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Enrollment

Provider Enrollment Application Tutorial 
Please click here for the Provider Enrollment Application Tutorial.  Refer to the applications below.
 

Provider Enrollment Application Workshop
Provider Enrollment Application Workshop (04/14)
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.
 

Out of State Provider Enrollment and Claims Submission
Answers to frequently asked questions about out of state provider enrollment and claims submission.


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. The rendering provider will affiliate with a clinic/facility that will submit claims and provide reimbursement to the individual. 

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 a rendering provider (using the SSN) to provide services to the client, and as a dental clinic (using the EIN) to complete the Standard Provider Application to submit claims.

 


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.


Ownership/Controlling Interest and Conviction Disclosure Completion Instructions for Enrollment using an SSN 

Ownership/Controlling Interest and Conviction Disclosure Completion Instructions for Enrollment using a Federal EIN
 

Please click on the appropriate application or provider type to access the necessary enrollment documents. 
 

All documents are in the Adobe Acrobat PDF format. You can download the free Adobe® Reader® by clicking on the link at the bottom of this page.

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

Physician Assistant

Behavioral Health Organization

Certified Registered Nurse Anesthetist

Registered Nurse

Case Manager

Dental Hygienist

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Chiropractor (SSN only) 

Dentist

Community Mental Health Clinic

Nurse-Midwife

Dental Clinic

Nurse Practitioner

Developmental Evaluation Clinic

Occupational Therapist

Dialysis Center

Optometrist

Family Planning Clinic

Orthodontist

Federally Qualified Health Center (FQHC)

Osteopath

HCBS Developmental Disabilities (EIN or SSN depending on service)

Physical Therapist

HCBS BI/CMHS/EBD/PLWA/CHCBS/CLLI/CWA Services (EIN or SSN depending on service)

Physician

Health Maintenance Organization

Podiatrist

Home Health

Psychologist (PhD or MA)

Hospice

Speech Therapist

Hospital (General or Mental) 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Independent Laboratory

Non-Physician Practitioner Group

Nursing Facility

Optician/Optical Outlet

Organized Health Clinic

Outpatient Substance Use Disorder

Pharmacy

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)

X-Ray Facility


NOTE:
Individual Substance Use Disorder providers including physicians, nurse practitioners, and psychologists-(PhD or MA) must complete the Standard Provider Application.

Mail All Enrollment Documents to:
Xerox State Healthcare
Provider Enrollment
P.O. Box 1100
Denver, CO 80201-1100
 

For further assistance please contact: Xerox State Healthcare Provider Services Call Center 1-800-237-0757.
 

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