Provider FAQ Central

Billing

Accounting

Accounting Fact Sheet (includes EDI, EFT, and Paper Warrant information)

Appeals

If all means of achieving satisfactory claim resolution through the fiscal agent and the Claims Processing unit have been exhausted, providers may file a written appeal with the Office of Administrative Courts, at the address listed in Appendix A on the Billing Manuals web page under Appendices.

Appeals submitted to the Office of Administrative Courts must be received within 30 days from the mailing date of the last notice of action.

Eligibility

Eligibility Fact Sheet

Load Letters

Load Letter Fact Sheet

Change of Ownership (CHOW) FAQs

The following are specific resources to assist in better understanding questions around when a change of ownership has occurred and what steps providers need to take to prepare.

What is a change of ownership?

A change of ownership occurs when a new Federal Employer Identification Number (EIN) is issued.

If there is no change in the EIN, a change of ownership notification is not necessary. Other changes, such as a change in owners or board of directors may be submitted through the Disclosures panel of the Provider Maintenance or Revalidation applications.

Legal name changes are submitted using the Legal Name Change Form. Complete the form, include the required documentation, and submit via the Provider Web Portal using the steps indicated on the form.

If my organization's board of directors turns over and a new board is appointed, does that constitute a change of ownership?

No. Appointing a new board of directors does not constitute a change of ownership.

How do I prepare for the change of ownership?

Before the new owner starts billing, an application must be approved for the new business. The seller must stop billing claims before the new owner begins billing.

What needs to be done if there is a Change of Ownership?

Providers with a change in EIN must re-apply through the Provider Enrollment Portal, complete a new Medical Assistance Program Provider Participation Agreement, and be fully approved in order to participate in Health First Colorado. The previous Health First Colorado number must be disenrolled and a new Health First Colorado number will be assigned.

The disenrolling entity needs to submit a Disenrollment request choosing “Change of Ownership” as the disenrollment reason. This is done on the Provider Portal using the “Disenroll” button.

Can the same National Provider Identifier (NPI) be used after the ownership has changed?
No. House Bill (HB) 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.
Can a provider change their Tax ID on their enrollment record?
No. Providers must apply for a new Health First Colorado ID with the new EIN.

Fingerprinting

 

Federal regulations (42 CFR 455.434) established by the Centers for Medicare and Medicaid Services (CMS) require enhanced screening and revalidation of all Medicare, Medicaid, and Children’s Health Insurance Program providers. Fingerprint criminal background checks are based on the level of screening for risk of fraud, waste and abuse as determined for that category of provider type.

No. Only providers designated as high-risk, and owners of high-risk providers, must comply.

Yes, all high-risk providers need to comply.

Your background will be checked with the Colorado Bureau of Investigation and the Federal Bureau of Investigation through the state-approved vendors IdentoGo or Colorado Fingerprinting.

Yes, fingerprint criminal background checks apply to both existing and new enrollments.

Per state and federal regulations, any entity enrolling as a provider type designated as high categorical risk and any person with five percent (5%) or more ownership or control interest in a provider designated as high categorical risk, must consent to criminal background checks and submit a set of fingerprints within 30 calendar days upon request from the CMS, the Colorado Department of Health Care Policy & Financing (the Department), the Department’s agents, or the Department’s designated contractors.

The five percent (5%) ownership threshold applies to all forms of organizations, including partnerships.

Provider types designated as high categorical risk:

  • Enrolling Durable Medical Equipment suppliers.
  • Enrolling Home Health agencies.
  • Enrolling Personal Care Agencies providing services under the state plan.
  • Enrolling providers of the following Home and Community Based Services:
    • Assistive Technology.
    • Homemaker.
    • Personal Care.
    • Specialized Medical Equipment and Supplies.
    • In-Home Support Services.
  • Providers for whom the Department imposes a payment suspension based on credible allegation of fraud, waste, or abuse, for the duration of the suspension.
  • Providers the Department has identified as having a delinquent debt owed to the State, not including providers currently under a settlement or repayment agreement.
  • Providers that have previously been excluded by the Health and Human Services (HHS) Office of Inspector General, had their provider agreement terminated for cause by the Department, its contractors or agents, or another State's Medicaid program within the previous 10 years.
  • Providers applying for enrollment within six (6) months from the time that the Department or CMS lifts a temporary enrollment moratorium on the provider’s enrollment type.

