- Enrollment Best Practices
- Trading Partner Enrollment Information
- Enrollment and Web Portal Quick Guides
- Information for Ordering, Prescribing, Referring (OPR) Providers
Need to speak to a live agent for help with your enrollment? Please call the Provider Services Call Center at 1-844-235-2387, then select option 2 and then option 5.
Federal regulations established by the Centers for Medicare and Medicaid Services (CMS) require enhanced screening for all existing (and newly enrolling) providers. These regulations are designed to increase compliance and quality of care and to reduce fraud. All providers, medical or nonmedical, who are enrolled with and bill Medicaid for services under the state plan or a waiver must be screened under rule CCR 2505-10 8.100 by enrolling. In addition, providers that provide services through Managed Care Organizations (MCOs), including Child Health Plans Plus (CHP+) and Regional Accountable Entities (RAEs), need to enroll. This is necessary because the validity and currency of all provider licenses to perform any service must be screened.
Ordering, Prescribing or Referring (OPR) Provider Information
- An Overview of the Federal Medicaid Requirements for Ordering, Prescribing or Referring (OPR) Providers
The Affordable Care Act (ACA) requires physicians and other eligible practitioners to enroll in Health First Colorado to order, prescribe and refer items or services for Health First Colorado members, even when they do not submit claims to Health First Colorado.
Physicians, other practitioners and facilities who render services to Health First Colorado members based on the order, prescription or referral of an OPR provider will not be paid for such items or services unless the OPR provider is enrolled in Health First Colorado and the National Provider Identifier (NPI) number is included on the claim submitted to Health First Colorado.
- Enrolling in Health First Colorado as an OPR Provider
- Individuals who are already enrolled in Health First Colorado as rendering providers are not required to enroll separately as OPR providers. Individuals should only have one enrollment.
- OPR providers will not be listed as a Health First Colorado provider for member assignment or referral.
- Ensures that orders, prescriptions and referrals for Health First Colorado members are accepted and processed appropriately.
- Does not obligate providers to see Health First Colorado members
- In response to provider concerns, the Department will now allow provider types 05-Physician and 26-Osteopathwith training licenses to enroll as OPR providers with Health First Colorado. Providers enrolling with a training license must use taxonomy code 390200000X on the enrollment application to indicate the training license. Training licenses are not accepted for Individual Within a Group (IWG) or billing individual enrollments, full licenses are required.
- Ordering, Prescribing or Referring (OPR) Application Not Required for Individual Within a Group (IWG) Providers with Prescriptive Authority"
Providers with prescriptive authority who are enrolled as an active IWG (rendering provider) may be prescribers. They are not required to complete an additional OPR application. OPR enrollments are for providers who do not submit payment directly to Health First Colorado (Colorado's Medicaid Program) but only prescribe, refer or order for Health First Colorado members. Submitting an OPR application with the same Social Security Number (SSN) as a previously enrolled IWG may result in the application being denied as a duplicate or in denied claims.
Enrollment News and Updates
- Updating 1099 Address in Provider Web Portal
Effective October 28, 2020, the Provider Maintenance option in the Provider Web Portal has been updated to allow providers to add, view or modify the Internal Revenue Service (IRS) 1099 form mailing address linked to the associated tax ID.
Previously, providers were unable to review or update the 1099 form mailing address.
A confirmation letter will be sent to all linked provider service locations stating an update was completed. The letter will contain:
- The provider service location ID
- The user information who completed the change
- The details of the address changes made (previous and new)
Visit the Provider Maintenance - Provider Web Portal Quick Guide web page to view Address Changes for instructions on how to update an address in the Provider Web Portal.
- New Provider Specialties for COVID-19 Long-Term and Temporary Enrollment
Effective April 10, 2020, providers will be allowed to temporarily enroll in Health First Colorado (Colorado's Medicaid program) to provide services during the public health emergency. Temporary enrollment will end once the public health emergency ends. Prior to any temporary enrollments being terminated, providers will be notified and given the opportunity to convert from temporary enrollment to long term enrollment by updating the application and completing the requirements.
New applicants will be required to indicate temporary enrollment due to the public health emergency or long term enrollment.
In addition to selecting a provider type and primary specialty, each applying provider will need to add one of the following secondary specialties to their application:
- COVID-19 Long Term Enrollment - Add this secondary specialty to the application if the provider intends to continue providing services beyond the public health emergency.
- COVID-19 Temporary Enrollment - Add this secondary specialty to the application if the provider is only enrolling to provider services during the public health emergency.
This applies only to provider types for which application fees, fingerprinting and/or site visits are required, including:
- Ambulatory Surgery Center
- Community Mental Health Center
- Dialysis Center
- Federally Qualified Health Center
- Home and Community - Based Services (certain specialties only)
- Home Health
- Independent Laboratory
- Indian Health Services
- Nursing Facility
- Personal Care Agency
- Pharmacy with Durable Medical Equipment
- Physical Therapist
- Psychiatric Residential Treatment Facility
- Rehabilitation Agency Comprehensive Outpatient Rehabilitation Facility
- Rural Health Clinic
- X-Ray Facility
For providers choosing to enroll temporarily:
- By adding the COVID-19 Temporary Enrollment secondary specialty to the application, providers are acknowledging that application fees, fingerprinting and site visits, which are usually required for enrollment, will be waived.
