Colorado interChange Provider Manual REVISED: 09/19/2018 Page i Provider Manual Table of Contents Before You Begin ............................................................................................................ 1 Updates and Changes to Provider Enrollment Information........................................... 1 Field Lists .................................................................................................................... 1 How to Use this Manual .................................................................................................. 2 Roles and Related Tasks ............................................................................................. 2 Resources ................................................................................................................... 2 Document Maintenance ............................................................................................... 3 Provider Manual Overview .............................................................................................. 4 Required Materials – Computer-Based Training .......................................................... 4 Required Information for Enrollment ............................................................................ 4 National Provider Identifier (NPI) .............................................................. 4 Address Information ................................................................................ 4 Provider Taxonomy Codes....................................................................... 5 Provider Federal Tax ID (EIN) or Social Security Number (SSN) ................ 5 Provider License Number ........................................................................ 5 Current Legacy Provider Identification Number ......................................... 5 Completed W-9 Form .............................................................................. 5 Office Phone Number .............................................................................. 5 Valid Email Address ................................................................................ 6 Malpractice & Liability Insurance Information............................................. 6 Banking Information ................................................................................ 6 Billing Agent Name & information (if applicable) ........................................ 6 Ownership/Controlling Interest & Conviction Disclosure Information ........... 6 Terminology ................................................................................................................. 6 Dynamic Properties of the Provider Enrollment Process .............................................. 7 More Information on a Field ......................................................................................... 7 Help Feature on Each Page ......................................................................................... 7 Accessing the Provider Enrollment Portal ....................................................................... 9 Enrollment..................................................................................................................... 12 Provider Enrollment Panel ......................................................................................... 12 Welcome Panel.......................................................................................................... 14
Transcript
Colorado interChange Provider Manual
REVISED: 09/19/2018 Page i
Provider Manual Table of Contents Before You Begin ............................................................................................................ 1
Updates and Changes to Provider Enrollment Information ........................................... 1
Field Lists .................................................................................................................... 1
How to Use this Manual .................................................................................................. 2
Roles and Related Tasks ............................................................................................. 2
Before You Begin This document is the Provider Manual for the Colorado interChange Online Provider Enrollment (OPE) Tool. The intended audience for this manual includes providers and provider staff currently enrolled, and first time enrollees in the Colorado Medicaid Program. This manual will also serve as a resource for Department personnel and fiscal agent staff.
To navigate through the Provider Portal, please have one of the following browsers installed on your personal computer (PC):
o Internet Explorer 6.x - 10.x o Fire Fox 2.x - 18.x o Safari 1.x - 6.x o Google Chrome 44.x
• You will need Adobe Flash Player 9+ installed on your PC.
Prior to reading this manual, you should take the Web-Based Training (WBT) courses found at Provider Enrollment WBT Courses. This self-paced training is intended to assist you through the Colorado Medicaid Provider Enrollment process. This manual will serve to supplement that training.
Updates and Changes to Provider Enrollment Information
Unless an application is returned to a provider (RTP) for updates or corrections, no changes may be made to information entered in the Provider Portal until after November 2016.
Field Lists
Below each sample panel is a list of the fields on that panel. These fields are listed in the order of completion, moving down the panel.
How to Use this Manual The Provider Manual outlines the online enrollment process. The intended audience for this document is Colorado Medicaid providers and Department staff that may receive provider questions.
The manual can be used by Colorado Medicaid providers as a supplemental guide to facilitate their successful online enrollment. It can also be utilized by Department staff to assist in responding to provider questions about the Provider Enrollment Process.
The Provider Manual will be updated as needed throughout the life of the Online Provider Enrollment Tool.
Roles and Related Tasks
Fiscal Agent (HPES) – The fiscal agent’s responsibility is to author and update this manual in cooperation with the Department.
Department – The Department responsibilities include: determining and communicating program policy and supporting the provider community during the enrollment training period and the enrollment process.
Medicaid Provider Community – Your responsibilities include: completing the Provider Enrollment training, reading all communications including this manual and any subsequent updates, and completing the enrollment process in a timely manner.
Resources
The Provider Manual will be stored in the Colorado interChange Contract SharePoint site as well as be accessible on the Department’s Revalidation and Enrollment Instructions web page.
The Provider Manual is also supplemented with the Department’s Frequently Asked Questions (FAQ) list. The FAQ list is located at FAQ List. This list is updated often and should be bookmarked for future reference.
For additional support, providers may contact the Department via email at [email protected].
Additionally, the “Provider Resources” section of the Department’s website may be accessed at Provider Services for additional information. Detailed information about Change of Ownerships (CHOWs), enrollment back dating, and Trading Partner Agreements (TPAs) may be accessed on the Next Steps web page.
This document contains a revision log. When changes occur, the document’s revision log will reflect the revision date, the section and description of the change, and the pages impacted.
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Provider Manual Overview This Provider Manual is intended to assist Colorado Medicaid providers with the online enrollment process. This manual will guide you systematically through the enrollment process to complete the various online forms and questions required to complete your enrollment.
Required Materials – Computer-Based Training
Prior to reading this manual, you should take the Web-Based Training (WBT) courses found at Provider WBT Courses. This self-paced training is intended to help you during the Colorado Medicaid Provider Enrollment process. This manual will serve to supplement that training.
Required Information for Enrollment
Prior to beginning the Enrollment process, you should have the following information available which will help make the Enrollment process quicker. Additional requirements will vary depending on your provider type & enrollment type. Please visit Colorado.gov/HCPF/Information-Provider-Type to view additional requirements for your provider type. National Provider Identifier (NPI) - The NPI is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). You can apply for your NPI (if necessary) here: nppes.cms.hhs.gov/NPPES/Welcome.do
If you are enrolling as: Then you will need to know: A Group Your organizational NPI & associated zip code A Facility Your organizational NPI & associated zip code An Individual within a group Your group’s organizational NPI, your individual
NPI, & the associated zip codes A Billing individual Your individual NPI & the associated zip code An Atypical provider You may not need an NPI An OPR Your individual NPI & the associated zip code
Address Information • Service Address – This is the location at which the Provider renders care.
