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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. The final regulations are being implemented at a federal level and were published in the Federal Register in February 2011.
Federal law and regulations require the Department to screen all Colorado Medicaid providers according to the provisions of the federal provider screening rule.
All screening pursuant to this rule will be conducted by the Department and the Department’s contractors.
There is a cost to some provider types. Please see the Fees and Exemptions FAQs for more details. To find out if your provider type(s) require 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 of the HCBS services you provide can be added to one application. Do NOT submit a separate application for each specialty.
Yes, all providers who are enrolled with and bill Medicaid for services under the state plan or a waiver must be screened under this rule.
All providers must revalidate at least every five years. The Department may require certain providers to revalidate more frequently.
The Department sent the initial revalidation notice letters to all enrolled providers between September 2015 and March 2016. In the future, providers will be notified of the need to revalidate via email.
No, all providers need to revalidate, regardless of whether you received the Revalidation Notice letter.
This depends on your provider type and enrollment type; please follow the instructions on our Provider Revalidation and Enrollment web page.
The Provider Manual located on our website walks you through all the enrollment screens and has helpful hints on what is needed to complete the application. There are also Web-Based Training courses that are intended to help you prepare for the enrollment process. Please review the applicable trainings before you begin enrollment. All training resources can be found on our Revalidation and Enrollment Instruction web page.
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 Medicaid providers according to established guidelines. Your SSN is required for the screening process, even though your Medicaid 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 BHO/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:
Yes, but not until November 2016 when we switch over to using the Colorado interChange for claims payments. Closer to November 2016, you will be able to log into the Provider Portal and change this field, if necessary. Upon full implementation of interChange, providers will be able to change this field at any time 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 Colorado Medicaid 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 these types of practitioners would be a Psychologist – Masters or Psychologist – Doctorate, respectively. LMFT, LPC, or Addiction Counselor is indicated through the taxonomy code.
Use the date on the Colorado Department of Education License or your current effective date if you are currently enrolled in Colorado Medicaid.
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 Colorado Medicaid. 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 Colorado Medicaid 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 Medicaid provider number once their enrollment application is approved. This Medicaid provider number should be included on all transactions submitted to Colorado Medicaid.
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.
The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are alphanumeric and are 10 positions in length. These codes are not “assigned” to health care providers; rather, health care providers select the taxonomy code(s) that most closely represents their education, license, or certification.
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.
A quick Google search for “provider taxonomy codes” will provide you with many options.
In accordance with federal regulations and guidance, providers with multiple service locations (sites) must enroll each location separately. For example, a Federally Qualified Health Center (FQHC) with several service locations would need to enroll each service location separately.
Not always. Please see the information by HCBS service provided page for more details.
Colorado Medicaid 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). Each year, CMS will publish the application fee via the Federal Register 60 days prior to the new CY. The fee for calendar year 2016 is $554.00. 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 2017 to $560.00. This new fee amount will go into effect on January 1, 2017.
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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:
An application that is subsequently denied as a result of the imposition of a temporary moratorium enrollment of a particular provider type
Maybe. Service locations that have enrolled or revalidated with Medicare (and have been approved) are not required to pay the fee again to Colorado Medicaid. However, service locations that are not enrolled or revalidated with Medicare will require the fee.
Yes. Colorado Medicaid 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, Colorado Medicaid is still required to collect an application fee unless you are also approved for a waiver through Colorado Medicaid.
At the end of the provider enrollment application, providers will be prompted to pay the enrollment application fee, if required. Colorado Medicaid accepts credit, debit cards, or direct bank account withdraw for enrollment application fee payments; cash or checks are not accepted. Colorado Medicaid 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 Colorado Medicaid.
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.
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.
We will not enroll clearinghouses or software vendors until closer to November 2016. 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.
Regardless of provider type, the following providers will be screened as high risk:
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:
(a) Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII);
(b) Any Medicare intermediary or carrier; and
(c) Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health related services for which it claims payment under any plan or program established under title V or title XX of the Act.
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--
(a) Has an ownership interest totaling 5 percent or more in a disclosing entity;
(b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;
(c) Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;
(d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;
(e) as an officer or director of a disclosing entity that is organized as a corporation; or
(f) Is a partner in a disclosing entity that is organized as a partnership.
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.
(a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or
(b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.
Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (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 Medicaid 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).