Facility Enrollment Checklist | Department of Health Care Policy and Financing

Last revised 3/27/2024

Request Information Page

Enrollment Type

Select the Facility enrollment type from the dropdown.

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 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.

Taxonomy Code

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.

Tax ID Number

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

Contact Information

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

Change of Ownership

Indicate if this enrollment is due to a change of ownership with a change of EIN.

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

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.
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.

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

Provider Legal Name

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.

Organizational Structure

This should match the federal tax classification indicated on the W-9.

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.

Durable Medical Equipment Information (if applicable)

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

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.

National Council for Prescription Drug Programs (NCPDP) information (if Pharmacy)

NCPDP ID # (if applicable)
Pharmacy Classification (required)
Do not forget to attach proof of NCPDP on the Attachments and Fees page of the application. Please follow the instructions to download proof of the NCPDP.

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.

Retail Pharmacy Information (if applicable)

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

Financial Institution Information (this is required)

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

Insurance Information

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).

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)

Addendums Page

Pharmacy Dispensing Fee Addendum (if Pharmacy)

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

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 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 Information by Provider Type web page under "School Health Services", for disclosure instructions specific to the provider type.

Attachment and Fees Page

Scan and attach:

Insurance face sheet (applicable to Nursing Facilities only)

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.

W-9 (signed and dated within the past 6 months)

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.

Clinical Laboratory Improvement Amendments (CLIA) certificate (if applicable)

For application fee payment (if applicable)

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.

Proof of payment

If the application fee for another state’s Medicaid program, for this service location, has already been paid.

Hardship waiver request letter and supporting documentation (if applicable)

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

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.