- Once the public health emergency designation is lifted, no new temporary enrollment applications will be approved.
- Temporary providers will be able to submit claims, maintain access to program tools and finalize billing for up to 6 months following the public health emergency end date for dates of services within the emergency designation date spans.
- Temporary providers must be licensed and legally authorized to practice or deliver the services for which they will file claims in the state where the services are performed and cannot be listed on the Office of Inspector General's exclusion list for Medicare/Medicaid services.
- Provider Enrollment Application Fee Amount for Calendar Year 2021
The Affordable Care Act (ACA) requires certain providers to remit an application fee. The Centers for Medicare and Medicaid Services (CMS) sets the fee annually. This fee is assessed at initial enrollment, revalidation, and change of ownership, as required, and is assessed in full for each service location enrolled in Health First Colorado.
Effective January 1, 2021, the Provider Enrollment Applications Fee has been set at $599 for the 2021 calendar year.
Contact the Provider Services Call Center with any questions.
- Enrollment Application Date of Birth (DOB) Requirement Reminder
Providers are reminded to enter the actual DOB for individuals, owners and managing employees, in the appropriate sections of the enrollment application (Provider Identification and Disclosures). In accordance with federal screening rule 42 CFR § 455.104 and Colorado Code of Regulations 10 CCR 2505-10 8.125.15, a verification is completed for all individuals and when the DOB does not match, the application is returned to the provider for correction(s) or denied.
- Provider Enrollment Letters Updated to Include Health First Colorado (Colorado's Medicaid Program) ID
In response to provider suggestions, the Department and DXC have updated provider enrollment letters. Effective July 4, 2019, provider enrollment letters will now include the Health First Colorado ID. The National Provider Identifier (NPI) will also continue to be included in provider enrollment letters.
- Recommended Internal Revenue Service (IRS) Documentation for Provider Enrollment Application
Providers are encouraged to attach IRS documentation for groups and facilities or Atypical providers that includes the legal name and tax identification number with their Health First Colorado (Colorado's Medicaid Program) enrollment application. If additional verification is needed during the screening process, the application documents can be used to expedite the enrollment application.
- Enrollment Processing Timelines
New applications and enrollment updates are currently being processed by the Department's fiscal agent within 10 business days on average. Applications for new enrollments and changes to existing applications have been given priority, so revalidation application processing times may be delayed for the next several months.
- Individual Providers Enrolling with a Social Security Number (SSN) May Only Have One Medicaid ID
Providers with any of the following individual types may only have one application associated to an SSN, even if they provide services in multiple locations: Billing individuals, Individuals within a group (IWG), Ordering, prescribing and referring (OPR) providers. An additional application for any of these individual types with the same SSN and same NPI as a previous application (regardless of whether the individual type is the same as on the previous application) may result in the application being denied as a duplicate or denied claims. Individuals may affiliate with multiple groups in different locations.
- Provider Enrollment Type Changes
Ordering, Prescribing, and Referring (OPR) to Individual Within a Group (IWG)
OPRs are not allowed to be rendering individuals on a claim. This may prompt individuals enrolled as OPRs to change their enrollment type to an IWG to allow them to be the rendering on a claim. Before the enrollment type can be updated from OPR to IWG, providers must update their license. If only a training license is on file, then the provider must submit a current, full license through the Provider Web Portal. Once the update is submitted, providers must call the Provider Services Call Center at 1-844-235-2387 to request the change from OPR to IWG. Once the change is complete, an affiliation must be made. Providers may affiliate via the group profile through the Provider Web Portal, or the individual will have access to make the affiliation after the enrollment type change is made.
Individual Within a Group (IWG) to a Billing Individual (BI)
IWGs do not receive direct payment for services rendered. This may prompt individuals enrolled as IWGs to change their enrollment type to a BI to allow them to submit claims for his/her own services and receive direct payment. (Income is reported to the IRS under the individual's SSN.) Before the enrollment type can be updated from IWG to BI, providers must submit an Electronic Funds Transfer (EFT) update including a W-9 (with the SSN listed) and a voided check or bank letter (signed and dated within the last 6 months). Refer to the Updating an Electronic Funds Transfer (EFT) Provider Web Portal Quick Guide located on the Quick Guides web page. In addition, a separate Provider Maintenance update is required by attaching a completed Affidavit of Lawful Presence form, current license and insurance. The Affidavit of Lawful Presence form is available on the Provider Forms web page under the Provider Enrollment and Update Forms drop-down section. Once the updates are submitted, providers must call the Provider Services Call Center at 1-844-235-2387 to request the change from IWG to BI.
Provider Type Changes
The provider type (e.g. Physical Therapist, Podiatrist, Psychologist) cannot be changed.
If an enrolled individual with an SSN wants to change provider types, the existing enrollment needs to be disenrolled, the affiliations ended and a new application completed. Individual providers such as a billing individual, Individual within a group and ordering, prescribing and referring providers may not be enrolled as two different provider types under the same Social Security Number (SSN).
An additional application for any of these individual types with the same SSN will result in the application being denied as a duplicate. Individuals Within a Group may affiliate with multiple groups in different locations.