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ATTENTION: The Provider Web Portal will limit the number of open/outstanding provider enrollment updates per unique service location as follows: • One (1) open Provider Maintenance or Revalidation update and • One (1) open Electronic Funds Transfer (EFT) update Refer to the examples below: • If the service location has previously submitted an EFT enrollment application and the application is still under review, the location will be unable to submit another EFT enrollment application. • If the service location has previously submitted a provider maintenance request and the request is still under review, the location will be unable to submit another provider maintenance request or a revalidation application. Refer to the Provider Maintenance Quick Guide, Provider Maintenance – License Update Quick Guide, Provider Maintenance – Adding an NPI Quick Guide, and Provider Maintenance – Hospital Providers Adding an NPI Quick Guide available on the Quick Guides and Webinars web page for more information. Contact the Provider Services Call Center at 1-844-235-2387 with questions.
The Affordable Care Act (ACA) requires certain providers to remit an application fee. The Centers for Medicare & Medicaid Services (CMS) sets the fee annually. This fee is assessed at initial enrollment, revalidation, and change of ownership, as required, and is assessed in full for each service location enrolled in CO Medicaid.
Effective January 1, 2020 the Provider Enrollment Applications Fee has been set at $595 for the 2020 calendar year.
For questions, please contact Provider Services Call Center (1-844-235-2387).
Pursuant to State Bill 16-027, pharmacies are no longer required to enroll as “mail order” pharmacies to provide maintenance medications through the mail to eligible members. Members may use the pharmacy of their choice to receive maintenance medications, which includes in-state and out of state pharmacies.
Effective October 2, 2019, out of state mail order pharmacies will be allowed to enroll with the Health First Colorado (Colorado’s Medicaid Program) mail order program without submitting the previously required Pharmacy Attestation Questionnaire form. Following this change, all application and enrollment criteria for out of state mail order pharmacies is the same as for in-state pharmacies.
Providers are reminded to enter the actual DOB for individuals, owners and managing employees, in the appropriate sections of the enrollment application (Provider Identification and Disclosures). In accordance with federal screening rule 42 CFR § 455.104 and Colorado Code of Regulations 10 CCR 2505-10 8.125.15, a verification is completed for all individuals and when the DOB does not match, the application is returned to the provider for correction(s) or denied.
New applications and enrollment updates are currently being processed by DXC within 10 business days on average.
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.