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Incorrect Taxonomy Code - The NPI and taxonomy code submitted with the provider’s enrollment application must match the information on record with the National Plan and Provider Enumeration System (NPPES).
Missing or Non-Matching Attachment Information - Information on the document(s) provided as proof of licensure, certifications, insurance, or any additional required documentation must match the information provided on the application.
Legal entity information on the application must match the documents provided as proof of legal entity status. The W-9 must also be dated within six months of the enrollment application date.
Tax Identification Numbers: Social Security Number (SSN) and Federal Employer Identification Number (FEIN) - Individuals are required to use a personal SSN as a form of valid Tax ID. Facilities and groups will input a FEIN available to use as a Tax ID.
Disclosures - Business ownership information is required when completing the Disclosures section of the application.
An SSN is required for each owner when disclosing information for individual owners of the business. A secondary question, ‘Is this entity an individual?’, must be answered ‘Yes’ when disclosing information for individual owners of the business. An additional question, ‘Date of Birth’ will be populated and must be answered when disclosing information for individual owners of the business.
If there is no ownership of 5%, board of directors may be used.
New applications are currently being processed by DXC within 5 business days on average. Enrollment updates are currently processed within 2-3 business days.
Enrollment updates for legal name changes for Taxpayer Identification Number (TIN) matching may take an additional 2-3 business days.
Providers with any of the following individual types may only have one application associated to a Social Security Number (SSN), even if they provide services in multiple locations: Billing Individual (BI); Individual within a Group (IWG); Ordering, Prescribing and Referring (OPR) providers. An additional application for any of these individual types with the same SSN and same National Provider Identifier (NPI) as a previous application (regardless of whether the individual type is the same as on the previous application) may result in the application being denied as a duplicate or denied claims. Individuals may affiliate with multiple groups in different locations.
If a provider wants to change enrollment type, a request should be submitted by calling the Provider Services Call Center (1-844-235-2387).
If the license on the original application is expired, the provider should submit a current license through the Provider Web Portal. Refer to the Provider Maintenance – License Update Provider Web Portal Quick Guide for more information.
Enrollment Type Changes
Ordering, Prescribing, and Referring (OPR) to Individual within a Group (IWG)
Before the enrollment type can be updated from OPR to IWG, providers must update their license. If only a training license is on file, then the provider must submit a current, full license through the Provider Web Portal. Providers may affiliate via the group profile of the portal or they can wait until after the enrollment type change is made. Providers cannot affiliate with an OPR enrollment type.
Individual within a Group (IWG) to a Billing Individual (BI)
Before the enrollment type can be updated from IWG to BI, providers must submit an EFT update including a W9 with the SSN listed and a lawful presence document.
Provider Type Changes
The provider type (e.g. Physical Therapist, Podiatrist, Psychologist) cannot be changed.
If an enrolled individual with an SSN wants to change provider types, the existing enrollment needs to be disenrolled and the affiliations need to be ended, and a new application needs to be completed. Providers may not be enrolled as two different provider types under the same SSN.
Need to speak to a live agent for help with your enrollment? Please call the Provider Services Call Center at 1-844-235-2387, then select option 2 and then option 5.
All providers, medical or nonmedical, who are enrolled with and bill Medicaid for services under the state plan or a waiver must be screened under this rule by enrolling. In addition, providers that provide services through Managed Care Organizations (MCOs), including Child Health Plans Plus (CHP+) and Regional Accountable Entities (RAEs), need to enroll as well. This is necessary because the validity and currency of all provider licenses to perform any service must be screened.
Federal regulations established by the Centers for Medicare and Medicaid Services (CMS) require enhanced screening for all existing (and newly enrolling) providers. These regulations are designed to increase compliance and quality of care, and to reduce fraud.
The Affordable Care Act (ACA) requires physicians and other eligible practitioners to enroll in Health First Colorado to order, prescribe and refer items or services for Health First Colorado members, even when they do not submit claims to Health First Colorado.
Physicians, other practitioners and facilities who render services to Health First Colorado members based on the order, prescription or referral of an OPR provider will not be paid for such items or services unless the OPR provider is enrolled in Health First Colorado and the National Provider Identifier (NPI) number is included on the claim submitted to Health First Colorado.