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Call the Provider Services Call Center at 1 (844) 235-2387 (toll-free) for information related to AR balances. Hours of operation are Monday, Tuesday, and Thursday from 7:00 a.m. to 5:00 p.m. MST as well as Wednesday and Friday from 10 a.m. to 5 p.m. MST
There are several reasons that an AR balance may be created:
Allow 30 days for processing.
If the AR balance remains after that period, please call the Provider Services Call Center at 1 (844) 235-2387 and provide the following information to expedite the request:
Checks for payment should be made out to Colorado Department of Health Care Policy and Financing and mailed to:
P.O. Box 30
Denver, CO 80201
However, we highly recommend submitting electronically as we will automatically set up an AR balance.
All information can be updated on an existing profile in the Provider Web Portal. There is a Provider Maintenance Quick Guide on the website that can help you understand what can and cannot be changed in the Provider Portal. The only information you cannot change in the Provider Web Portal is a different Tax ID or provider type, these require a new application.
If your billing enrollment is filed with the wrong provider type, you will need to re-enroll. Most other information can be updated.
If you have any issues or questions, call the Provider Services Call Center (1-844-235-2387).
An enrollment type is one way the Department categorizes providers. You can find your enrollment type here.
Once your enrollment/revalidation application is approved, you can begin billing. The financial cycles run every Friday, and the following Thursday is when the provider is paid for properly billed claims. The first check will likely be paper.
As a reminder, you will only be paid for claims that are properly billed.
The following questions and answers are designed to help all providers with common problems that often occur when billing the Colorado Medical Assistance Program.
Please call the Provider Services Call Center at 1 (844) 235-2387 for the following:
The Provider Services Call Center is available Monday, Tuesday, and Thursday from 7:00 a.m. to 5:00 p.m. MST as well as Wednesday and Friday from 10 a.m. to 5 p.m. MST.
Allow 30 days for the Colorado Medical Assistance Program to process the crossover claim. If automatic crossover does not appear on the Colorado Medical Assistance Program RA within 30 days of the Medicare processing date, it is the provider's responsibility to submit crossover claims electronically or on paper.
If the crossover claim is submitted on paper, a copy of the Medicare Standard Paper Remit (SPR) must be attached. Be sure to retain the original SPR for audit purposes.
Retain member records for at least six years, or longer if required by regulation or a specific contract between the provider and the Colorado Medical Assistance Program.
Records must fully disclose the nature and the extent of services provided and substantiate submitted claim information. Upon request, information about payments claimed for Colorado Medical Assistance Program services must be furnished.
Providers must bill their usual and customary charge to the Colorado Medical Assistance Program. The TOTAL CHARGES are the provider's usual and customary charges.
The NET CHARGE (TOTAL CHARGES less THIRD PARTY PAID) is the payment actually received plus the contractual write-off amount.
If the THIRD PARTY PAID amount is less than the Colorado Medical Assistance Program allowable amount, the Colorado Medical Assistance Program will pay the difference up to the Colorado Medical Assistance Program allowable amount toward the other insurance co-pay amount.
If the THIRD PARTY PAID amount is greater than the Colorado Medical Assistance Program allowable amount, the Medical Assistance Program makes no payment.
CHP+ information may be accessed by visiting the Child Health Plan Plus (CHP+) web page.
The current fee schedule and the instructions for reading the fee schedule may be accessed by visiting the Provider Rates & Fee Schedule web page. Code information includes: procedure code, system parameter, price begin date, price end date, factor code, relative value, gender, min age, max age, post-op days, and if a PAR is required.
If the newborn and the mother are both still in the hospital, bill using the mother's Colorado Medical Assistance Program member ID along with all of the mother's information (i.e., date of birth and name).
Use the -UK modifier. The -UK modifier on the CMS 1500 paper claim form identifies the claim as belonging to the baby.
Note: The use of the mother's Colorado Medical Assistance Program member ID number and the -UK modifier only applies to charges billed on the CMS 1500 for members in the Fee-for-Service Health First Colorado. This does not apply to members covered under Health First Colorado-contracted HMOs.
If the baby is still hospitalized after the mother is discharged, or if the baby is transferred to another hospital, the baby's charges must be billed using the baby's Colorado Medical Assistance Program ID number.
The birth of babies of women on Health First Colorado need to be reported to the assigned county or Medical Assistance (MA) site case worker in the member's county of residence.
An online form provides a secure means of submitting the newborn's information to the Department. For emergent requests, the newborn's information will be added to its mother's case within two business days from its receipt. A confirmation of receipt of the form is provided through the online process.
No, Health First Colorado members cannot be billed for any service covered by Health First Colorado. More information is available in the Policy Statement: Billing Health First Colorado Members for Services.
The Department requires EFT for the following:
Providers can establish an EFT through the new Provider Web Portal. For information on setting up an EFT, please review the information in this Provider Web Portal Quick Guide.
Yes. Each time bank information changes, a new EFT document must be submitted. Processing EFT information takes about a month. While EFT information is in process, providers will receive paper checks (warrants).
If after the bank has been contacted and the deposit has not been received within seven days from the paid date, please call the Provider Services Call Center at 1 (844) 235-2387 to verify the account information on file. Please provide the following information over the phone in order to expedite the process:
Call the Provider Services Call Center at 1 (844) 235-2387 to obtain an electronic copy of an RA prior to March 1, 2017. All other RAs are posted to the Provider Web Portal.
The member's county's Department of Human/Social Services agency helps to establish member eligibility for Colorado Medical Assistance Program benefits. More information can be found on the Colorado Department of Human Services website.
A member's Colorado Medical Assistance Program eligibility may be made retroactive prior to the application date. Charges for services are the member's responsibility until eligibility is established. Claims are denied if the member's eligibility status is not available through eligibility verification methods.
Load Letters (LL) allow providers to submit claims that are outside of the timely filing period. Providers may submit requests on the LL form. Providers have 60 days from the date of the load letter to submit the claim with the attached form for review by the fiscal agent.
NOTE: The purpose of the Load Letter is to allow providers to submit claims outside of the timely filing period if the member was retroactively enrolled; however, it is not a guarantee of payment. If the member was enrolled on the date of service but failed to inform the provider of that existing coverage, the provider must obtain that information within 365 days.
For CHP+ members, please contact the HMO listed on the back of the member's medical card for a Load Letter.
The Load Letter Request form is available under Claim Forms and Attachment in the Forms section. Upon receiving the request from providers, the Department will generate a Load Letter as long as the request meets all criteria.
All Load Letter requests should be faxed to the Department at 303-866-2082 or via encrypted email to email@example.com. Use Load Letter Request as the subject. Do not use the member's State ID in the subject line.
