For enrollment forms and information, please go to the Enrollment page.

 

Lawful Presence Verification August 2006   - This document contains additional information about complying with C.R.S. § 24-76.5-103 (verifying the lawful presence in the United States). It also contains the "REQUEST FOR WAIVER RESTRICTIONS ON PUBLIC BENEFITS" form.

 

The New Version of the Colorado Medical Assistance Provider Participation Agreement is Now Available

 

To download an application: Click on Enrollment on the left menu bar; then click on Providers not yet enrolled; select your specialty and download the July 2007 version of the Provider Participation Agreement. Effective September 1, 2007, ACS will only accept the July 2007 version of the Provider Application. All other versions of the application will be returned to the provider.

 

All Pharmacy forms, including prior authorization forms, can be found from the  Pharmacy Home Page .

 

Claim Forms

Institutional Certification  - Effective February 1, 2008, this document must be completed and attached to all institutional claims submitted on the paper UB-04.   Colorado 1500 Claim Form    This form must be completed when submitting charges that are billable on the paper Colorado 1500 claim form. By completing and signing the Colorado 1500 claim form, the provider agrees to all terms described in the Colorado 1500 Certification .   EPSDT Claim Form - This form must be completed when submitting charges that are billable on the paper EPSDT claim form. By completing and signing the EPSDT claim form, the provider agrees to all terms described in the EPSDT Certification

 

Critical Incident Reporting System Forms

The following forms are for HCBS Service Providers and SEP Agency Case Managers who experience a critical incident involving a client enrolled under the following waiver programs: Brain Injury, Children's HCBS, Children with Autism, Consumer Directed Care, Elderly, Blind and Disabled, Mental Illness and People Living with AIDS.   Provider Critical Incident Reporting Form   Critical Incident Follow-Up Form

 

Dental Forms

Dental Certification - Effective October 1, 2005, this document must be completed and attached to all dental claims submitted on paper.   Dental Assistant Surgeon Report Form  - This form must be completed and submitted with the paper claim form for all dental assistant surgery procedures.   2009 Handicapping Malocclusion Assessment Form - Complete this form and submit it with all supporting diagnostic and radiographic services used to determine and fully diagnose the client's condition. Submit all documentation and the dental claim to Colorado Medicaid.

 

DME-Supply Questionnaires

Please print the relevant questionnaire from the list below and enter all requested information. All questions must be answered in order to make a Prior Authorization Request determination. Mail the completed the form and the completed Prior Authorization Request (PAR) to Prior Authorization Request PO Box 30 Denver CO  80201-0030   Questionnaire #1 - Hospital Bed   Questionnaire #2 - Pressure Relief Mattress   Questionnaire #3 - Lift   Questionnaire #4 - Seat Lift   Questionnaire #5 - Blood Pressure Unit/Monitor   Questionnaire #6 - Pulse Oximeter   Questionnaire #7 - Apnea Monitor   Questionnaire #8 - CPAP/BiLevel (PAP)   Questionnaire #9 - TENS or NEMS   Questionnaire #10 - Oral & Enteral Nutrition Formula   Questionnaire #11 - Adult Orthotics and Prosthetics   Questionnaire #12 - Wound Closure Therapy   Questionnaire #13 - Augmentative Communication Device   Questionnaire #14 - Mechanical High Frequency Chest Wall Oscillation   Questionnaire #15 - Wheelchair Tilt/Recline Device

 

Medicaid Provider Information

 

Department of Health Care Policy and Financing Press Release / Fact Sheet

 

Sample Letter sent to Medicaid clients - Note: Clients must call HealthColorado to make their choice.

 

Continuity of Care and the Medical Home

 

PETI Forms

 

Medical Necessity Certification Form - Dental Services Criteria

 

Medical Necessity Certification Form - Eyeglasses (Corrective Lenses) Criteria

 

Medical Necessity Certification Form - Health Insurance Premiums, Deductibles, or Coinsurance Medical Criteria

 

Medical Necessity Certification Form - Hearing Aid & Other Audiology Criteria

 

Nursing Facility PETI Program Request Form

 

Nursing Facility PETI Program Appeal Information

 

Prior Authorization Request Forms

 

PAR submissions, responses and inquiries should be made through the State's Provider Web Portal. Medical, Dental, and Supply Prior Authorization (PAR) transactions to allow 25 detail lines and all miscellaneous procedure codes was implemented on November 11, 2006. An "Additional Provider Comment" field has been added to the PAR request page. Please review the online Training, User Guide, and the Help feature for additional information.