(each service address requires a separate application) • Mailing Address – This is the location at which the Provider receives physical mail.
• Billing Address – This is the location from which the Provider submits their claims. • If you are enrolling as an individual within a group - you will also need the
group address for any Group Practices to which you belong.
Provider Taxonomy Codes – The Healthcare Provider Taxonomy Code Set is a hierarchical code set that consists of codes, descriptions, and definitions designed to categorize the type, classification, and/or specialization of health care providers. Tip: You can use this lookup to see the taxonomy codes you used when you applied for your NPI.
Provider Federal Tax ID (EIN) or Social Security Number (SSN) – An Employer Identification Number (EIN) is also known as a Federal Tax Identification Number, and is used to identify a business entity.
If you are enrolling as: Then you will need to use: A Group The business’s EIN A Facility The business’s EIN An Individual within a group Your SSN (Do not enter the Group’s EIN) A Billing individual Your SSN An Atypical provider Varies An OPR Your SSN
Provider License Number (not applicable to everyone) – This is the identification number assigned by the Colorado Department of Regulatory Agencies (DORA).
Current Legacy Provider Identification Number – This is the identification number that the Provider currently uses to submit claims to the current Medicaid Management Information System (MMIS) maintained by Xerox State Healthcare. Providers that are newly enrolling in the Colorado Medicaid Program will not have this information yet.
Completed W-9 Form (must be signed & dated within the last 6 months) If you are enrolling as: Then you will need: A Group No W-9 Needed A Facility Your organizational W-9 (with EIN) An Individual within a group The Group’s W-9 (with EIN) A Billing individual Your individual W-9 (with your SSN) An Atypical provider Varies An OPR Your individual W-9 (with your SSN)
Office Phone Number – This is the contact phone number for the Provider’s primary office.
Valid Email Address • Contact email address – This is the email that will receive application related
communications. • Email for provider publications
Malpractice & Liability Insurance Information – This is the face sheet for the Provider’s current professional insurance.
If you are enrolling as: Then you will need: A Group The Group’s general or liability insurance A Facility Organization’s general or liability insurance An Individual within a group Provider’s professional/malpractice insurance A Billing individual Provider’s professional/malpractice insurance An Atypical provider Varies An OPR Provider’s professional/malpractice insurance
Banking Information i.e.: Account Number, Routing Number, Address – In order for Providers to receive Electronic Fund Transfers (EFT) payments, the Department requires the submission of the appropriate financial information. Entry of actual financial institution address is optional. You will also need to attach a copy of a voided check or a bank letter that is dated in the past 6 months. Yes, this is required even if you are already an existing provider.
Billing Agent Name & information (if applicable)
Ownership/Controlling Interest & Conviction Disclosure Information For each person or entity with an ownership or control interest in the enrolling provider (including a Board of Directors) you will need to know their:
• Name • Address • Federal employer ID number (EIN) or Social Security Number (SSN) • Date of birth (DOB)
Terminology
In numerous sections of this manual the words “Panel” and “Screen” are used. The word “Panel” is used to refer to specific web pages and information that will be shown. The word “Screen” is used to refer to the user’s computer monitor. For example: The “Welcome” panel will be shown on your screen.
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Dynamic Properties of the Provider Enrollment Process
The Provider Enrollment Application is a dynamic tool. This means that depending on selections and entries that you make, you will be presented with the appropriate questions for your provider type and specialty. For example, choosing an Enrollment Type of “Facility” will present you with questions that are different from those that an “Individual within a Group” would see.
More Information on a Field
Throughout the Enrollment Process a red asterisk * next to a field indicates that it is required information. You cannot proceed beyond a panel if you have not completed all required fields.
In certain fields, additional information can be found by hovering your cursor over the symbol. Hovering over this symbol will open a gray box that will give more information about the field.
The gray information box will disappear when you move your cursor.
Help Feature on Each Page
Throughout the Enrollment Process there is a question mark symbol towards the top right corner of each page. Clicking on it will open a dialog help window specific to the screen you are currently in:
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Accessing the Provider Enrollment Portal
To access the Provider Enrollment Portal, open an internet browser, then navigate to Colorado.gov/HCPF/Our-Providers. Then click “How to become a provider (enroll)”.
To access the Provider Enrollment Portal, open an internet browser, then navigate to Colorado.gov/HCPF/Our-Providers. Then click “How to become a provider (enroll)”.
Clicking on “How to become a provider (enroll)” will bring you to the Revalidation and Enrollment Instructions web page: Colorado.gov/hcpf/revalidation-and-enrollment-instructions. Read through this entire page (making sure you click on each step to read commonly asked questions). Then click the “Online Provider Enrollment Tool” button at the bottom of the page.
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Clicking on the “Online Provider Enrollment Tool” button at the bottom of the page will bring you to the Provider Enrollment Portal. You are no longer on the Department’s web site. Click “How to become a provider (enroll)”.
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Enrollment Provider Enrollment Panel
After clicking “How to become a provider (enroll)”, the panel below will be on your screen. Click the link “Enrollment Application” to begin the Enrollment or Revalidation Process.
Provider Enrollment Panel
The additional links on this panel are:
• Resume Enrollment: This allows you to finish a Provider Enrollment application that was started earlier or open up an application that has been returned for correction. See the Resume Enrollment Section for more information on this topic.
• Enrollment Status: This allows you to check the status of a previously submitted Provider Enrollment application. See the Enrollment Status Section for more information on this topic.
• Provider Help: This allows you to navigate to the Provider Resources area. • Billing Manuals: This allows you to navigate to the current manuals needed to
support claim submission. • Provider Bulletins: This allows you to navigate to the Department’s Provider
Bulletins.
