Health First Colorado Add-A-Baby Emergent Request Form

This page is for providers to submit an Emergent Request to add a baby to an existing Health First Colorado (Colorado’s Medicaid program) case. An Emergent Request is only for babies who need intensive medical attention for Border, Synagis, or Neonatal Intensive Care Unit (NICU).

Providers, before submitting an Emergent Request:

  • Verify with the parent(s) that a request to add a newborn has not been submitted to the county and/or submitted via PEAK or the Health First Colorado Mobile App.

If a request has already been submitted by the parent(s) to the county and/or by the parent through PEAK or the Health First Colorado App:

  • Do not submit an Emergent Request using the Add-A-Baby Request Form, as this may cause a delay in approval of benefits and a delay in provider payments.
  • Do not submit a request to obtain the newborns Member ID only.
  • Please check the Provider Web Portal, contact the parent(s) and/or the county to obtain the Member ID.
  • Providers can verify a newborn’s eligibility through the Provider Web Portal. Providers can search with two of the following: Name, SSN, DOB. This information can be found on the Eligibility Verification section in the Provider Web Portal (see Verifying Member Eligibility Quick Guide)

Please inform the parent(s) you are submitting a request to add the baby, so parents will not submit a duplicate request. Duplicate requests will cause delays.

For all non-emergent requests, please contact the parent’s county department of human services. The parent can also contact their county department of human services or use PEAK or the Health First Colorado App to add the newborn.

Instructions

  1. DO NOT SUBMIT A DUPLICATE REQUEST. If the newborn baby is not showing as eligible within 7 business days after submitting a request, send an email to hcpf_add-a-baby@state.co.us.
  2. Complete all fields in the form below. Fields with * are required. If mandatory fields are not completed, the request form will not submit.
  3. Complete the "Add Additional Baby" section on the request form if you are adding twins/triplets.
  4. CHECK FOR ACCURACY BEFORE SUBMITTING THE REQUEST. Errors may delay the ability to process your request.

IF YOU ARE NOT A MEDICAL PROVIDER, DO NOT USE THIS REQUEST FORM and do not send an email. The request will not be processed.

Webform


Information about Submitter


Information About Mother

What is a Member ID? A Member ID is the state identification number an individual is assigned when approved for Medical Assistance. It consists of a letter followed by a six-digit number. It is also referred to as a Health First Colorado (Colorado Medicaid) ID number and can be found on the Medical Identification Card (MIC). Example: D999999
What is a case number? A case number is assigned when an individual submits an application for public assistance. It consists of seven characters and begins with 1B. It is also referred to as a CBMS Case ID and can be found on county/state paperwork such as an approval or denial notice. Example: 1B99999

Information about the Newborn

NOTE: The newborn’s information must be the same as it appears on the birth certificate application. Please include the middle name, if available.


NOTE: Please review all information you have entered on the request form to ensure accuracy.