 

Colorado Medical Assistance Program Prior Authorization (PAR) Form - This form must be completed for Medical Assistance Program services requiring prior authorization. Do not use this form for Long Term Home Health, Private Duty Nursing, EPSDT Extraordinary HH PARs. Please use the Long Term Home Health, Private Duty Nursing, EPSDT Extraordinary HH Prior Authorization Request (PAR) form listed below

 

Long Term Home Health, Private Duty Nursing, EPSDT Extraordinary HH Prior Authorization Request (PAR) form

All providers submitting PARs for Long Term Home Health, Private Duty Nursing, and EPSDT Extraordinary HH must complete this form.

 

Request for HCBS Prior Approval and Cost Containment for HCBS-BI form- This document contains procedure codes, descriptions and completion instructions.  Providers should download the form as needed and begin using it immediately.

 

HCBS Cost Containment/Authorization Process Diagram

 

Diagnostic Imaging Prior Authorization Request (PAR) Form

This is the CFMC prior authorization form for non-emergent CT Scans, non-emergent MRIs, and all PET scans.   

 

REQUEST FOR ADULT HCBS PRIOR APPROVAL AND COST CONTAINMENT FOR HCBS -EBD, -MI, AND -PLWA form    This is a new Prior Approval form for adult HCBS services and contains procedure codes, descriptions and completion instructions. Providers should download the form as needed and begin using it immediately.

REQUEST FOR CHILD HCBS PRIOR APPROVAL AND COST CONTAINMENT FOR HCBS -CWA, -CHCBS, AND -PHW form - This is a new Prior Approval form for child HCBS services and contains procedure codes, descriptions and completion instructions. Providers should download the form as needed and begin using it immediately.

 

Sterilization Consent Forms

 

Consent to Sterilization - MED 178 (English)

 

Declaración Del Paciente (Spanish)

 

Update Forms

 

CLIA Update Form - Complete this form if you are a laboratory provider enrolled in the Colorado Medical Assistance Program and need to update or change your CLIA information.

 

EDI Update Form  - Complete this form if you are enrolled in the Colorado Medical Assistance Program and enrolled for the Web Portal and need to update or change your EDI information.

 

Provider Enrollment Update Form  - Follow the instructions on the form to update your provider information. 

 

PCP Forms

 

PCP (Primary Care Physician) Application  Complete this form if you would like to participate in the Primary Care Physician Program.

 

PCP Contract- Complete this form if you would like to participate in the Primary Care Physician Program. Please download, complete and mail the form(s) to:

 

ACS State Healthcare

Colorado Medical Assistance Program Provider Enrollment

P.O. Box 1100

Denver, CO 80201-1100

 

PCP Update Form - Providers with location, billing or mail-to address changes and/or PCP changes need to complete, sign and submit this form to Medical Assistance Program Provider Enrollment, PO Box 1100, Denver, CO 80201-1100.

 

Other Forms

 

Adjustment Transmittal Form  - Use this form to adjust paid claims only.

 

Add-A-Baby Form (Fill-in) - Use this form to report the birth of a child born to a Medicaid or CHP+ client via email.

 

Add-A-Baby Form  (Print and Fax) - Use this form to report the birth of a child born to a Medicaid or CHP+ client via fax or mail.

 

Certification of Oxygen Use   - This form must be used by nursing facilities to certify oxygen use for clients.

 

EFT - Authorization Agreement for Automatic Deposits form. Complete this form to receive Medical Assistance Program payment by Electronic Funds Transfer. Completion of this form is required.

 

Forms Requisition Form - Medical Assistance Program claim forms may be ordered from the fiscal agent by completing and mailing this form to the fiscal agent.

 

Out-of-State Pharmacy Letter- All out-of-state pharmacies must complete and return this letter with their Medical Assistance Program Provider Application.

 

Publications Preference Form - Providers wanting to receive electronic bulletin notification should complete and submit this form to Provider Enrollment. The form also contains information about submitting and updating electronic bulletin information through the Web Portal.  

 

Request for Reconsideration Form  - Use this form to submit claims for reconsideration when there are extenuating circumstances or mitigating factors that prevented compliance with filing requirements.  The form(s) should be attached to the front or on top of the claim(s) and any related claim information.

 

Trading Partner ID Termination - This form must be completed when requesting the termination of your Trading Partner ID. Complete and submit the form according to the instructions on the form.

 

W9- This form is required for Taxpayer Identification Number Verification.

 

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