Members with coverage by Medicare and Health First Colorado are referred to as Medicare-Medicaid enrollees. Providers are reminded that Health First Colorado is always the payer of last resort, therefore, services for Medicare-Medicaid enrollees must be billed first to Medicare. Providers must be able to show evidence that claims for members with dual eligibility, where appropriate, have been denied by Medicare prior to submission to the Colorado Medical Assistance Program. Per the Provider Participation Agreement, this evidence must be retained for six years following the Medicare denial. The Colorado Medical Assistance Program requires that the Medicare Standard Paper Remit (SPR) accompany any paper claims submitted for Medicare-Medicaid enrollees.
Please call the Provider Services Call Center at 1 (844) 235-2387 (toll-free) 7am – 5pm Monday, Tuesday & Thursday, and 10am - 5pm Wednesday and Friday (MST). with questions.
Presumptive Eligibility (PE) allows children age 18 and under and pregnant women to be enrolled in either Health First Colorado or CHP+ as presumptively eligible. Health First Colorado PE for children includes coverage of all Health First Colorado covered services. However, Health First Colorado PE for pregnant women only covers outpatient services.
Health First Colorado PE for pregnant women includes:
Health First Colorado PE for pregnant women does not include:
Health First Colorado PE for children includes full Health First Colorado benefits, and is not limited to:
The Modified Medical Program provides care for Colorado old age pensioners with limited incomes who do not qualify for the Colorado Medical Assistance Program.
Elderly and disabled Medicare beneficiaries with incomes below the federal poverty level and resources at twice the Supplemental Security Income (SSI) level are eligible for Health First Colorado payments of Medicare deductibles and coinsurance. Individuals who qualify are called Qualified Medicare Beneficiaries (QMBs).
Benefits available to non-citizens are limited to care and services necessary to treat immediate emergency conditions, including labor and delivery.
For additional information on eligibility, please see the Health First Colorado Programs Fact Sheet.
A baby born to a woman on Health First Colorado at the time of the newborn's birth is guaranteed continuous eligibility through the baby's first birthday.
The Colorado Medical Assistance Program utilizes this important business letter to confirm the legal name of the business identified with a corresponding TIN. We request this information to verify that we are reporting payments correctly to the IRS and to verify that you are enrolled correctly.
When the claim requires a rendering or attending physician's number, the individual doctor's provider number must be used in these fields when:
If it has been 30 days since the date of the payment, verify with your bank to ensure the check was not cashed. If not, please call the Provider Services Call Center at 1 (844) 235-2387 (toll-free) to see if the check has been cashed.
If the Provider Services Call Center has determined the check has not been cashed, please fill out the Affidavit of Lost Warrant form and mail to:
Department of Health Care Policy and FinancingAccounting Department1570 Grant StreetDenver, CO 80203-1714
Ask the customer service representative for the warrant number for your reference. Once the signed affidavit is returned, the accounting team will cancel the lost check and reissue in the Colorado interChange system.
The following is the charge per warrant requested:
Make checks payable to the Department of Health Care Policy and Financing and mail to:
Both the request and check may be mailed to the address above.
Include the following details with your request:
Checks may have been returned to the Department's fiscal agent. Providers who have the capability should update their information through the Provider Web Portal.
The safest, fastest, and easiest way to receive Medical Assistance Program payments is through EFT.
(See Electronic Funds Transfer (EFT) Questions to learn how to set up EFT.) EFT permanently solves paper check (warrant) problems.
The specification manuals can be downloaded from the Provider Information Specifications section.
The Colorado Medical Assistance Program Secure Web Portal (Web Portal) is a secured website that is accessible from the Secured Site option via the Department of Health Care Policy and Financing's (the Department) website at colorado.gov/hcpf. The Web Portal is used to submit and retrieve transactions and/or reports, including Accept/Reject Reports, Prior Authorization Letters, and Remittance Advices (RAs). There is no need to dial into a system, and the response time through the Web Portal is faster. The Web Portal is available 24 hours a day 7 days a week from any computer with internet access.
The Web Portal offers a centralized database, which could mean fewer data inconsistencies. The Web Portal is accessed through secure internet connections, and information stored in the database is secure and available only to the specified trading partner. Among other functions, historical claims can be stored, member and provider data can be managed, and inquiries can be made on the status of a Prior Authorization Request (PAR) and claims submitted on paper. The Web Portal prevents information from being stored on personal computers or waiting for a response from other sources.
The Web Portal currently offers: Interactive Eligibility Inquiries, Batch Eligibility Inquiries, Claim Status Inquiries, Professional, Institutional and Dental Claim Submission, and PAR Status Inquiries. Additional services include: Provider Specialty Lookup, which is useful for searching for Medical Assistance Program Providers for referral purposes, and a Dashboard on the Main Menu page for system and transaction status information.
The following are specific resources to assist in better understanding questions around when a change of ownership has occurred and what steps providers need to take to prepare.
A change of ownership occurs when you answer yes to either of the following questions:
If there is no change in the tax identification number, a change of ownership notification is not necessary. Other changes, such as a change to the organization's legal name or a change in owners or board of directors can be handled with a simple update to the provider's existing information.
No. Appointing a new board of directors does not constitute a change of ownership.
Before the new owner starts billing, an application must be submitted for the new business. The seller must stop billing claims before the new owner begins billing.
Providers are strongly encouraged to apply for a new NPI whenever a new tax identification number is issued. If the decision is made to transfer the existing NPI to the new owner, the previous owner is advised to submit all claims before the transfer is made. A separate taxonomy will be required for the new owner if the NPI will be shared.
Providers with a change in tax ID number must re-apply, complete a new Medical Assistance Program Provider Participation Agreement, and be fully approved in order to participate in Health First Colorado. The previous Health First Colorado number must be disenrolled and a new Health First Colorado number will be assigned.
No. Providers must apply for a new Health First Colorado ID with the new Tax ID.
Fingerprint Criminal Background Check (FCBC)
Yes, but you are not able to reply to a Closed Secure Correspondence message. Closed calls are logged in the CTMS (Call Tracking Management System) and accessible by the call center reps if further action is needed. When documenting your correspondence, please note the CTN (Call Tracking Number) automatically assigned to the case. This will make conversations with the call center easier to reference.
Any written communication containing PHI and protected by HIPAA. All correspondence with DXC Technology (formerly HPE), aka the fiscal agent for Health First Colorado.
Currently, the Provider Web Portal does not provide a print option for Secure Correspondence but you could use your browser's print capability.
The turnaround time depends on the question asked, but is typically 3-5 business days.
Yes, these type of questions can be asked via Secure Correspondence on the Provider Web Portal.
If the request is urgent, we suggest you call. Otherwise, secure correspondence is the preferred method of communication for non-urgent requests.
No, reconsiderations must be submitted via the Provider Web Portal, paper or batch. However, a reconsideration is not necessary for denied claims. Please correct the reason for denial and resubmit as a new claim.
