Facility Enrollment Checklist

Last revised 1/22/2026

Request Information Page

• Select the Facility enrollment type from the dropdown.

• See a complete list of provider types on the Find Your Provider Type web page.

• 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.

• Know the organizational (Type-2) NPI and zip code +4.
• Don’t have an NPI and need one? One can be obtained from the National Plan & Provider Enumeration System website.
• The application will be returned for correction if an individual (Type-1) NPI is used on the application.

• A complete Health Care Provider Taxonomy Code Set can be found on the National Uniform Claim Committee website.
• 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).
• Health First Colorado does not offer advice about which taxonomy code(s) should be used, but the NPPES NPI Registry lookup can be used to see the taxonomy codes that are currently associated with the NPI.

• Enter the Federal Employer Identification Number (EIN) of the business.
• Effective date for the EIN can be left blank or enter a date equal to or earlier than the requested enrollment effective date.

• This Contact email address will receive notifications regarding the status of the application.

Change of Ownership (if applicable)

• A change of ownership occurs when a new Federal Employer Identification Number (EIN) is issued. Appointing a new board of directors does not constitute a change of ownership and these changes may be submitted through the Disclosures panel of the Provider Maintenance or Revalidation applications. Additionally, House Bill 18-1282 requires newly enrolling Organization Health Care Providers (not individuals) to obtain and use a unique National Provider Identifier (NPI) for each service location and provider type enrolled with Health First Colorado.

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 and then use the Taxonomy dropdown to indicate the area of specialty.

Addresses Page

• Each service location requires a separate application.
• 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 "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.

• 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.
• 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 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.

• Bond #, effective date, end date, ACC effective date, and ACC end date.

• 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.

• CLIA number, effective date, and end date.

• DEA number, effective date, and end date.

• NCPDP ID # (if applicable)
• Pharmacy Classification (required)
• Do not forget to attach proof of NCPDP on the Attachments and Fees page of the application. Refer to the NCPDP Resources web page for instructions on printing proof of NCPDP.

Network Participation Page

• Complete if participating in any of Colorado Medicaid’s Managed Care Organizations (MCO) or Regional Accountable Entities (RAE).

Languages and Primary Employer/Owner Page

EFT Enrollment Page

• Federal Program Agency name, identifier, and location code.

• Pharmacy name, chain number, parent organization ID, payment center ID, NCPDP number, and Medicaid provider ID.

• 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.
• Do not forget to attach a copy of the insurance face sheet on the Attachment and Fees page of the application (applicable to Nursing Facilities only).

• Please read each question carefully and answer yes or no as applicable. Enter the applicable states when indicated.

 Additional Information

☑  Additional Provider Search Options (optional)

Addendums Page

• Note: This list of questions is provided for convenience only. Addendum MUST be completed from within the application.
• Please list the total number of prescriptions dispensed in the last 12 months. If the pharmacy has been open for less than 12 months, please list the total number of prescriptions dispensed for the months the pharmacy has been open. If the pharmacy is the only Medicaid-participating pharmacy within twenty miles (driving distance) of its physical location, then claim "Yes" on the rural line. NOTE: The prescription date range should not exceed one (1) year.
  • Total prescriptions, from date, to date, rural (y/n).
  • Please list the approximate percentage of prescriptions dispensed for each classification. NOTE: The percentages should add up to 100%.
  • Medicaid %, Medicare %, other third-party %, cash %.

Disclosures Page

• Health First Colorado cannot advise providers on how to determine owner data and controlling interest requirements, but can provide the following resources:
  • Disclosure Completion Instructions for Enrollment using a Federal Employer Identification Number (EIN) (located under “Provider Enrollment and Update Forms” heading).
  • The enrolling entity is the "disclosing entity" for the purpose of these questions.
• School Health Services providers - see the Find Your Provider Type web page under "School Health Services", for disclosure instructions specific to the provider type.

Attachment and Fees Page

Scan and attach:

• Some providers are required to have specific licenses and certifications. Check the Find Your Provider Type web page for a list of requirements based on provider type.

• The address on the W9 must match one of the addresses entered in the application.

• 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.

• Please see the Find Your 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