Same link for a new
application or revalidation application
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• Privacy Notice: This allows you to access the Department’s Privacy Notice. • Contact Us: This link will open a page that leads to the Provider Resources web
At the next panel, click the “Continue” button to begin the enrollment process.
Please note that on the upper left side of the panel, “Welcome” indicates the panel that you are currently on. As you proceed through the Enrollment Application Process each page completed will become a clickable link. This allows you to go back to a previous page if a correction is needed.
Going back to a previous panel does not save your work. In order to save the work done on an application, please see the Additional Links/Finish Later Option Section.
Welcome Panel
Click “Continue” to move to the next panel. This link is indicated by a blue arrow on the picture above.
Cancel: Clicking this button will prompt the end of the application process without saving your work. Please note that you are required to confirm cancellation per the panel shown before proceeding. It appears on every enrollment panel. If the user has entered information or attachments on any page previous and not saved their
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application there is no way to restore it. The application must be started again. The below Cancel Confirmation screen will appear. If you select “Yes,” all work since the last application was saved will be erased.
Request Information Panel
After clicking “Continue”, the Request Information panel will be shown on your screen.
On the upper left side of the panel, “Welcome” is now a clickable link. This link will take you back to the Welcome panel, shown on the previous page. This allows you to go back to a previous page if a correction is needed. Clicking a link to go back to a previous panel will not save the application. In order to save an application, please see the Additional Links/Finish Later Option Section.
The Provider Enrollment Application is a dynamic tool. This means that depending on selections and entries that you make, you will be presented with the appropriate questions for your provider type and specialty. For example, choosing an Enrollment Type of “Facility” will present you with questions that are different from those that an “Individual within a Group” would see.
Throughout the Enrollment Process a red asterisk * next to a field indicates that it is required information. You cannot proceed beyond a panel if you have not completed all required fields. In certain sections on numerous panels of the enrollment screens there are fields that are marked as required only if information is entered in the section. In certain fields, additional information can be found by hovering your cursor over the
symbol.
Hovering over this symbol will open a gray box that will give more information about the field. The gray information box will disappear when you move your cursor.
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Request Information Panel
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Initial Enrollment Information Panel The first section of the Request Information panel to be completed will be the Initial Enrollment Information panel. On this panel you will select the type of Enrollment you are applying for, your Provider type, and the Enrollment effective date. Providers requiring backdating should visit the Next Steps web page for more information.
Initial Enrollment Information Panel
Click the drop down menu next to Enrollment Type.
This drop down will open the Enrollment Type selection box. Select the Enrollment Type most appropriate for you.
Initial Enrollment Information Panel – Enrollment Type Drop Down
The remainder of the panel will change, depending on the selection that you make as there are different requirements for each Enrollment Type.
What Enrollment Type are you? Your enrollment type will be dependent on a couple of different factors; including how your billing is set up and whether you want income reported under an EIN or SSN.
You can view the definition of each enrollment type on the next page. Make sure you cross check your provider type to your enrollment type, not all enrollment types are available for each provider type or specialty.
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Individual within a Group: This enrollment type is for an individual that renders services but does not bill Colorado Medicaid directly. Providers must be associated with a Group that submits claims on their behalf.
• Must use SSN as the Tax ID Type • Must associate to at least one “Group” provider enrollment type
Group This enrollment type is a clinic or practice that will submit claims on behalf of one or more Individuals within a Group provider enrollment type. Income is reported to the IRS under the business EIN.
• Must use EIN as the Tax ID Type • Billing/direct pay entity • Must have at least one enrolled “Individual within a Group” provider enrollment
type associated (this association is indicated on the “Individual within a Group” application.
Billing Individual This enrollment type is an individual who receives direct payment for services rendered and submits claims for his/her own services. Income is reported to the IRS under the individual’s SSN.
• Must use SSN as the Tax ID Type • Billing/direct pay entity
What if I am an Individual, but I want to use my EIN for enrollment? This is a common scenario; maybe you are a physician and you own your practice. Even if you are the only practitioner, if you want to use an EIN this is technically a business and in order to enroll your business, you will need to complete an application for a group. In this example, the group would be a "Clinic - Practitioner Group" provider type. Must use EIN as the Tax ID Type.
After the physician in this example, has submitted an application for his/her business; they would also need to submit a second application as the practitioner. The application for the practitioner in this example would be an enrollment type of "individual within a group" and a provider type of "Physician". While completing the "individual within a group" application, the physician will indicate that they are affiliated to the group that was enrolled for the business. Must use SSN as the Tax ID Type.
This will allow the individual Physician to bill under their business EIN.
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Facility This enrollment type is for an entity that will be submitting claims for services rendered. An associated Individual within a Group provider enrollment type is not required.
• EIN only • Billing/direct pay entity
Atypical Atypical providers are those who are not required to have a National Provider Identifier (NPI) or taxonomy code. These providers may include, but are not limited to, Home and Community-Based Waiver Services (HCBS) providers, Managed Care Organizations (MCOs), and Behavioral Health Organizations (BHOs).
• Enrollment requirements vary
OPR = Ordering, Prescribing, Referring This enrollment type is for individuals who only order, prescribe or refer items or services covered by Colorado Medicaid for Colorado Medicaid members. These physicians and other professionals are not enrolled as an Individual within a Group or a Billing Individual and will not submit claims for payment of services rendered.
Initial Enrollment Information Panel – Individual w ithin Group
For the purposes of this example, we have selected “Individual within a Group”.
After you select “Individual within a Group” the panel below will be displayed.
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In this field, Provider Type, enter two asterisks (**) in the field, and valid provider type choices will appear specific to the Enrollment Type that was selected in the prior field. If ** does not return the value that you are trying to enter, type the first few characters of the word. For example, type “Phys” and the panel will return items with “Phys” in the value.
Initial Enrollment Information Panel – Provider Type
What Provider Type are you?
You can download the below lists of all of the available provider types supported in the Colorado interChange, or you can read about them on this web page; these are the ONLY provider types the system will accept.