No. Claims must be resubmitted via the web portal, batch or paper. The claim can be rebilled with corrections. A reconsideration or appeal is not necessary. If you believe you were denied services without cause, you should first submit a reconsideration for your claim via the Provider Web Portal, paper or batch. If you are not satisfied with the outcome of the reconsideration, you can appeal and ask for a State Fair Hearing. Call the Colorado Office of Administrative Courts at 303-866-2000. Or, write to:Colorado Office of Administrative Courts
1525 Sherman Street, 4th Floor
Denver, CO 80203
Yes, batch (X12) files can be transmitted through a Clearinghouse and through the Provider Web Portal; both methods (of batch submission) require a Trading Partner ID.
If you want to transmit batch through the Web Portal, you need to obtain a DXC Technology TPID.
You do NOT need a DXC Technology TPID, to submit single claims (not batch) through the Web Portal.
Yes, a TPID is needed to upload 837 files.
Yes, if you would like to download your own 835 you will need a TPID. You will also need to use the Manage Accounts page within the Provider Web Portal to define which TPID will submit your claims and which TPID will receive your 835.
A Billing Agent will be able to create delegates who can then upload and download files.
Providers could use the file exchange to upload and download batch files (including X12 reports) directly through the Provider Web Portal, rather than through FTP or through a Clearinghouse.
Yes, it is fairly common for a Clearinghouse to act as a Trading Partner for multiple providers. Note: A Clearinghouse could use the same TPID with all of their clients (providers).
No, the Provider Web Portal will not give indication that a Trading Partner serves more than one provider.
Please visit our EDI Support webpage, or call the Provider Services Call Center at 1-844-235-2387.
No, you do not need to enroll as a Trading Partner to submit single (interactive) claims through the new Provider Web Portal.
No, your vendor would need to enroll as a Trading Partner, but you would not.
Not necessarily. If you're submitting your claims individually through the Provider Web Portal but typing the claim information into the portal, you are not submitting batch files. Batch is a technical term and does not refer to "many" claims, but rather the file format.
You do not need a TPID to:
You do need a TPID to:
Not necessarily, a Group is the billing provider for one or more individuals within a Group (rendering providers). Example: Salud Clinic may be a Group, and the doctors who work there may be the Individuals within a Group. Health First Colorado will report the income paid to Salud, to the IRS.
A Trading Partner is someone who submits batch claims or eligibility files on behalf of a billing provider, but may not receive the income from Health First Colorado. Example, Trizetto may submit claims for Salud Clinic, but does not receive the income from Health First Colorado. They are simply handling the file transmission to or from the fiscal agent, DXC Technology (formerly HPE).
If Salud submits their own batch files, however, they would be the Group and the Trading Partner in that instance.
Yes, if you are going to retrieve your own 835, you will need a Trading Partner ID.
A trading partner is anyone who trades information (submits or retrieves the X12 HIPAA compliant file). If you are not submitting your own X12 files or retrieving your own X12 files, you do not need a trading partner ID.
Health First Colorado does not make recommendations for who you should use as a Trading Partner, but a Google search for "medical claims Clearinghouse companies" should give you a good place to start. You can contact DXC Technology (formerly HPE) to verify they are enrolled in the Health First Colorado program.
You will want to register for the Provider Web Portal. If you are going to be the primary user of the Provider Web Portal, then you don't need to be a delegate.
Either will work. The display name is something you'll only see in the Provider Web Portal, and the display name won't affect your claims (or anything else).
NOTE: A temporary issue with Display Names has been identified. Please review this work-around.
That's really a personal preference. However, if you have a billing person or Department, you may want to check and see if they have a preference. Otherwise, you can just stick with the default option and change it later if you need to.
We do have a list published here, but you can also check with your billing agent. They will need to give you their TPID in order for you to "authorize" them as a Trading Partner.
Yes, the Search Payment History panel on the Provider Web Portal will provide this information for providers. You do not need to enroll as a trading partner to access remittance advice (RA), previously called provider claim reports.
Not necessarily. You could submit single claims (through the Provider Web Portal) on behalf of your clients, and that would not require you to be a Trading Partner. However, it would require each of your clients to "delegate" claims access to you.
Yes, anyone who wants to transmit batch (X12) files needs to enroll as a Trading Partner, and complete file testing for HIPAA compliance.
Yes, both you and your Clearinghouse can enroll as Trading Partners and receive a Trading Partner ID. Then on the Manage Accounts page within the Provider Web Portal you will indicate which transactions each Trading Partner ID will submit/receive.
While you could enroll for 16 different Trading Partner IDs, we recommend that you only enroll for one Trading Partner ID, and authorize that TPID to submit for all your locations.
There is no minimum threshold for batch claims. Batch is a technical term referring to the file type and method of submission:
Here is our Getting Started Guide, but you can also visit our EDI Support webpage, or call the Provider Services Call Center at 1-844-235-2387.
The testing process for Trading Partners is a separate process, not requiring access to the parts of the Web Portal that are not yet active.
Yes. You can view claims submitted through any media: paper, electronic batch, portal.
You can copy any adjudicated claim (one that is denied or paid), including claims from Xerox. A suspended claim cannot be copied.
If you will use the Provider Web Portal to submit individual claims via the Submit Claim process, you do not need a Trading Partner ID. You only need a Trading Partner ID if you are going to submit/receive X12 transactions.
You can submit single claims thru the Provider Web Portal.
A provider and/or anyone to which the billing provider has delegated claims inquiry access, will only be able to see the claims on which they are the "billing provider". The RAs will have the Provider ID on them.
If you only enter individual claims via the Provider Web Portal you do not need a Trading Partner ID. You will only need a Trading Partner ID if you will be submitting/receiving X12 transactions.
Yes. Only dental claims for members who have a non-citizen, emergency services only eligibility status, will be submitted via the provider Web Portal. All other Dental claims for Health First Colorado members will continue to be processed through DentaQuest.
The main call center number has an option specifically for claims on 3/1/17. You can also use the secure correspondence option in the portal. The Call Center is open 7am -5pm Mon, Tuesday, and Thursday, and from 10am to 5pm Wednesday and Friday 1-844-235-2387.
You will use the new Provider Web Portal to submit your individual claims.
You would have to do either an adjustment or rebill after the originally submitted claim has been adjudicated.
Via the Provider Web Portal, providers will have access to all of their claims stored in interChange. Xerox data from the past 6 years will be migrated into the new system.
You will be able to use the new Provider Web Portal to submit claims with attachments. On Step 3 of the Submit Claim process in the new Provider Web Portal, there is a section where you can upload your attachments and submit them with the claim.
Yes, but the LBOD is now done differently. Instead of submitting an LBOD, you will enter the last submitted ICN for that service in the Previous ICN field. Please review the Guide to Go Live for more information on LBOD changes.
Select crossover claim from the Claim Type dropdown menu. The Medicare Crossover Details section will be displayed to enter information.
The first two digits of the type of bill are the "Facility Type Code" (example - 13 for outpatient claims) - the third digit (frequency type) will be automatically added depending on what type of claim you are submitting (original vs adjustment vs void)
You could copy the claim for the patient for the month previous and modify that information to submit for the new month (using new dates of service).
