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Revised: November 2014
Yes, for direct pay providers. When the legal name of an enrolled provider changes (individual, business venture, or institution), a W-9 completed with the new information is required. Please include a letter indicating the change and attach a copy of the supporting documentation for the legal name change.
Indirect pay, or rendering individuals do not require a W-9, only a letter requesting the name change. The request must include a copy of the supporting documentation for the legal name change.
Electronic Funds Transfer (EFT)
IRS LTR 147C Form
An IRS LTR 147C is a form issued by the Department of the Treasury Internal Revenue Service (IRS) that shows the entity legal name, dba, address and EIN exactly as registered. Providers requesting direct payment are added to the State’s financial system and the information is screened with the IRS.
A copy of the IRS LTR 147C form may be required for legal name and EIN verification. Providers may want to submit a copy of the form with the W-9 to avoid delays in payments. A copy of the IRS LTR 147C form can be obtained by calling 1-800-829-4933.
A group provider is a facility, agency or clinic that will submit claims on behalf of one or more rendering providers enrolled with Colorado Medicaid. Group providers complete and submit the standard provider application, income is reported under the EIN. Examples: organized health clinic, dental clinic, rehab agency, rural health clinic, and federally qualified health center.
If a provider does not submit any claims for 24 consecutive months, the State of Colorado will terminate for no claims activity. Notification is sent to effected providers 30 days prior to termination with instructions. Once terminated, if the provider wants to reactivate their enrollment, a new application with the originally assigned provider number noted on the application must be completed and submitted.
Medicare Certification is a letter from Medicare confirming the provider’s Medicare enrollment including the effective date. The Medicare Remittance Notice (MRN) does not meet the requirements because it does not indicate the enrollment effective date. Crossover claims are affected if the Medicare Certification is incorrect or missing.
An application takes eight business days to process unless the provider type requires State approval or if information is missing or incomplete. Providers are responsible for submitting all required information to ensure timely application processing.
General Hospital (in state), Psychiatric Residential Treatment Facility, Residential Child Care Facility, Rural Health Clinic, Mental Hospital, Behavioral Health Organization, Hospice, Case Manager, Federally Qualified Health Center, School Health Services, Nursing Facility, HCBS Waiver Programs, Health Maintenance Organization, Community Mental Health Center, Family Planning Clinic, Dialysis Center, out of state Supply/Transportation, Pharmacy, Mail Order Pharmacy, Rural Dispensing Physician Site Pharmacy, Indian Health Service/Tribally Operated Pharmacy, Home Health, HCBS Developmentally Disabled, Regional Care Coordination Organization, and Audiologists for the Colorado Hearing Intervention Program (CHIP).