Provider Types & Specialties
HCBS Provider Types & Specialties
For the purposes of this example, we will choose Physician.
The Requesting Enrollment Effective Date field immediately below it defaults to the date the application is started. You can set a future date (within 90 days) here, but not a past date.
• New providers requiring backdating should visit the Next Steps web page to complete the Backdating form.
• Revalidating providers need not worry about completing a form, your current effective date will be added to your application at a later date.
Initial Enrollment Information Panel – Effective Date
Group Association
The next section of the Request Information Panel is the Group Association panel. On this panel, you can indicate any group affiliations. This panel is required and will only show for providers that previously selected “Individual within a Group”. Providers are also allowed to associate with multiple groups if appropriate.
Prior to completing this portion of the Enrollment process, please check with the Group representative(s) to make sure they have submitted their enrollment application. If the Group has not submitted its Enrollment, the processing of your application will be delayed.
The information needed to complete this panel is as follows:
Group Name – Enter the Group Name. Group Name is a required field. Service Location – Enter the Service Address for the Group. If 2 lines are required for the complete address, please use both lines. This field allows up to 55 alphanumeric characters. This is a required field. City – Enter the City for the Group’s Service Location. This field allows up to 30 alphanumeric characters. This is a required field. County – Enter the County for the Group’s Service Location. This is not a required field. State – Select a state from the drop down list box characters for the Group’s Service Location. This is a required field. Zip – Enter the zip code for the Group’s Service location. This is a required field. Medicaid ID – Enter the Group’s legacy Colorado Medicaid ID. This is not a required field. Group NPI – Enter the 10-digit National Provider Identifier for the Group. This is a required field.
After entering all of the information above, click the “Add” button if the information is correct. If the information is not correct and you would like to start over, click the “Reset” button and re-enter the information.
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After you click the “Add” button, the panel will update and will look similar to the following:
Group Association Panel - Add
If a provider is part of more than one group, indicate all groups by adding additional affiliations here. If a provider is affiliated to more than 16 groups, the 17th through last group will need to be typed up and uploaded to the application in the “Attachment and Fees” panel.
If you need to add an additional Group Association, click the small “+” symbol to the left of the blue arrow shown above. Repeat this procedure as needed.
Provider Information
The next section within Request Information is the Provider Information Panel. On this panel you will indicate required information including your NPI Number, Provider Taxonomy, Tax ID and legacy Medicaid Provider Number. The legacy Medicaid Provider Number is not a required field unless the following questions are answered with a Yes: Do you have a current CO Medicaid ID (for this provider Type)? Were you previously (but are not currently) enrolled as a provider?
Note: Not all provider types will have an NPI number. For the purposes of this example, the red asterisk indicating a required field is driven by the previous selection of “Physician”.
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Provider Information Panel
NPI – Enter your 10-digit National Provider Identifier. This information is required for most provider types. Some Atypical providers may not have an NPI, and therefore this field will not show as required, if you selected the Atypical Enrollment Type.
NPI Zip + 4 – Enter the zip code associated with your service address, as listed in NPPES. Enter a 5-digit or 9-digit zip code. If you do not have an NPI, no entry is required in this field.
Taxonomy Codes – Enter the 10-digit alphanumeric Taxonomy code that classifies you as a healthcare provider according to the services you provide. You can also enter two or more characters to begin a search then select an entry from list that is shown. If you do not have an NPI, no entry is required in this field. Tip: You can use this lookup to see the taxonomy codes you used when you applied for your NPI.
Tax ID Number – Enter the 9-digit EIN or SSN associated with your practice or organization. This field defaults to “EIN”. Be sure to click the “SSN” option if you are entering that criteria. This field is required for all providers.
If you are enrolling as: Then you will need to use: A Group The business’s EIN A Facility The business’s EIN An Individual within a group Your SSN (Do not enter the Group’s EIN) A Billing individual Your SSN An Atypical provider Varies An OPR Your SSN
Tax ID Type – Select whether you have entered your EIN or SSN in the Tax ID Number field. This field is required for all providers.
Effective Date • If you entered an EIN - The effective date for this field should be the date the
corporation (entity) began doing business. • If you entered an SSN - The effective date for this field should be the
practitioner’s date of birth.
Do you have a current CO Medicaid ID? – Indicate whether you are currently enrolled in the Colorado Medicaid program and have an ID. This field defaults to “No”. This field is required for all providers. Selecting “Yes” will open a field to the right, “Current Provider Identifier”.
Current Provider Identifier – Enter your current Colorado Medicaid Provider number in this field. This field is required if “Yes” was selected in the previous field.
Were you previously enrolled as a provider (but are not currently)? – Indicate whether you were ever previously enrolled in the Colorado Medicaid program. This field defaults to “No”. This field is required for all providers. Selecting “Yes” will open a field to the right, “Previous Provider Identifier”.
Previous Provider Identifier – Enter your prior Colorado Medicaid Provider number in this field. This field is required if “Yes” was selected in the previous field.
Provider Information Panel - Completed
Contact Information
The next section of the Request Information Panel is the Contact Information Panel. On this panel you will indicate required contact information for your practice or organization.
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Contact Information Panel
Last Name – Enter the last name of the contact individual at your practice or organization. This field allows up to 50 alphanumeric characters. This field is required for all providers.
First Name – Enter the first name of the contact individual at your practice or organization. This field allows up to 25 alphanumeric characters. This field is required for all providers.
Suffix – If appropriate, enter the suffix for the name of the contact individual at your practice or organization. This field allows up to ten alphanumeric characters. This field is not required.
Phone – Enter the office phones number of the contact individual at your practice or organization. This field allows a 10-digit phone number, including area code using 999-999-9999 format. This field is required for all providers.
Ext – If appropriate, enter the phone extension of the contact individual at your practice or organization. This field is not required.
Fax Number – Enter the fax number of the contact individual at your practice or organization. This field allows a 10-digit phone number, including area code using 999-999-9999 format. This field is not required.
