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Atypical Enrollment Checklist

Last revised 3/27/2024

request information page with Atypical highlighted

See a complete list of provider types on the Information by Provider Type web page.  

Note: This checklist is for Atypical providers that are NOT Home and Community-Based Services (HCBS) providers. HCBS (waiver) providers may visit the Enrollment Type web page for different instructions.

Request Information Page

  
  • Select the Atypical enrollment type from the dropdown.
  • Note: Individual/Social Security Number (SSN) enrollments are limited to one enrollment only.
  
  
  • A future enrollment effective date is not allowed. A backdate (up to ten months) can be requested; however, the request is not a guarantee of approval. See the Backdate Enrollment Quick Guide.
  
  
  
  • Some Atypical provider types require an organization to enter an EIN, some require an individual to submit an SSN, some may use either. Please check the Tax ID requirements for the service(s) being provided on the Information by Provider Type web page.
  • Enter the Federal Employer Identification Number (EIN) or Social Security Number (SSN) as applicable and select the corresponding Tax ID Type.
  
  • This Contact email address will receive notifications regarding the status of the application.

Specialties Page

  
  • Select the appropriate specialty from the dropdown.
  • There are many instances where the only specialty option is the provider type chosen. If this is the case, select the only option available.
  • When an NPI is required use the “Taxonomy” dropdown to indicate the area of specialty.
  
  • Do not add taxonomy codes if an NPI is not provided.

Addresses Page

  
  • A primary email address and office phone number are required.
  • Each service location requires a separate application for business (FEIN) enrollments. Individuals (SSN) enrollments are limited to one enrollment only.
  • Service location must be a physical address and cannot be a PO Box.
  • Including the 9-digit (zip code + 4) service location zip code is crucial for claims payment. Don’t know the 9-digit zip code? Look it up on the USPS website.
  
  • A primary email address and office phone number are required.
  • A "Pay to Name" is required; e.g., Office Manager, Billing Manager.
  • One of the addresses (service location, billing or mailing) must match the address on the W-9.
  
  • A primary email address and office phone number are required.
  • A "Mail to Name" is required (e.g., Attn: Front Desk, mail room)

Provider Identification Page

  
  • The "Provider Legal Name" field currently only allows 50 characters, and "Doing Business As" allows 30 (including spaces). Please truncate Legal and DBA names, if necessary.
  • Individuals (SSN enrollment) enter their full name – E.g., First Middle Last, First M. Last.
  • The "Doing Business As" is optional. If a DBA is used, please enter it exactly as registered.
  
  • This should match the federal tax classification indicated on the W-9.
  
  • Select the Title XIX Payer option. (Applicable Payer checkboxes will be enabled and at least one Payer must be selected. Medicaid is Title XIX Payer, Colorado BHA is the Colorado Department of Human Services, Behavioral Health Administration.)
  
  • Issuing authority, license #, effective date, expiration date, issuing state, and type are required. 
  • Be sure to enter the entire license number including alpha and numerical characters as well as dots, dashes, etc.
  • Don’t forget to attach a copy of the license on the Attachment and Fees page of the application.
  
  • Specialty, certification type, effective date, end date, certification #.
  • If the certification does not have an end date, use 12/31/2299. If there is no certification number, enter "N/A".
  
  • The Effective Date for the Medicare number and the Medicare Type is needed.
  • The information included in the application should match what was submitted to Medicare.

Network Participation Page

  
  • Complete if participating in any of Colorado Medicaid’s Managed Care Organizations (MCO) or Regional Accountable Entities (RAE).
  • For each MCO or RAE contracted with, attach a copy of one of the following on the Attachment and Fees page of the application:
    • A completed Network Participation Verification Form (located under the Provider Enrollment & Update Forms or
    • The contract page(s) that identifies the contracting parties, the program name (e.g., Denver Health Medicaid Choice, Colorado Access, etc.) and the page(s) with signatures of both parties, including the date; or
    • The entire contract with the MCO or RAE.

Languages Page

  

EFT Enrollment Page

  
  • Federal Program Agency name, identifier, and location code.
  
  • Financial Institution name, ABA routing number, type of account (checking/savings), account number, and the EIN or NPI.
  • Have a copy of a W-9 and a bank letter or voided preprinted check, to attach later in the application. The W-9 and bank letter must be dated within the last 6 months and match one of the addresses previously entered (service location, billing and/or mailing).
  • Note: EFT is required for all applications except for Out-of-State providers, and Colorado State Government Entities. If qualified for an EFT exemption and not wanting to provide EFT information, please follow these EFT Exemption Instructions.

Other Information Page

  
  • Carrier name, policy ID, insurance type, effective date, and expiration date.
  
  • Please read each question carefully and answer yes or no as applicable. Enter the applicable states when indicated.
  

Addendums Page

  

Disclosures Page

  

Attachment and Fees Page

Scan and attach:

  
  
  • If applying using the SSN for the Tax ID, the W-9 should also use the SSN.
  • If applying using an EIN for the Tax ID, the W-9 should also use the EIN.
  
  • Voided checks must be preprinted; temporary checks are not accepted. The imprinted name on the check or bank letter needs to match the legal or DBA name.
  
  • A completed Network Participation Verification Form (located under the Provider Enrollment & Update Forms heading); or
  • The contract page(s) that identifies the contracting parties, the program name (e.g., Denver Health Medicaid Choice, Colorado Access, etc.) and the page(s) with signatures of both parties, including the date; or
  • The entire contract with the MCO or RAE.
  
  • Requires a copy of one of the following:
    • A valid Colorado driver’s license or Colorado ID card; or
    • A United States military or military dependent’s ID card; or
    • A United States Coast Guard Merchant Mariner card; or
    • A Native American Tribal Document
  
  • Please see the Information by Provider Type web page for a list of requirements based on provider type to determine if an application fee is required.
  • Either a credit card number or EFT account information is needed.
  • Application fee can only be paid online (via the Attachments and Fees page of the application).
  • Credit card payment-processing fee is an additional 2.95%; EFT payment-processing fee is $2.50.
  
  • If the application fee for another state’s Medicaid program, for this service location, has already been paid.
  
  • Recommended supporting documentation includes most recent entity tax return(s), financial profit/loss exports (i.e., QuickBooks, Xero, etc.), three or more bank statements, and any additional documentation that would validate the hardship(s) indicated within the hardship letter.
    • Additional supporting documentation may include but is not limited to historical cost reports, recent financial reports such as balance sheets and income statements, cash flow statements, liability obligations, tax returns, etc.

Agreement

  
  • If multiple payers were selected, multiple agreements must be read, agreed to, and accepted.

Summary