The old portal will not be available. However, Xerox data will be back loaded and searchable in the new portal up to 6 years in the past.
No, only the following providers are eligible for an EFT exemption:
If the above applies to you, and you want to receive paper checks, please see these EFT exemption instructions.
No, if you provided your EFT information during revalidation, you do not need to provide it again.
You can change your EFT information online through the new Provider Web Portal. You will just log in and click the link that says "EFT/ERA Enrollment." After DXC processes your EFT/ERA Enrollment, your information must be verified by the bank used by the Department. This process takes 10 - 14 days. You will receive paper checks during this period. Providers are encouraged to verify the mailing address on file. You can find detailed instructions for changing your EFT/ERA here.
No, EFT information will not migrate over from Xerox. However, any EFT information you submitted in your enrollment or revalidation application will remain in the system.
The EFT/ERA information is for the billing (group) provider.
No, you only need to be a trading partner for batch eligibility and batch claims.
There is Provider Enrollment information and training available here.
There are two situations where this may occur:
If you do not fit either of the above situations, please call the Provider Services Call Center (1-844-235-2387) to determine why your account has been restricted.
No. The Provider Web Portal was built to be used with any modern Web Browser. See the website requirements.
This updated information should have been provided during your revalidation in the new system. If it has changed you can update it using Provider Maintenance in the Provider Web Portal.
This is the service location ID and is usually the same as the Provider ID.
The user will be requested to update their password after 90 days.
Old web portal login information will not work for the new Provider Web Portal. You will need to register with the new system.
The provider can use the Forgot User ID and Forgot Password functionality of the Provider Web Portal to determine their User ID or reset their Password. However, if they are locked out, they will need to call the Provider Services Call Center (1-844-235-2387) to reset the lock.
Only claims where you are the billing provider, per HIPAA regulations.
Yes, you can verify if the member is eligible for dental benefits.
Yes, and only one month at a time.
The Client Overutilization Program (COUP, also known as ‘Lock-In') is a statewide surveillance and utilization control program that safeguards against unnecessary or inappropriate use of care or services. The Lock-In Details describe the provider(s) the member is eligible to see for the given service.
Yes, the member's Managed Care Assignment will be listed on the Coverage Details page within the Provider Web Portal. A member's Medicare insurance will display on the Other Insurance Detail Information page of the Provider Web Portal.
Yes. Member IDs will not be changing.
Yes, the Limit Details section will display both dollars and units.
The Verification for Newborn option can be used to look up newborn eligibility information, if the newborn Member ID is not known.
No, not through the Provider Web Portal.
The Member Focus viewing page will show the member's city and state.
If you have enrolled, been approved, and have registered for Provider Web Portal access, yes.
Yes, there is a Print Preview button at the top of the Coverage Details page.
Yes, Member ID is the same as Client ID.
The EQ Process will not change at all. If you have questions relative to how your Provider ID change affects the EQ process, contact EQ at 1-888-801-9355.
The PA number in interChange is 10 digits: 1 digit for the media type (how the PA enters interChange), 2 digits for the year, 3 digits for the Julian date, and a 4-digit sequence number.
Nursing Facility PETI and Referral PAs can be submitted via the DXC Technology (formerly HPE) Provider Web Portal. Referral PAs are completely optional and have no impact on your claims.
Both! To update your license information and other practitioner details, you will need to log in as an individual. For billing, you will need to use your company NPI.
A provider (or administrator, if the provider has someone else in charge of submitting their enrollment) will use the provider's information to register with the Provider Web Portal. This provider (or administrator) can then create delegates for each user in the company who may need to access the Provider Web Portal on behalf of the provider.
A provider (or administrator, if the provider has someone else who is in charge of submitting their enrollment) will use the provider's information to register with the Provider Web Portal. This provider (or administrator) can then create delegates for each user in the company who may need to access the Provider Web Portal on behalf of the provider.
As an MCO, your Provider ID will be the same as your legacy ID. The Provider Web Portal log-in information will be changing with the new system, and will be created by you during registration. The new system will also require a DXC Technology (formerly HPE) Trading Partner ID for those who will be submitting/receiving X12 transactions.
A provider will use the Manage Accounts page within the Provider Web Portal to enter their delegates' information and will receive a delegate code for each delegate. The delegate will then use their information, along with the assigned delegate code, to register with the Provider Web Portal.
Using the delegate functionality available in the Provider Web Portal is the best way. Each group and provider will link to the delegate on the Manage Accounts page. The delegate will then be able to use their one log-in to switch between each group and provider that has assigned them as a delegate.
Both groups and individual providers can add delegates.
Yes, just return to the Manage Accounts page, click on the delegate's name, and update the functions they are able to access on your behalf.
No, if the group is the billing entity on the claim, the group will register with the Provider Web Portal and be able to submit claims for the provider.
Correct, if they are not already a delegate for another provider and do not have a delegate code for the new Provider Web Portal, then you will use the first tab. If the delegate is already assigned to another provider and already has a delegate code for the new Provider Web Portal, then you will use the second tab.
Yes, you will register the group and the individual providers with the Provider Web Portal.
The trading partner will need to be linked to each billing provider. The trading partner does not need to be linked to the rendering providers.
No. If you are a billing agent with a Trading Partner ID, you will register with the Provider Web Portal using your Trading Partner ID. Each of the providers you work on behalf of will need to use the Manage Accounts page to indicate which Provider Web Portal functions and X12 transactions you can perform on their behalf.
No, you will need to register with the Provider Web Portal to create a User ID and Password for the new system.
No, the group will register with the Provider Web Portal to update their location information. However, the individual within a group provider will need to register to update any of their personal information such as License.
For a given delegate (one individual), the same delegate code should be used for all providers (locations) for which they are a delegate. This will allow the delegate to have one login to the Provider Web Portal where they can then switch between providers using the Switch Provider function in the Provider Web Portal.
Each provider would register separately. You can then use the delegate functionality on the Manage Accounts page to delegate each provider to the same delegate. The delegate will then be able to use their one login to switch between each provider.
You will need to create a separate registration on the Provider Web Portal for each Enrollment application you submitted. So if you submitted two Provider Enrollment/Revalidation applications, you will need two different provider registrations. However, if you have two taxonomies on the same Enrollment/Revalidation application, you will only need to have one provider registration and you will register with the primary taxonomy.
Yes, an RAE will be able to add delegates.
You will enter the Group NPI when registering the group, and the individual NPI when registering the individual provider.
Registration for the Provider Web Portal is different than Revalidation. Registering with the Provider Web Portal will give you access to the new Provider Web Portal and can only occur after your Revalidation application has been approved.
A delegate code is provided by the first provider to add you as a delegate.