 

Not necessarily. Only individuals enrolled as a high-risk provider, or with a five percent (5%) ownership interest in a high-risk provider, must comply.

Providers with multiple enrollments and risk levels will be screened at the highest risk level.

Individuals only need to provide fingerprints once, and the information will apply to all applicable enrollments.

Notifications began in May 2018 for high-risk provider types. Individual providers or persons with five percent (5%) or more direct or indirect ownership interest in a high- risk provider type must submit fingerprints at an IdentoGo or Colorado Fingerprinting location. You can find more information on the CBI website.

If a provider is required to submit a fingerprint background check, the provider will be noticed electronically.

Applicants will be required to pre-enroll and schedule an appointment to have their fingerprints taken and submitted electronically to CBI for processing utilizing the IdentoGo or Colorado Fingerprinting enrollment sites. To better serve all Colorado citizens, enrollment sites have been strategically placed throughout Colorado.

Individual providers or persons with five percent (5%) or more direct or indirect ownership interest in a high-risk provider type obtains their fingerprints from one of the approved sites which can be found IdentoGo or Colorado Fingerprinting. Fingerprint cards will no longer be accepted.

There is a fee for the approved agency to perform the fingerprinting. All individuals are advised to call the approved fingerprint site for availability, cost and acceptable forms of payment can be found at the CBI Website.

The original completed fingerprints will be submitted directly to CBI from the approved finger printing site.

Allow 30 calendar days from the date the Colorado Bureau of Investigation receives the fingerprints for the process to be completed.

If the fingerprints submitted are poor quality, smudged or for any reason unusable, the individual will be notified of next steps. A replacement may be required for submission. Visit the CBI website for more information.

Individuals will not be notified directly upon passing fingerprint criminal background check. Enrollments and revalidations will continue processing once an individual enrolling as a provider type designated as high categorical risk, and each person with five percent (5%) or more ownership or control interest in a provider designated as high categorical risk have completed and passed the fingerprint criminal background.

To ensure that your fingerprint background check results are routed to the correct place, use the following codes when you set up your appointment.

IndentoGo
 

ServiceCode ServiceName
25YQG9 Department of Health Care Policy & Financing - Medicaid

 

Colorado Fingerprinting
 

CBI Unique ID Reason Fingerprinted
CPACMDCI Department of Health Care Policy & Financing - Medicaid

 

Individuals that are required by law to participate in the fingerprint criminal background check process may be denied or terminated for failure to comply.

If you are required to complete the fingerprint criminal background check process and have already done so with Medicare or another state Medicaid agency, please complete the Fingerprint Criminal Background Check Other Information panel.

The Department will verify fingerprint criminal background check completion for Medicare via the Provider Enrollment, Chain, and Ownership System (PECOS). The Medicare enrollment must be in an approved status and must indicate a ‘completed pass’ result within the last five years to be valid.

The Department will similarly verify fingerprint criminal background check completion with other state Medicaid agencies. If verification cannot be confirmed in PECOS or through another state Medicaid agency within 10 business days, then fingerprints will be required.

You will need to comply until the business or ownership interest has sold.

The provider will need to go into the Colorado interChange and update the ownership of the entity immediately.

Yes, state agencies are not allowed to share the results across departments.

Pharmacy Info and FAQs

Pharmacy Info and FAQs

Timely Filing FAQs

These frequently asked questions focus on common issues providers ask when trying to better understand the rules and exemptions for timely filing. Additional information on timely filing is also available in the General Provider Information manual located on the Billing Manual web page.