshop (03/12)
This presentation contains slides from the Colorado Medical Assistance Program Provider Enrollment Application Workshop. Providers are strongly encouraged to review this document either before or while completing the application.
Please check the Training & Workshops section in Provider Services for the next Provider Enrollment Application Workshop. Workshop attendance provides valuable interaction with provider field representatives and other providers regarding the provider enrollment process
Which application to complete and submit?
Enrollment applications are based on how reimbursements are reported to the Internal Revenue Service (IRS) and provider type. Some provider types must enroll using a federal Employer Identification Number (EIN) and some must enroll using a Social Security Number (SSN).
Standard Provider Application enrollment most often requires the use of an EIN , with a few exceptions for enrollment using a SSN. This is a direct pay, or billing entity, where reimbursements are reported to the IRS under the EIN. Enrollment using an EIN may require at least one association, or affiliation, with the individual that will directly render services to the Medicaid client. The direct pay entity submits claims on behalf of the rendering individual when appropriate.
Rendering Provider Application enrollment requires a SSN only. A rendering provider is the individual that provides services to a Medicaid client. In most instances, a rendering provider has the option to be either a direct pay entity or an indirect pay entity under only his/her SSN. If an individual has obtained an EIN to identify a business entity, both a rendering and a standard application may need to be completed. For instance a dentist will need to enroll once as an indirect pay, or rendering provider, using his/her SSN and as a direct pay provider using the EIN to complete the Standard Provider Application for a dental clinic.
Change of Ownership (CHOW) or Change in EIN Information for Providers
Providers must contact Provider Services prior to the effective date of the Change of Ownership (CHOW) or change in EIN. Advance notice is crucial for claim submissions regarding both the termination of the old provider number and assignment of the new provider number.
Please click on the appropriate application or provider type to access the necessary enrollment documents.
Standard Provider Application Only
|Standard or Rendering Provider Application Options
||Rendering Provider Application Only
| ♦ EIN only (except as indicated below)
♦ Billing/direct pay entity with IRS reporting.
| ♦ Individual enrollment required to provide services to Medicaid clients.
♦ SSN only
♦ Can be direct pay but not required. If direct pay, complete the Standard Provider Application.
♦ If rendering only, affiliation to a billing/direct pay entity required. Complete the Rendering Provider Application.
| ♦ SSN only
♦ Must affiliate to a billing/direct pay entity.
|Ambulatory Surgical Center||Audiologist
|Behavioral Health Organization||Certified Registered Nurse Anesthetist
|Case Manager||Dental Hygienist
|Chiropractor (SSN only)
|Community Mental Health Clinic||Nurse-Midwife
|Developmental Evaluation Clinic
|Family Planning Clinic||Orthodontist
|Federally Qualified Health Center (FQHC)
|HCBS Developmental Disabilities (EIN or SSN depending on service)
|HCBS BI/CMHS/EBD/PLWA/CHCBS/CLLI/CWA Services (EIN or SSN depending on service)
|Health Maintenance Organization
||Psychologist (PhD or MA)|
|Non-Physician Practitioner Group
|Organized Health Clinic
|Outpatient Substance Abuse
|Psychiatric Residential Treatment Facility|
|Regional Care Coordination Organization (RCCO)
|Rehabilitation Agency (CORF or Practitioner)
|Residential Child Care Facility
|Rural Health Center
|School Health Services
|Supply (EIN or SSN)
|Transportation (EIN or SSN for non-emergent, EIN for all others)
Individual Substance Abuse providers including physicians, osteopaths, nurse practitioners, and psychologists-(PhD or MA) must complete the Standard Provider Application.
Mail All Enrollment Documents to:
Xerox State Healthcare
P.O. Box 1100
Denver, CO 80201-1100
For further assistance please contact: Xerox State Healthcare Provider Services Call Center 1-800-237-0757.