You will need to create a separate registration on the Provider Web Portal for each Enrollment application you submitted. If some employees work for both programs, the delegate functionality can be used. For a given delegate (one individual), the same delegate code should be used for all providers for which they are a delegate. This will allow the delegate to have one login to the Provider Web Portal where they can then switch between providers using the Switch Provider function in the Provider Web Portal.
Yes, you will need to create a separate registration on the Provider Web Portal for each enrollment application you submitted. You can then assign delegates for each in the Provider Web Portal. For a given delegate (one individual) the same delegate code should be used for all providers they are a delegate for. This will allow the delegate to have one login to the Provider Web Portal where they can then switch between providers using the Switch Provider function in the Provider Web Portal.
Yes, you would add them as a new delegate in the new Provider Web Portal.
Yes, if you did not provide an NPI during revalidation, you can use your Provider ID to register with the Provider Web Portal.
You will receive two emails after you have registered with the Provider Web Portal. In the first email there will be a link that you must click and then enter your password to verify your registration. After this verification, you will receive a second email indicating you have successfully registered.
No, you can only register as a provider once with the NPI and taxonomy that was submitted during Enrollment/Revalidation. The provider will then create the necessary delegates for others that need to work on their behalf.
You will need to create a separate registration on the Provider Web Portal for each Enrollment application you submitted.
Yes, your application needs to be approved in order to register in the Provider Web Portal.
This is not the recommended process, but the system will not stop you from doing this.
Each enrollment needs to register with the Provider Web Portal. Then, within each registration you can assign the same delegate. You can then use this one delegate to login to the Provider Web Portal and switch between the different providers.
Use the primary taxonomy code to register with the Provider Web Portal.
You will be able to download Remittance Advice (RA) reports, Prior Authorization (PA) reports, Prior Authorization (PA) letters and Contact Tracking Management System (CTMS) letters from the Provider Web Portal.
No. We will transfer over 6 years of claims data, but not in the form of reports.
According to dictionary.com, a file delimiter is, "a blank space, comma, or other character or symbol that indicates the beginning or end of a character string, word, or data item."
While an excel file may look like this:
a file with a comma as the delimiter, would show you "Column 1,Column 2,Column 3".
Yes, you can change your preferred file delimiter at any time in the "My Profile" section of the Provider Web Portal.
The new Provider Web Portal does not have the capability to automatically send reports out to different parties. However, your Trading Partner may log into their Trading Partner account and pull your 835 report at any time, so long as you have authorized their TPID to do so.
It's not a problem, but you'll probably receive some emails you don't need. If you would like to disenroll, just call the Provider Services Call Center at 1 (844) 235-2387.
They can be opened from the portal and printed which initiates a temporary download. The file size is very small so this option really depends on preference.
As of right now, there is no limit. The Department will notify you if this changes.
The accept/reject report will no longer be a report option; the 999 will be still be available.
The 835 will be the next report following the 999 in the life cycle of the file.
Yes, you can take a session as many times as you like. You can also view a recording of the sessions on or after February 6, 2017.
PowerPoint versions of the slides presented in the session are available by request. Send an email noting which sessions you would like to firstname.lastname@example.org
No. Provider Web Portal training is not a prerequisite for Enrollment, Revalidation or Provider Web Portal registration. However, enrollment/revalidation training is highly recommended.
Certificates will not be issued; however, we do have attendance records if they are needed at a later date.
We recommend it; however, it's not required.
Existing Enrolled Provider with an NPI
Provider must contact DXC Technology (formerly HPE) via secure correspondence link on the Portal to have the old NPI closed. The provider should then submit a new application with the new NPI number. This application will go through all of the standard enrollment checks including NPPES, PECOS, Lexis Nexis. In the event that the application the provider is submitting requires an application fee, the provider can give DXC Technology the previous ATN so that DXC Technology can verify that the fee was paid. If the application requires attachments DXC Technology will tie the applications together via enrollment comments.
Existing Enrolled Provider with no NPI on file
The Provider must contact DXC Technology (formerly HPE) via secure correspondence link on the Portal to have the new NPI added. DXC Technology will first verify that the provider has no existing NPI on file. The provider should give the new NPI and tax ID or Provider ID. The enrollment analyst will then conduct the standard manual checks to verify an NPI. This includes NPPES and PECOS. The NPI will go through Lexis Nexis in the next monthly batch cycle.
Provider that has not completed the Enrollment Process
The Provider should contact the Provider Call Center to request that the application be returned to them. They can then add the NPI and it will continue the enrollment process including all standard enrollment checks including NPPES, PECOS, Lexis Nexis.
You will need to login to the Provider Web Portal as either the Individual within a Group or a Group, and then click the Provider Maintenance link. From here you can click "Group Affiliations" or Affiliations" and then add the information. You can find detailed instructions for Affiliations here.
Important: Individuals Within a Group must be affiliated with a Group! Affiliating an individual to any other Enrollment type (Facility, Atypical, etc.), will likely cause claim denials.
A separate revalidation enrollment application should have been submitted for each service location unless the provider is an Individual within a Group or a Billing Individual. An Individual within a Group just needs to affiliate to each Group location. Billing Individuals may be affiliated to a Group, but the affiliation can only be done by the Group from its portal profile.
It is not required, unless you participate in (and have a signed contract with) a Managed Care Organization (MCO) or Regional Accountable Entity (RAE). This lets the MCO or RAE bill for the provider. It also allows members to search for a provider who is in that network.
A new Provider Enrollment Application will need to be submitted for any new service location. In accordance with federal regulations and guidance, providers with multiple service locations (sites) must enroll each service location separately.
If they do not require approval, updates are effective immediately. If they do, then it depends on how long verification takes, generally 3 weeks.
You may add or update a secondary Specialty; however, a change to Provider Type or Primary Specialty will require a new Provider Enrollment Application.
If they are just leaving your group, but do not want to end their participation with Health First Colorado, you can just remove them from your list of affiliated providers.
If they are leaving your group and ending their participation with Health First Colorado, that should be a disenrollment.
If the provider you want to add is already enrolled as an Individual within a Group, they can just add you to their list of affiliated groups, or you can add them to your list of affiliated providers.
If the provider isn't enrolled with Health First Colorado yet, then they will need an enrollment application.
No. As of 3/1/17, all updates to provider information need to be made online through the new Provider Web Portal.
Yes. The information shown in the Provider Web Portal is populated from the information you gave us during revalidation or enrollment. You only need to make a change if you need to add, remove, or update information.
Yes. You should receive an email confirming your update request, and then another when the update has been made.
The provider should use the disenroll section if they are ending their participation with Health First Colorado. If the provider is just leaving your group, but does not want to end their participation with Health First Colorado, you can just remove them from your affiliated providers list.
Opioid Policy Update FAQs for Providers
Pharmacy Info and FAQs
As stated in § 455.414, a State Medicaid agency must screen all providers at least every 5 years. This requirement is consistent with the Medicare requirement that providers, suppliers, and eligible professionals must re-enroll at least every 5 years.