Contact Email – Enter the valid Email address of the contact individual at your practice or organization. Enter email with 'name@domain' format. This field is required for all providers.
Confirm Email – Confirm the valid Email address of the contact individual at your practice or organization. Enter email with 'name@domain' format. This field is required for all providers.
Email for Provider Publications – Enter the valid Email address of the contact individual at your practice or organization to which Provider Publications should be sent. Enter email with 'name@domain' format. This field is required for all providers.
Confirm Email – Confirm the valid Email address of the contact individual at your practice or organization to which Provider Publications should be sent. Enter email with 'name@domain' format. This field is required for all providers.
Preferred Method of Communication – Select “Email.” Between September 15, 2015 and November 1, 2016 all communication will be via Email.
Additional Links/Finish Later Option Three additional buttons are located at the bottom of this and each future panel.
Additional Links/ Finish Later Option
These buttons allow you to:
Continue – Continue to the next panel of the enrollment application.
Finish Later – Saves your work and allows you to come back to the application later.
Cancel – Stops the application process without saving your work.
At this and future points in the Provider Enrollment process, you are able to save your application and complete it later.
Note: We recommend that you select “Finish Later” before continuing on to the second page. Be sure to write your password and tracking number down; you cannot reset your password until November 2016.
Select “Finish Later”. The following box will appear:
Suspend Incomplete Application Pop Up
Select “No” and you will return to the application process. Select “Yes” and the following Provider Enrollment: Credentials panel will appear.
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Provider Enrollment: Credentials Panel
Password – Select a password that you would like to use for the enrollment process. This field is required for all providers saving their application. This user-defined password must be between 8-20 alphanumeric characters.
Confirm Password – Confirm the password that you would like to use for the enrollment process. This field is required for all providers saving their application.
What is your mother’s maiden name? – Enter your mother’s maiden name. This field is required for all providers saving their application. This user-defined response can have a maximum of 50 alphanumeric characters.
What is your high school mascot? – Enter your high school mascot. This field is required for all providers saving their application. This user-defined response can have a maximum of 50 alphanumeric characters.
What is your father’s middle name? - Enter your father’s middle name. This field is required for all providers saving their application. This user-defined response can have a maximum of 50 alphanumeric characters.
Select “Submit” to save this information and proceed to the next panel. Select “Cancel” to stop this process and return to the Enrollment process.
The next panel that is presented is the Provider Enrollment: Tracking Information Panel.” This panel will give you the Application Tracking Number (ATN) that will be required to resume your application. In the upper right corner of this panel is a "Print Preview” button. Use this button to send a copy of this panel to a local or network printer connected to your computer.
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Provider Enrollment: Tracking Information Panel
Select Exit to return to the Home page shown in the Provider Enrollment Panel Section.
Specialties
The next panel that is shown is the Specialties panel. This panel has two sections: Specialties and Additional Taxonomies
Specialties Panel
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The specialties that can be added for each provider type are based on the selection previously made on the Request Information screen. You are required to have at least one specialty on file. You can add multiple specialties, however only one specialty can be designated as the primary specialty.
The system will only accept certain specialties
You can download the below lists of all of the available provider types and associated specialties supported in the Colorado interChange, or you can read about them on this web page; these are the ONLY specialties the system will accept.
Provider Types & Specialties
HCBS Provider Types & Specialties
A Taxonomy code must be provided for each specialty, except for when “Atypical” is selected as the Enrollment Type.
Specialties Panel – Specialties
• Specialty – Use the drop down box to select “Specialty”. Your choice here, will drive the chioces available under the “Taxonomy” drop down. Note: There are many instances where the only “Specialty” option is the “Provider Type” you choose. If this is the case for you; select the only option available and then use the “Taxonomy” drop down to indicate your area of specialty. Example: If you are a Pediatrician, you would select the only option shown (Physician) as your specialty, and then choose Pediatrics in the “Taxonomy” drop down.
• Effective Date – Enter the effective date of the specialty. This selection can be done by clicking the calendar icon next to the date field. The calendar icon is shown here. This is a required field.
• End Date – Enter the End date, if appropriate, for the specialty. For example, when a provider wants to end date one specialty and add a new specialty designation. This selection can be done by clicking the calendar icon next to the date field. The calendar icon is shown here. This is not a required field.
Specialties Panel – Taxonomy Code
• Taxonomy – Select a taxonomy (specialization) that is associated with the provider.
This selection is accessed via drop down. This is a required field. • Primary – If appropriate, check this box to indicate this as your primary specialty.
Only one specialty can be designated as the primary specialty.
Don’t forget to click the button!
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Specialties Panel – Additional Taxonomies
• Taxonomy – Select an additional taxonomy code if desired. This is an
alphanumeric look-up search field that responds to the characters entered into the field to return a list of valid taxonomy codes. You can enter 2 or more characters to begin a search then select an entry from the list that is shown.
When you have completed this panel, click:
• Continue – To proceed to the next panel of the enrollment application. • Finish Later – To save your work and allow you to come back to the application
later. Please note that you must finish the required items on the panel before this button will save your work. Please see the Additional Links/Finish Later Option Section for more information.
• Cancel – To exit the application process without saving your work.
Additional Taxonomies are NOT required. Simply press the continue button if you
don’t want to add additional taxonomy codes.
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Addresses
The next panel to be shown is the Provider Addresses panel.
The provider addresses identify the location where a provider renders services, as well as locations that are used for billing and payment. There are slight differences in the information collected for each address type.
At least one address must be selected as the primary address.
All providers regardless of enrollment type must enter a service location address, mailing address, and billing address.
Provider Addresses Panel
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Provider Addresses Panel – Service Location
• Address Type – Use the drop down box to select “Service Location”. This will
immediately open the “Service Address Information” panel at the bottom of the screen. This is a required field.
• Primary Address – Check this box if the Service Address that you are entering is to be designated as the primary address. The Primary Address box must be checked on either the Service Location, Billing, or the Mailing Address panel.
