Last revised 3/27/2024
Request Information Page
☐ Enrollment Type
- Select the Billing Individual enrollment type from the dropdown.
- Note: Individual/Social Security Number (SSN) enrollments are limited to one enrollment only.
☐ Provider Type
- See a complete list of provider types on the Information by Provider Type web page.
☐ Requesting Enrollment Effective Date
- 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.
☐ National Provider Identifier (NPI)
- Know the individual (Type-1) NPI and zip code +4; applications will be returned if using an organizational (Type 2) NPI.
- Don’t have an NPI and need one? One can be obtained from the National Plan & Provider Enumeration System website.
☐ Taxonomy Code
- Know the individual's primary taxonomy code.
- At least one of the taxonomy codes included in the application must match at least one of the taxonomy codes associated to the NPI in the National Plan & Provider Enumeration System (NPPES).
- A complete Health Care Provider Taxonomy Code Set can be found on the National Uniform Claim Committee website.
- The NPPES NPI Registry lookup can be used to see the taxonomy codes that are currently associated with the NPI.
☐ Tax ID Number
- Enter the Social Security Number (SSN) for the individual and check SSN in the Tax ID Type. (An individual must enter their SSN.)
- Effective date for the SSN is optional.
☐ Contact Information
- This Contact email address will receive notifications regarding the status of the application.
Specialties Page
☐ Specialty
- 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 and then use the Taxonomy dropdown to indicate the area of specialty.
☐ Additional Taxonomy Codes (optional)
Addresses Page
☐ Service Location Address Information (including zip code + 4)
- A primary email address and office phone number are required.
- 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.
☐ Billing Address Information (including zip code + 4)
- 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 (billing, mailing, or service location) must match the address on the W-9.
☐ Mailing Address Information
- 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
☐ Legal Name (First and last names are required)
☐ Gender
☐ Birth Date
☐ Degree Information (if applicable)
- Degree, School, year of graduation
☐ Organizational Structure
- This should match the federal tax classification indicated on the W-9 under the SSN of the enrolling individual.
☐ Payer
- Select the appropriate Payer. 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.
☐ License Information (if applicable)
- 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.
☐ Certification Information (if applicable)
- 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".
☐ Medicare Number (if applicable)
- 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.
☐ Clinical Laboratory Improvement Amendments (CLIA) information (if applicable)
- CLIA number, effective date, and end date.
☐ Drug Enforcement Administration (DEA) information (if applicable)
- DEA number, effective date, and end date.
Network Participation Page
☐ MCO/RAE Network;
- 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
☐ All languages that are able to be translated (if applicable)
EFT Enrollment Page
☐ Federal Agency Information (if applicable)
- Federal Program Agency name, identifier, and location code.
☐ Financial Institution Information (this is required)
- Financial Institution name, ABA routing number, type of account (checking/savings), account number, and the EIN or NPI.
- EFT is required for all Billing Individual applications except for Out-of-State providers.
Other Information Page
☐ Insurance Information
- Carrier name, policy ID, insurance type, effective date, and expiration date.
☐ Supplemental Questions – Medicaid Participation
- Please read each question carefully and answer yes or no as applicable. Enter the applicable states when indicated.
☐ Website address (optional)
Disclosures Page
☐ Disclosure Information
- Health First Colorado cannot advise providers on how to determine owner data and controlling interest requirements, but can provide the following resources:
- Disclosure Completion definitions and Instructions for Enrollment using a Social Security Number (SSN) (located under “Provider Enrollment and Update Forms”.)
- Please note the applicant is the “disclosing entity” for these questions.
Attachment and Fees Page
Scan and attach:
☐ Certifications and licenses (if applicable)
- Some providers are required to have specific licenses and certifications. Check the Information by Provider Type web page for a list of requirements based on provider type.
☐ Proof of Education (if applicable)
- Transcripts are not sufficient and will not be accepted.
☐ W-9 (signed and dated within the past 6 months, completed using SSN)
- The address on the W9 must match one of the addresses entered in the application.
☐ Voided check or bank letter (bank letter signed and dated within the past 6 months)
- 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.
☐ For each MCO or RAE contracted with, a copy of one of the following is required:
- 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.
☐ Completed Affidavit of Lawful Presence Form(located under the Provider Enrollment & Update Forms heading)
- 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
☐ Drug Enforcement Administration (DEA) License (if applicable)
Agreement
☐ The terms of enrollment are identified in the Provider Participation Agreement which must be read, agreed to, and accepted for enrollment.
- If multiple payers were selected, multiple agreements must be read, agreed to, and accepted.
Summary
☐ Review all data entered in the enrollment application, make additional changes if needed and print a file copy of the application.