You will receive a letter informing you that it is time to revalidate. The letter will specify the date you need to have your revalidation completed and any requirements for your revalidation. Ongoing revalidation deadlines will vary based on your contract with the Department. If additional information is required for the revalidation process, you will receive another letter explicating what is needed. The letter will include your deadline for revalidating.
Beginning March 1, 2017, all providers are required to have completed the enrollment process in the new Colorado interChange, regardless of whether they were enrolled in Health First Colorado prior to the transition effective March 1.
All providers, medical or nonmedical, who are enrolled with and bill Health First Colorado for services under the state plan or a waiver must be screened under this rule by enrolling/revalidating. 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/revalidate as well. This is necessary because the validity and currency of all provider licenses to perform any service must be screened.
New federal regulations established by the Centers for Medicare and Medicaid Services (CMS) require enhanced screening and revalidation for all existing (and newly enrolling) providers. These regulations are designed to increase compliance and quality of care, and to reduce fraud.
Please note the Department and DXC began the revalidation process in September 2015.
Revalidation confirms that all provider licenses are current and valid. Revalidation is an extensive process that includes, but is not limited to, verifying correct addresses, background checks, services provided, and license screenings.
All screening pursuant to this rule will be conducted by the Department's fiscal agent.
The Department and DXC have been using the terms "enrollment" and "revalidation" as somewhat interchangeable.
To enroll as a Health First Colorado provider, you must complete the enrollment application.
The Department and DXC have been using the term "revalidation" to acknowledge that most providers completing the process have been enrolled with Health First Colorado for some time.
To be reimbursed for services to Health First Colorado members, you must be approved through initial enrollment/revalidation, which puts you, the provider, into the new Colorado interChange system. Enrollment and revalidation are combined in your initial enrollment. For instructions and guidance for completing the application, click here .
Ongoing requirement for revalidation:
Once your initial enrollment/revalidation is complete, you will be required to revalidate every 3-5 years depending on your risk-level. The Department and DXC will notify you when you need to revalidate. Find your risk level on the Information by Provider Type web page.
Providers interested in becoming Health First Colorado providers can begin the enrollment process at any time. The only real deadline associated with enrollment is that providers are not guaranteed payment for services rendered to Health First Colorado members until they are enrolled providers. We highly recommend enrolling/revalidating prior to seeing Health First Colorado members.
Providers may be backdated from the date of the enrollment approval if they are licensed and meet all other enrollment requirements through those dates. The Department previously published enrollment and revalidation deadlines associated with its Go Live on March 1, 2017. Those deadlines do not exclude providers from applying at any time.
Per federal regulation, all providers must revalidate every 3-5 years from their initial enrollment date. The Department and DXC will send notification letters via email to providers when their revalidation is due.
A step-by-step guide for enrollment and revalidation can be found online on the provider's webpage on the Colorado Health Care Policy and Financing website. The Provider Web Portal has many resources including best practices for revalidation. If you need additional help, contact the Provider Services Call Center (1-844-235-2387).
Using the available resources before beginning an enrollment application may save time while filling out the application. When filling out the application, be as thorough as possible and use the Revalidation Best Practices to avoid making common mistakes. After you submit your application, it may take up to ten business days to review.
If your application requires changes or is returned for additional information, you must respond to the requested updates. After you resubmit the application, it will go through the review process again.
If you are a provider who is required to have a site review by a fiscal agent, this might take an additional 10 days to get a representative to your facility, but is subject to change.
Yes, you will receive an email with notification that your initial enrollment/revalidation application has been received.
There is a fee for some provider types. Please see the Fees and Exemptions FAQs for more details. To find out if your provider type(s) requires an application fee, please see our Information by Provider Type and Information by HCBS Service Provided pages.
Note: If you are enrolling as more than one provider type, a separate application (and fee, if applicable) is required for each provider type. HCBS (waiver) providers, please note: all HCBS services you provide can be added to one application. Do NOT submit a separate application for each specialty.
A step-by-step guide for enrollment and revalidation can be found online on the provider's webpage on the Colorado Health Care Policy and Financing website. Once you have completed the application, the provider's webpage has many resources that may be useful to you, including instructions for completing the revalidation process, updates, known issues, FAQs, and Quick Guides. If you need additional help, contact the Provider Services Call Center (1-844-235-2387).
You can find your provider type on the provider's webpage on the Colorado Department of Health Care Policy and Financing website. Knowing your provider type in the first step in the revalidation process. Your provider type is based on the services you provide, so if you provide multiple services, you may need to enroll in multiple provider types. Taking time to review the provider types will minimize issues with claims submissions in the future.
The Department has aligned risk levels for most providers with the risk levels determined by the Federal Centers for Medicare and Medicaid Services. For "Medicaid only" providers, including many providers who are unlicensed by the state of Colorado, the Department assigned risk levels. These risk levels were determined based on several criteria, including input from a workgroup and stakeholders, and the unique circumstances of each provider type.
Find your provider risk level here.
If your enrollment/revalidation application is returned, you will receive an email notifying you about the problem(s) with your application. After you correct the problem(s), be sure to double-check all other sections; confirming that your information is entered properly. Once you have corrected your application, resubmit your application. For extra help, check out the Revalidation Best Practices, make sure your provider type and enrollment type are correct, and follow the step-by-step guide to revalidating before you resubmit your application. You can also contact the Provider Services Call Center (1-844-235-2387).
Common reasons for an enrollment/revalidation application to be returned include: names and addresses that do not match the W-9, an incorrect tax ID, errors in insurance policy or ID numbers, missing documents (i.e., attached copies of insurance, licenses, and certifications), and W-9s or bank statements that were not signed and dated within the past six months. To avoid these common mistakes, check out the Revalidation Best Practices and follow the step-by-step guide to revalidating.
Common reasons for an enrollment/revalidation application to be denied include: incorrect enrollment or provider type, an application that duplicates one already in the system, a license issue that cannot be resolved, etc. Providers whose applications have been denied may submit a Grievance to the fiscal agent, asking that the application be re-opened for review, but applications denied for the wrong provider or enrollment type cannot be approved. Providers will need to start over with a new application in these cases.
If you are a new provider, you should start to see Provider Enrollment responses within 10 business days. If an application must be returned to the provider (RTP) for updates or corrections, processing time may be extended beyond the standard 10 business days.
Please note: this timeline might be affected by risk level and whether you are requesting a hardship exemption for the application fee.
You will need to submit a Group application first for the practice. Then, submit an Individual Within a Group application for each of your two physicians. Each individual application must include an affiliation with the practice.
Part of the federally required revalidation process involves screening all Health First Colorado providers according to established guidelines. Your SSN is required for the screening process, even though your Health First Colorado reimbursement is paid against your practice Tax ID.
Copies of documents and PSV are fine.
Please upload a separate, typed document, with any additional affiliations, in the "Attachments and Fees" panel.