• Location Code – Use this drop down box to indicate the address location in relation to the State of Colorado. Possible selections are Border Provider, In-State, Out-of-State. This is a required field.
“Primary Email” and “Phone” (Office Phone) are required for each address – even though there isn’t an *
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• Address – Enter the street address of the location. This address can be two lines, if needed. This field allows up to 55 alphanumeric characters. This is a required field.
• City – Enter the appropriate city or town for this location. This field allows up to 30 alphanumeric characters. This is a required field.
• County – Enter the appropriate county for this location. This field allows up to 30 alphanumeric characters. This is not a required field.
• State – A list of the valid state options a provider can select for an address. This defaults to Colorado.
• Zip Code – Enter the 5 or 9-digit zip code for this location. This field allows up to 9 numeric characters. This is a required field.
• Primary Email – Enter the primary email address associated with the provider. This field allows up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is a required field.
• Confirm Email Address (1 of 2) – Re-enter the primary email address associated with the provider. This field allows up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is a required field.
• Secondary Email – Enter the secondary email address associated with the provider. This field allows up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is not a required field.
• Confirm Email Address (2 of 2) – Re-enter the secondary email address associated with the provider. This field allows up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is not a required field unless the Secondary Email Address field is completed.
• Phone (Type 1 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location.
• Phone (1 of 4) – Enter the first 10-digit phone number associated to the provider location. This is a required field.
• Ext (1 to 4) – Enter the extension associated with the first phone number associated to the provider location. This is not a required field.
• Phone (Type 2 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (2 of 4) – Enter the second 10-digit phone number associated to the provider location.
• Ext (2 of 4) – Enter the extension associated with the second phone number associated to the provider location. This is not a required field.
• Phone (Type 3 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (3 of 4) – Enter the third 10-digit phone number associated to the provider location.
• Ext (3 of 4) – Enter the extension associated with the third phone number associated to the provider location. This is not a required field.
• Phone (Type 4 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (4 of 4) – Enter the fourth 10-digit phone number associated to the provider location. This is not a required field.
• Ext (4 of 4) – Enter the extension associated with the fourth phone number associated to the provider location. This is not a required field.
Service Address Information • Opt Out Of Provider Directory – Use this check box to indicate whether the
Service Location should be omitted from the provider directory. This field only shows for service address. Leaving this field blank will include the location in the provider directory. This field is not required.
• Accepting New Patients – Use this check box to indicate if the Service Location is accepting new patients. This field only shows for service address. This field is not required, however leaving the field blank will indicate that the location is not accepting new patients.
• ADA Compliant – Use this check box to indicate if the Service Location is compliant with the American Disabilities Act (ADA). This field only shows for service address. This field is not required, however leaving the field blank will indicate that the location is not compliant.
• Accepting New Patients with Special Needs – Use this check box to indicate if the Service Location is accepting new patients with special needs. This field only shows for service address. This field is not required, however leaving the field blank will indicate that the location is not accepting new patients with special needs.
• TDD Capability – Use this check box to indicate if the service location provides a telephone device for the deaf (TDD). This field only shows for the service address. This field is not required; however, leaving the field blank will indicate that the location does not offer TDD capability.
• Phone (TDD) – Use this field to enter the 10-digit phone number associated with the TDD capability. This field is only required if the TDD Capability box is checked.
• Ext (TDD) – Use this field to enter the 4-digit extension associated with the TDD if applicable. This field is not required.
• TTY Capability – Use this check box to indicate if the service location provides a telephone typewriter for the deaf (TTY). This field only shows for the service address. This field is not required; however leaving the field blank will indicate that the location does not offer TTY capability.
• Phone (TTY) – Use this field to enter the 10-digit phone number associated with the TTY capability. This field is only required if the TTY Capability box is checked.
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• Ext (TTY) – Use this field to enter the 4-digit extension associated with the TTY if applicable. This field is not required.
After entering the appropriate information on this panel, click the “Add” button. This will store the information to your application. This does not save the information until either the “Finish Later” button is clicked or the application is submitted at the end of the process. After the “Add” button is clicked, the panel will update to the version below.
Provider Addresses Panel – Service Location - Add
Click the “+” symbol located beside the words “Click to add address” to begin the process to add the next address.
Provider Addresses Panel – Service Location – Add another Address
To add a Billing address or Mailing address select “Billing” or “Mailing” in the Address Type field. As a time saving feature, you may also click “Copy” to start another address with all the information copied over, and then edit what you need. This could be helpful for example, if your billing and service addresses are the same.
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All providers must enter at least one Service Location, Billing Location, and Mailing Location.
Billing Address
Upon selection of “Billing” from the Address Type drop down menu, the panel below will display.
Provider Addresses Panel – Billing Address
• Address Type – Use the drop down box to select “Billing Location”. This will
immediately open the “Billing Address Information” panel. This is a required field. • Primary Address - Check this box if the Billing Address that you are entering is to
be designated as the Primary Address.
“Primary Email” and “Phone” (Office Phone) are required for each address – even though there isn’t an *
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• Location Code – Use this drop down box to indicate the address location in relation to the State of Colorado. Possible selections are Border Provider, In-State, Out-of-State. This is a required field.
• Pay To Name – Enter the provider or facility name to which payments should be made. This name MUST match the name on the W-9. This is a required field.
• Address – Enter the address of the location. This address can be two lines, if needed. This field allows up to 55 alphanumeric characters. This is a required field.
• City – Enter the appropriate city or town for this location. This field allows up to 30 alphanumeric characters. This is a required field.
• County – Enter the appropriate county for this location. This field allows up to 30 alphanumeric characters. This is not a required field.
• State – A list of the valid state options a provider can select for an address. If you select a Location Code of In-State this defaults to Colorado.
• Zip Code – Enter the 5 or 9-digit zip code for this location. This field allows up to 9 numeric characters. This is a required field.
