Follow the format below for the EFT “Dummy” Information.
Important: Only the following providers are eligible for an EFT exemption:
- Out of State providers (any provider type)
- Case Manager (11) provider type
- Colorado State Government Entities (any provider type) Instructions
On the EFT page of the application, enter the following:
- Financial Institution Name: “EFT Exemption”
- ABA Routing Number: “111111111” (9)1’s
- Type of Account at Financial Institution: Checking Provider's Account Number with Financial Institution: “111111111” (9)1’s
- Account Number Linkage to Provider Identifier: Must enter real provider Tax Identification Number (TIN) or National Provider Identifier (NPI)
- Include with Enrollment Submission on the Attachments and Fees page: Bank Letter
