Provider Forms

Accounting
  • If it has been 30 days since the date of the payment, verify with your bank to ensure the check was not cashed. If not, please call the Provider Services Call Center at 1 (844) 235-2387 (toll-free) to see if the check has been cashed.

    If the Provider Services Call Center has determined the check has not been cashed, please fill out the Affidavit of Lost Warrant form and mail to:

Department of Health Care Policy & Financing
Accounting Department
1570 Grant Street
Denver, CO 80203-1714

Ask the customer service representative for the warrant number for your reference. Once the signed affidavit is returned, the accounting team will cancel the lost check and reissue in the Colorado interChange system.

Claim Forms and Attachments

Women's Health

Critical Incident Reporting System Forms

The following forms are for HCBS Service Providers who experience a critical incident involving a client enrolled under the following waiver programs, Brain Injury, Children's HCBS, Children with Autism, Consumer Directed Care, Elderly, Blind and Disabled, and Community Mental Health Supports,and need to report the critical incident to the SEP Agency Case Manager.

Dental Forms
  • Dental Certification - Effective October 1, 2005, this document must be completed and attached to all dental claims submitted on paper to the Department's Fiscal Agent.
  • For all other forms related to dental: DentaQuest Colorado Medicaid Dental Program Provider ORM(07/14). (This above link will redirect to the DentaQuest Colorado Providers page. Please scroll down to the DentaQuest Resources section to find the link to the current ORM).
Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) Forms

Please print the relevant questionnaire from the list below and enter all requested information. All questions must be answered in order to make a Prior Authorization Request (PAR) determination. Unless another address is specified on the form, mail the completed form and the completed PAR to:

ColoradoPAR Provider Line

ColoradoPAR Customer Service

ColoradoPAR Provider Fax

Additional information and ongoing updates can be found on ColoradoPAR.com or the Department's website.


Unit Limit and Prior Authorization Review (2016 - 2017)

In order to demonstrate sound stewardship of state resources and ensure that Medicaid members have access to and receive appropriate care, the Department sets reasonable limits on the type and amount of durable medical equipment and supplies that may be obtained without a prior authorization (PA).

In 2016, from September through December, the Department posted recommendations made by the Colorado Association for Medical Equipment Services (CAMES). They were primarily in regards to unit limits and the need or lack thereof for PA. During the posted time span, Stakeholder feedback was requested and responses were received. The Department will now review both CAMES's recommendations and the received Stakeholder feedback. Once the review is complete, any alterations to the current policy will be published with a future effective date.

For any questions regarding this review, please email: DMEPOS.BMReview@state.co.us.

For a list of the codes reviewed, please reference the DMEPOS Billing Manual.

Federally Qualified Health Center Forms
Federally Qualified Health Center Forms
Fingerprinting
Fingerprint Criminal Background Check Other State/Medicare Information Form - Complete this form if fingerprints have been submitted and approved by Medicare or another State Medicaid Agency.
Home Health Forms
Long-Term Services and Supports Case Management Tools
Pharmacy

All pharmacy-related documents and forms are now found on the Pharmacy Resources page.

Post-Eligibility Treatment of Income Forms (PETI)
Physician-Administered Drugs Forms
Prior Authorization Request (PAR) Forms

Medical PARs are submitted via the eQSuite® PAR Portal. This includes PARs for supply, surgery, out of state, therapy, audiology, home health and pediatric behavioral therapy. For further information, visit the ColoradoPAR Program website or call 1-888-801-9355. Medical PARs are not submitted through the Provider Web Portal.

Home and Community Based Services (HCBS) waiver PARs are submitted by Case Managers via the Bridge.

If a PAR status shows as "pending state review," providers are advised to contact the Provider Services Call Center (1-844-235-2387) to ensure the PAR was submitted via the correct method.

Provider Enrollment & Update Forms

For more provider enrollment instructions and information, please go to the Provider Enrollment web page.

Sterilization Consent Forms
Synagis® Prior Authorization Request Form
Transitions Services Forms

 

Transition Documents

Information & Reporting Forms

Housing Forms

Department staff have the ability to verify the social security number of clients who are submitting a HUD application, but do not have a social security card. You can learn about the process in the DAL SSN verification form and in the SSN verification form.

The Department of Health Care Policy & Financing works in partnership with the State of Colorado Division of Housing to administer housing vouchers for individuals transitioning from a long-term care facility.

For more information including application forms, guidance, and training, please visit the Division of Housing website or contact Kimberley Dickey at 303-864-7831 or Kimberley.Dickey@state.co.us

Visit Transition Services Website for more information