• Primary Email – Enter the primary email address associated with the provider. This field allow up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is a required field.
• Confirm Email Address (1 of 2) – Re-enter the primary email address associated with the provider. This field allow up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is a required field.
• Secondary Email – Enter the secondary email address associated with the provider. This field allow up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is not a required field.
• Confirm Email Address (2 of 2) – Re-enter the secondary email address associated with the provider. This field allow up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is not a required field unless the Secondary Email Address field is completed.
• Phone (Type 1 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free and Other. At least one “Office” number is required per location.
• Phone (1 of 4) – Enter the first 10-digit phone number associated with the provider location. This is a required field.
• Ext (1 to 4) – Enter the extension associated with the first phone number associated to the provider location. This is not a required field.
• Phone (Type 2 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (2 of 4) – Enter the second 10-digit phone number associated with the provider location.
• Ext (2 of 4) – Enter the extension associated with the second phone number associated to the provider location. This is not a required field.
• Phone (Type 3 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (3 of 4) – Enter the third 10-digit phone number associated to the provider location.
• Ext (3 of 4) – Enter the extension associated with the third phone number associated with the provider location. This is not a required field.
• Phone (Type 4 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (4 of 4) – Enter the fourth 10-digit phone number associated with the provider location.
• Ext (4 of 4) – Enter the extension associated with the fourth phone number associated with the provider location. This is not a required field.
After entering the appropriate information on this panel, click the “Add” button. This will store the information to your application. This does not save the information until either the “Finish Later” button is clicked or the application is submitted at the end of the process. After the “Add” button is clicked, the panel will update to the version below.
Provider Addresses Panel – Billing Address – Add
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Click the “+” symbol located beside the words “Click to add address” to begin the process to add the next address.
Provider Addresses Panel – Billing Address – Add another Address
To add a Service Location address or Mailing address select “Service Location” or Mailing” in the Address Type field.
All providers must enter one Service Location, Billing Location, and Mailing Location.
Mailing Address Upon selection of “Mailing” from the Address Type drop down menu, the panel below will display.
Provider Addresses Panel – Mailing Address
“Primary Email” and “Phone” (Office Phone) are required for each address – even though there isn’t an *
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• Address Type – Use the drop down box to select “Mailing Location”. This will immediately open the “Mailing Address Information” panel. This is a required field.
• Primary Address - Check this box if the Mailing Address that you are entering is to be designated as the Primary Address
• Location Code – Use this drop down box to indicate the address location in relation to the State of Colorado. Possible selections are Border Provider, In-State, Out-of-State. This is a required field.
• Mail To Name – Enter the provider or facility name to which mail should be sent. This field allows up to 30 alphanumeric characters. This is a required field.
• Address – Enter the street address of the location. This address can be two lines, if needed. This field allows up to 55 alphanumeric characters. This is a required field.
• City – Enter the appropriate city or town for this location. This field allows up to 30 alphanumeric characters. This is a required field.
• County – Enter the appropriate county for this location. This field allows up to 30 alphanumeric characters. This is not a required field.
• State – A list of the valid state options a provider can select for an address. If you select a Location Code of In-State this defaults to Colorado.
• Zip Code – Enter the 5 or 9-digit zip code for this location. This field allows up to 9 numeric characters. This is a required field.
• Primary Email – Enter the primary email address associated with the provider. This field allows up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is a required field.
• Confirm Email Address (1 of 2) – Re-enter the primary email address associated with the provider. This field allows up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is a required field.
• Secondary Email – Enter the secondary email address associated with the provider. This field allows up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is not a required field.
• Confirm Email Address (2 of 2) – Re-enter the secondary email address associated with the provider. This field allows up to 50 alphanumeric characters. Enter email with 'name@domain' format. This is not a required field unless the Secondary Email Address field is completed.
• Phone (Type 1 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location.
• Phone (1 of 4) - Enter the first 10-digit phone number associated to the provider location. This is a required field.
• Ext (1 to 4) – Enter the extension associated with the first phone number associated to the provider location. This is not a required field.
• Phone (Type 2 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (2 of 4) – Enter the second 10-digit phone number associated to the provider location.
• Ext (2 of 4) – Enter the extension associated with the second phone number associated to the provider location. This is not a required field.
• Phone (Type 3 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (3 of 4) – Enter the third 10-digit phone number associated to the provider location.
• Ext (3 of 4) – Enter the extension associated with the third phone number associated to the provider location. This is not a required field.
• Phone (Type 4 of 4) – Use the drop down to select the type of phone number being entered. Available selections are Cell, Fax, Office, Toll Free, and Other. At least one “Office” number is required per location. This is not a required field.
• Phone (4 of 4) – Enter the fourth 10-digit phone number associated to the provider location.
• Ext (4 of 4) – Enter the extension associated with the fourth phone number associated to the provider location. This is not a required field.
After entering the appropriate information on this panel, click the “Add” button. This will store the information to your application. This does not save the information until either the “Finish Later” button is clicked or the application is submitted at the end of the process. After the “Add” button is clicked, the panel will update to the version below.
Note: You can only add 1 service location address per application. If you are enrolling as: To add additional service locations: A Group Each location needs a separate application A Facility Each location needs a separate application An Individual within a group Associate to each group location (see page 25) A Billing individual Each location needs a separate application An Atypical provider Varies (see web site) An OPR NA
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Other Functions During the address entry process you can save time with the use of the “Copy” function.
Provider Addresses Panel – Copy Function
This will allow you to copy an address, make changes, and add the address quickly.
If you need to delete an entire row, you can click the “Remove” button. This will delete the entire row. Once deleted the row must be re-entered.
Provider Addresses Panel – Remove Function
When you have completed this panel, click:
• Continue – To proceed to the next panel of the enrollment application. • Finish Later – To save your work and allow you to come back to the application
later. Please note that you must finish the required items on the panel before this button will save your work. Please see the Additional Links/Finish Later Option Section for more information.