Please follow these instructions to download proof of your NCPDP.
No. You only need to include the group's W-9 on the Group application. You do not need to attach a W-9 to the Individual within a Group application.
For a "Billing Individual" application, a copy of the Provider's W-9 needs to be attached. All W-9 forms submitted must have been signed within the past six months.
The following documentation is acceptable as proof of contract with a RAE/MCO:
The information for the directory is pulled from the application. We don't yet have a list of all of the fields but the following will be included:
The response on this question is displayed in the Provider Directory, if you are listed. You may change your response anytime via the Provider Portal.
No, you will not. Providers who are affiliated with two or more groups should work with the group submitting the application to ensure all affiliated groups are accounted for. Submitting duplicate applications for an individual provider may result in future problems with claims payment.
All Health First Colorado and CHP+ providers are required to revalidate; a look-up will not be provided.
Yes. The rule requires the Department to conduct site visits before and after enrollment to:
Because these site visits will have a different purpose than site surveys performed by other state agencies, the Department may collect different information during these visits to ensure compliance with federal requirements. The Department will work with other agencies to coordinate site visits, when possible.
Please Note: Site visits are conducted by the Department's fiscal agent, DXC Technology (DXC). Site visits are typically unannounced but may be scheduled at DXC's discretion. A site visit should be occurring within 7-10 days after the application is moved to Site Review status.
Please review Information by Provider Type or Information by HCBS Service Provided (for waiver service providers) carefully for the correct provider type. Applications that are submitted with the wrong provider type will be rejected and you will need to start over.
Dermatologists enroll as physicians and then indicate dermatology as a specialty through their taxonomy code. Likewise, a dermatology clinic would enroll as a Clinic - Practitioner Group and indicate their dermatology specialty through their taxonomy code.
The "provider type" for an LCSW, LMFT, LPC or LAC should be Licensed Behavioral Health Clinician (PT38). Someone with a PhD should enroll under Licensed Psychologist (PT37).
Use the date on the Colorado Department of Education License or your current effective date if you are currently enrolled in Health First Colorado.
For the "Disclosures" section of the application, school districts only need to disclose their superintendent and CFO rather than their elected board of officials. The superintendent and CFO information must be entered in the Managing employee section (Section D) of the disclosures page. Please indicate "CFO" or "Superintendent" following the listed individual's name.
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Standard. An NPI is a unique identification number for covered health care providers, created to improve the efficiency and effectiveness of electronic transmission of health information. Covered health care providers and all health plans and health care clearinghouses must use NPIs in their administrative and financial transactions. Additional information regarding NPIs is located at: https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/.
Health care providers are required to indicate a National Provider Identifier (NPI) on enrollment applications and electronic and paper transactions submitted to Health First Colorado. The NPI is a 10-digit number obtained through the National Plan and Provider Enumeration System (NPPES). Providers should ensure that they have obtained an appropriate NPI prior to beginning their enrollment application.
There are two types of NPIs:
It is possible for a provider to qualify for both Entity Type 1 and Entity Type 2 NPIs. For example, an individual physical therapist may also be the owner of a therapy group that is a corporation and requires two Health First Colorado enrollments — one enrollment as an individual physical therapist and a different enrollment as a physical therapy group. A Type 1 NPI for the individual enrollment and a Type 2 NPI for the group enrollment are required.
National Provider Identifiers and classifications may be viewed on the NPPES website. The Centers for Medicare and Medicaid Services website includes more information on Type 1 and Type 2 NPIs. Health care providers who are federally required to have an NPI are responsible for obtaining the appropriate certification for their NPI.
Some providers (classified as "atypical") aren't required to have an NPI. Providers exempt from federal NPI requirements are assigned a system-generated Health First Colorado provider number once their enrollment application is approved. This Health First Colorado provider number should be included on all transactions submitted to Health First Colorado.
In this case, the incorporated practice and the individual should each have an NPI. You must apply for each NPI separately, and you will be asked to create a profile for each type of application on the NPPES Web site.
Technically yes, but having multiple locations under the same NPI does complicate billing. We strongly recommend that providers obtain a separate NPI for each service location.
Your Health First Colorado ID should remain the same if you enter in the same Tax ID, Social Security Number, provider type and location address. If any of this information is different, the system will assume it is a new enrollment and create a new number, which could potentially create claim denials.
If there are duplicate IDs that need to be merged, contact DXC.
A National Provider Identification number (NPI) is an identification number for providers. When a provider is registered, they are given a Health First Colorado ID, which is an identification number provided by Health First Colorado. When a provider is registered to be a Health First Colorado provider, they need to provide their NPI. For providers with an NPI, it is used to bill claims.
The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings based on the types of services they offer. These codes are not "assigned" to health care providers; rather, health care providers select the taxonomy code(s) that most closely represent their education, license, or certification.
A quick Google search for "provider taxonomy codes" will provide you with many options. You can also find your taxonomy on the National Plan & Provider Enumeration System (NPPES) website.
You will need your taxonomy code in order to obtain an NPI and to complete the Online Provider Enrollment application (unless you are an "Atypical" enrollment type). The primary taxonomy associated to your NPI, must be listed on your application.
No. The Health Care Provider Taxonomy codes are self-selected by the provider. Selection of a taxonomy code does not replace any credentialing or validation process that the organization requesting the code should complete. Definitions for some of the codes do reference specialty or certifying boards as a source, but this reference in no way implies that providers have met the requirements of that board if they choose the code to identify themselves.
Yes, every group or facility needs to enroll or revalidate with their billing type, appropriate licenses, and taxonomy individually. All locations where a service is provided needs to be billed; we highly recommend that each location obtains a different National Provider Identification (NPI) number.
For individuals within a group, only one number is assigned to a SSN even if that individual practices in multiple locations. The Health First Colorado ID can be affiliated to multiple groups at different locations.
Yes, one provider location can delegate to another location.
Yes, every group or facility location has a Health First Colorado ID and must use it to register. Currently, only the NPI is included on the enrollment letter; however, the Department is working to also include the Health First Colorado ID.
The enrollment is based on the provider's location not the member's location. Please see the information by HCBS service provided page for more details.
Health First Colorado must comply with Title 42 Code of Federal Regulations (CFR) §455.460, which require an application fee for certain provider types.
The amount of the application fee is subject to change every calendar year (CY). CMS will publish the application fee via the Federal Register 60 days prior to the new CY. In addition to the application fee, there will be a credit card processing fee of 2.95%, and/or an EFT processing fee of $2.50.
NOTE: CMS has increased the fee for calendar year 2019 to $586.00. This new fee amount went into effect on January 1, 2019.
Discover, MC, Visa, and American Express
Applicable provider types who are submitting applications for the following reasons are required to pay the Provider Enrollment Application Fee:
The application fee is non-refundable, except when submitted with one of the following:
Maybe. Service locations that have enrolled or revalidated with Medicare (and have been approved) are not required to pay the fee again to Health First Colorado. However, service locations that are not enrolled or revalidated with Medicare will require the fee.
