URGENT: The deadline for Non-Emergent Medical Transportation (NEMT) providers to complete revalidation is rapidly approaching. Refer to the June 2024 Provider Bulletin for more information.
Need help with your enrollment? Visit the Provider Contacts web page for options.
Completed your application?Federal regulations established by the Centers for Medicare & 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 Plan 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.
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.
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.
The Affordable Care Act (ACA) requires certain providers to remit an application fee. The Centers for Medicare & 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, 2024, the Provider Enrollment Applications Fee has been set at $709 for the 2024 calendar year.
Contact the Provider Services Call Center with any questions.
Moratorium on New Enrollments for Non-Emergent Medical Transportation (NEMT)
The Department has imposed a moratorium on new enrollments for Non-Emergent Medical Transportation (NEMT) due to a significant potential for fraud, waste, or abuse to the Medicaid program. An extension of a maximum of six months was requested and approved by CMS, effective April 1, 2024.
Only One Active Enrollment Update Per Provider ID
Providers are reminded that only one enrollment update can be processed at a time. If providers need to make an additional update while a revalidation application is in process, contact the Provider Services Call Center.
Updating 1099 Address in Provider Web Portal
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.
A confirmation letter will be sent to all linked provider service locations stating an update was completed. The letter will contain:
Note: If multiple provider IDs share the same tax ID, and one provider changes the tax ID 1099 address, that address will change for all providers with that tax ID.
Refer to the Provider Maintenance - Provider Web Portal Quick Guide to view Address Changes for instructions on how to update an address in the Provider Web Portal.
Colorado NPI Law
HB 18-1282 requires newly enrolling and currently enrolled organization health care providers (not individuals) to obtain and use a unique National Provider Identifier (NPI) for each service location and provider type enrolled in the Colorado interChange.
Enrollment Application Date of Birth (DOB) Requirement ReminderProviders 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.
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, revalidations and enrollment updates are currently being processed by the Department's fiscal agent within five (5) business days on average.
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 contact the Provider Services Call Center 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 six (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. Once the updates are submitted, providers must contact the Provider Services Call Center 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.
Provider Enrollment Portal Change Regarding a Backdated Enrollment Effective Date
Providers can request an enrollment effective date up to ten months prior to the current date on their enrollment application from the Request Information Panel by entering the specified date in the Requesting Enrollment Effective Date field. Refer to the example in the Backdating a New Enrollment Application Provider Enrollment Portal Quick Guide located on the Quick Guides web page.
This change will apply only to providers starting a new enrollment application and providers resuming an application that is still in process. For providers who are already enrolled and approved, a Backdate Enrollment Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down must be completed and uploaded as an attachment.
What constitutes 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.
Complete the form, include the required documentation and submit via the Provider Web Portal using the steps indicated on the form.
If the organization’s board of directors turns over and a new board is appointed, is that considered a change in ownership?
No. Appointing a new board of directors does not constitute a change of ownership.
This change may be submitted through the Disclosures panel of the Provider Maintenance or Revalidation applications.
If I have a legal name change, is that considered a change of ownership?
No. Legal name changes are submitted using the Legal Name Change Form located on the Provider Forms web page under the Provider Enrollment & Update Forms drop-down.
If a new EIN is issued, does that constitute a change of ownership?
Yes. 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.
Note that a new National Provider Identifier (NPI) will be required. 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.
What do I need to do 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.
Note that a new National Provider Identifier (NPI) will be required. 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 the same National Provider Identifier (NPI) be used after 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.
How do I prepare for a 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 is the fingerprint criminal background check, and why is it required?
Federal regulations (42 CFR 455.434) established by the Centers for Medicare & 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.
Who needs to complete the fingerprint criminal background check process?
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.
Does every provider and/or owner need to participate?
No. Only providers designated as high-risk, and owners of high-risk providers, must comply.
Which provider types are in the high-risk category?
Provider types designated as high categorical risk:
I am already enrolled with Health First Colorado or Child Health Plans Plus (CHP+) as a high-risk provider. Does this apply to me?
Yes, fingerprint criminal background checks apply to both existing and new enrollments.
I am an out-of-state high-risk provider enrolled in Health First Colorado (Colorado’s Medicaid program). Do I still need to comply?
Yes, all high-risk providers need to comply.
I live outside of Colorado. How will my background be checked?
Your background will be checked with the Colorado Bureau of Investigation (CBI) and the Federal Bureau of Investigation (FBI) through the state-approved vendors IdentoGO or Colorado Fingerprinting.
I had my fingerprint background check completed for another Colorado state agency. Do I have to submit prints again?
Yes, state agencies are not allowed to share the results across departments.
I have already completed the fingerprint criminal background check process for Medicare or another state’s Medicaid program. Why do I have to complete this process again?
If you are required to complete the fingerprint criminal background check process and have already done so with Medicare or another state Medicaid agency, complete the Fingerprint Criminal Background Check Other Information panel in the application.
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.
Do all employees of a high-risk provider need to comply?
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.
What if I have more than one enrollment and different risk levels for each?
Providers with multiple enrollments and risk levels will be screened at the highest risk level.
What if I have an ownership stake in multiple provider agencies?
Individuals only need to provide fingerprints once, and the information will apply to all applicable enrollments.
When did fingerprint criminal background checks begin?
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. Visit the CBI Employment and Background Checks web page for more information.
How will I be notified when the process begins?
If a provider is required to submit a fingerprint background check, the provider will be notified electronically.
Is there a specific form or format for fingerprint submissions?
Applicants are 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 websites. To better serve all Colorado citizens, enrollment sites have been strategically placed throughout Colorado.
What is the best way to submit my fingerprint card?
Fingerprint cards are not accepted. Applicants are 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 websites.
Where do I go to get my fingerprints taken?
Individual providers or persons with five percent (5%) or more direct or indirect ownership interest in a high-risk provider type obtain their fingerprints from one of the approved sites found at IdentoGO or Colorado Fingerprinting. Fingerprint cards are not accepted.
Is there a cost to me?
There is a fee for the approved agency to perform the fingerprinting. All individuals are advised to call the approved fingerprint site for availability. Visit the CBI Employment and Background Checks web page for cost and acceptable forms of payment.
How long does it take to process my fingerprints?
Allow 30 calendar days from the date the Colorado Bureau of Investigation (CBI) receives the fingerprints for the process to be completed.
How will I be notified of the results?
Individuals will not be notified directly upon passing fingerprint criminal background checks. 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.
How will I know if my fingerprint background check results were set to the right department?
To ensure that your fingerprint background check results are routed to the correct place, use the following codes when you set up your appointment.
IdentoGO
| Service Code | Service Name |
|---|---|
| 25YQG9 | Department of Health Care Policy & Financing - Medicaid |
Colorado Fingerprinting
| CBI Unique ID | Reason Fingerprinted |
|---|---|
| CPACMDCI | Department of Health Care Policy & Financing - Medicaid |
What if there are problems with my fingerprints and a replacement set is required?
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 Employment and Background Checks web page for more information.
What if I don’t want to participate or if I fail the fingerprint criminal background check?
Individuals who are required by law to participate in the fingerprint criminal background check process may be denied or terminated for failure to comply.
I am currently in the process of selling my business. Do I still need to comply?
You will need to comply until the business has been disenrolled.
I have sold my ownership in the business, or I am no longer a part of this business. How do I get removed from the list?
The provider will need to go into the Provider Web Portal and update the ownership of the entity immediately.
Fingerprint criminal background check links and documents.