Yes. Health First Colorado is required to collect an enrollment application fee for applicable provider types regardless of non-profit status or size.
Unfortunately, if no proof of payment can be obtained and included with the application, the application fee must be paid again.
Please see the hardship exemption process below.
If your hardship request was approved, then your application will continue to process as usual. If your request was denied, you will get an email from us letting you know that you have 60 days to pay the fee before your application is rejected.
According to CMS - "It is not enough for the provider to simply assert that the imposition of the application fee represents a financial hardship. The provider must instead make a strong argument to support its request, including providing comprehensive documentation (which may include, without limitation, historical cost reports, recent financial reports such as balance sheets and income statements, cash flow statements, tax returns, etc.)."
Other factors that may suggest that a hardship exception is appropriate include the following:
More information about the hardship exemption request can be found at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm7350.pdf.
Please refer this question to your accountant.
No. Please see "What are the refund policies regarding the fee?" for a list of instances in which a refund may be possible.
Even if you were granted a hardship waiver in another state's Medicaid program, Health First Colorado is still required to collect an application fee unless you are also approved for a waiver through Health First Colorado.
At the end of the provider enrollment application, providers will be prompted to pay the enrollment application fee, if required. Health First Colorado accepts credit, debit cards, or direct bank account withdraw for enrollment application fee payments; cash or checks are not accepted. Health First Colorado will not start processing an enrollment application until the application fee is paid. If an application fee is returned due to insufficient funds, an email notification will be sent to the provider. The provider must submit the enrollment application fee within 60 days or be denied enrollment with Health First Colorado.
Only if both provider types are required to pay the application fee and are operating from separate service locations. If you are applying for more than one provider type, operating from the same service location, you only need to pay the fee once.
A backdate request form must be filled out and sent to DXC.
No, your revalidation will not be automatically backdated. Currently, there is no functionality to automatically backdate. DXC is working on making this process easier.
Currently, the average processing time is one week.
We do not advise you to see a Health First Colorado member before enrolling. However, if you do, claims do not need to be billed while waiting for enrollment. The provider would qualify for a timely waiver (timely override) when submitting a claim older than 365 days from the date of service (DOS). Attach one of the following to the claim:
Please enter your primary TPID into the ERA panel and attach the second one in the "Attachments and Fees" panel.
EFT is required for all providers except:
If the above exceptions apply to you, and you do not want to provide your EFT information, please follow these EFT Exemption Instructions.
Either a voided check or bank letter dated within the last 6 months is required for enrollment. Note: A voided check must be pre-printed with matching legal or DBA name and the billing, location, or mailing address. A bank letter must include the name of the owner of the account, financial institution transit number, provider's account number, date (within the last six months), a bank representative signature, and be printed on the bank's letterhead. A temporary check or deposit slip is not acceptable.
Electronic Remittance Advice (ERA) is an electronic version of a payment explanation which provides details about providers' claims payment. ERA in the Online Provider Enrollment application is the same as the Provider Claim Report (PCR) you may currently receive. However, you do still need to include this information on your application in order for your application to be approved.
A Provider's Agent (Billing Agent) receives the payment for claims submitted to Medicaid and all the reports needed to process the payments and resolve Accounts Receivable (A/R). The Vendor only submits claims for payment and may receive reports but no payment is distributed to them.
No, a billing agent does not qualify as either a clearinghouse or vendor.
Billing agent information should also be included in the ERA panel.
Clearinghouses must be enrolled/validated in the Colorado interChange in order to submit claims/receive payments on behalf of their contracted providers. Please see the definitions below more information about what constitutes a clearinghouse or software vendor.
The Department has aligned risk levels for most providers with the risk levels determined by the federal Centers for Medicare and Medicaid Services. For "Medicaid only" providers, including many providers who are unlicensed by the state of Colorado, the Department assigned risk levels. These risk levels were determined based on several criteria, including input from a workgroup and stakeholders, and the unique circumstances of each provider type.
To find out what your risk level is, please see our Information by Provider Type and Information by HCBS Service Provided pages.
Providers enrolling as more than one provider type must submit an application for each provider type. Each application shall be screened at the appropriate risk level.
Different screening requirements are applied to each risk level:
Please Note: Site visits are conducted by the Department's fiscal agent, DXC Technology (DXC). Site visits are typically unannounced, but may be scheduled at DXC's discretion.
There will be a list on our website; however, the location has not yet been determined.
Disclosure Completion Instructions for Enrollment using a Federal Employer Identification Number (EIN)
Disclosure Completion Instructions for Enrollment using a Social Security Number (SSN)
Definitions (42 C.F.R. § 455.101)
Agent means any person who has been delegated the authority to obligate or act on behalf of a provider.
Disclosing entity means a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent.
Other disclosing entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or XX of the Act. This includes:
Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency.
Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).
Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.
Managed care entity (MCE) means managed care organizations (MCOs), PIHPs, PAHPs, PCCMs, and HIOs.
Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.
Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity.
Person with an ownership or control interest means a person or corporation that:
Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider's total operating expenses.
Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Health First Colorado (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).
Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider.
42 CFR § 455.102 Determination of ownership or control percentages
(a) Indirect ownership interest. The amount of indirect ownership interest is determined by multiplying the percentages of ownership in each entity. For example, if A owns 10 percent of the stock in a corporation which owns 80 percent of the stock of the disclosing entity,
A's interest equates to an 8 percent indirect ownership interest in the disclosing entity and must be reported. Conversely, if B owns 80 percent of the stock of a corporation which owns 5 percent of the stock of the disclosing entity, B's interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported.
(b) Person with an ownership or control interest. In order to determine percentage of ownership, mortgage, deed of trust, note, or other obligation, the percentage of interest owned in the obligation is multiplied by the percentage of the disclosing entity's assets used to secure the obligation. For example, if A owns 10 percent of a note secured by 60 percent of the provider's assets, A's interest in the provider's assets equates to 6 percent and must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider's assets, B's interest in the provider's assets equates to 4 percent and need not be reported.
Federal regulations require that the Department screen not only providers, but any person or entity with an ownership or control interest in the provider. Boards of Directors have a significant control interest; therefore, each member of the Board must be screened individually. A list of Board member names is not acceptable. Board member information will be kept securely in the Colorado interChange system, just like Health First Colorado member personal information, and will not be released to the public.
Yes. If your "enrollment type" is a group, facility, or atypical (enrolling with an EIN) you have ownership or controlling interest. Even if you have a volunteer board of directors with 0% controlling interest, you must disclose them. This is required in order to be compliant with the Federal Provider Screening Regulations (you can type 0 in the % interest box, if applicable).
These frequently asked questions focus on common issues providers ask when trying to better understand the rules and exemptions for timely filing. Additional information on timely filing is also available in the General Provider Information manual.