• Cancel – To exit the application process without saving your work.
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Provider Identification
The next panel to be shown will be the Provider Identification panel. On this panel, you may enter provider identification information, such as your legal name, a group practice or facility information, school information, and any appropriate identification numbers, such as U.S. Drug Enforcement Administration (DEA), state license numbers, and Medicare numbers. Please note that the Provider Enrollment Tool will present you with the identification fields that are appropriate to your provider type, based on your previous selections. For example, an individual will be presented with fields to identify their schooling, however a Facility will not see these fields.
Below is a comprehensive list of all of the Provider Identification fields that could be present:
Birth Date – Enter the birth date associated with the individual provider. This field allows eight numeric characters. This field is only displayed if the enrollment type is Individual. The Birth Date must be between 0 and 150 years old. This must be entered as a valid value in the format ‘MM/DD/YYYY’. CLIA # – Enter the Clinical Laboratory Improvement Amendment (CLIA) certification number assigned to the provider. The field allows up to ten numeric characters. CLIA # is a required field if any one CLIA field is entered. CLIA Type – Select the appropriate CLIA Type that indicates the provider’s CLIA certification from the drop down list box characters. CLIA Type is a required field if any one CLIA field is entered. DEA # – Enter the DEA (Drug Enforcement Agency) number that is assigned to the provider. This field allows nine alphanumeric characters. DEA # is required if Effective Date is entered. Degree – Select the appropriate professional degree received by the individual provider from the drop down list box characters. Degree is a required field if any one of the “Professional Education fields” is entered. Doing Business As – Enter the name of the provider. This field allows up to 30 alphanumeric characters. This is not a required field. Effective Date (CLIA) – Enter the start date of the CLIA certification. Effective Date is a required field if any CLIA information is entered. This field allows eight numeric characters. This must be entered as a valid value in the format 'MM/DD/YYYY'. Effective Date (DEA) – Enter the effective date for the DEA #. Effective Date is a required field if a DEA # is entered. This field allows eight Numeric characters. This must be entered as a valid value in the format 'MM/DD/YYYY'. Effective Date (License) – Enter the effective date for the license number assigned by the State to the provider. This field allows eight numeric characters. The Effective Date is a required field if one of the other License fields is entered. The End Date cannot be before the Effective Date. This must be entered as a valid value in the format ‘MM/DD/YYYY’.
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Effective Date (Medicare Number) – Enter the effective date of the Medicare #. This is the date the Medicare contractor received the signed and dated Certification Statement. This field allows eight numeric characters. The Effective Date is a required field if one of the other Medicare fields is entered. Effective Date is not valid or in the correct format. This must be entered as a valid value in the format ‘MM/DD/YYYY’. End Date (CLIA) – Enter the end date of the CLIA certification. This field allows eight numeric characters. End Date is a required field if any one CLIA field is entered. This must be entered as a valid value in the format 'MM/DD/YYYY'. End Date (License) – Enter the expiration date for the license number assigned by the State to the provider. If there is no end date for the license enter 12/31/2299. This field allows eight numeric characters. The End Date is a required field if one of the other License fields is entered. This must be entered as a valid value in the format ‘MM/DD/YYYY’. First Name – Enter the first name field for an individual provider. This field allows up to 25 alphanumeric characters. This is a required field Gender – Select the gender associated to an individual provider from the drop down list box characters. This is a required field. Health Plan Identifier (HPID) – Enter the Health Plan ID for the provider. This field allows up to 15 alphanumeric characters. Last Name – Enter the provider legal name. For an individual provider, this should be the last name field. This field allows up to 60 Alphanumeric characters. Last Name is a required field. License # – Enter the License Number assigned by the State to the provider. This field allows up to 20 Alphanumeric characters. License Number is a required field if any one of the other License fields is entered. License State – Enter the state that the license number is assigned from the drop down list box characters. License State is a required field if any one of the other License fields is entered. Medicare # – Enter the Medicare number assigned by the Federal government to the provider. This field allows ten alphanumeric characters. Medicare Number is a required field if any one of the other Medicare fields is entered. Medicare Type – Select the Medicare Type associated with the Medicare # from the drop down list box characters. Medicare Type is required if any one of the other Medicare fields is entered. Typical values could include: Medicare Part A, Medicare Part B, etc. Middle – Enter the Middle Initial associated to the middle name of the Provider. This field allows one alphanumeric characters. NCPDP Provider ID Number – Enter the NCPDP Provider ID number of the provider. This field allows the ten alphanumeric characters. Organization Type – Select the Organization type for the Billing Individual from the Drop Down List Box characters. Typical values could include: Corporation, Estate, Trust,
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etc. If you are unsure of the organization type you may be able to find this information by performing a records search on the Secretary of State website. Pharmacy Classification – Enter the classification of the Pharmacy ID. List includes values such as Chain, Federal Government, Hospital, etc. Provider Legal Name – Enter the Provider Legal Name for an individual, atypical provider, or facility. This field allows up to 70 alphanumeric characters. Provider Legal Name is a required field. School – Enter the Name of school from which the degree was received by the individual provider. This field allows up to 25 alphanumeric characters. School Name is a required field if any one of the Professional Education fields is entered. Suffix – Enter the Suffix field for an individual provider. This field allows up to ten alphanumeric characters. This field should be used to indicate MD, PhD, etc. Year of Graduation – Enter the Year in which the provider obtained the degree. This field allows up to four number characters. Year of Graduation is a required field if any one of the Professional Education fields is entered. Year of Graduation cannot be more than 125 years in the past. Year of Graduation cannot be in the future. When you have completed the Provider Information panel, click: • Continue – To proceed to the next panel of the enrollment application. • Finish Later – To save your work and allow you to come back to the application
later. Please note that you must finish the required items on the panel before this button will save your work. Please see the Additional Links/Finish Later Option Section for more information.
• Cancel – To exit the application process without saving your work.
This is the Network Participation panel where providers may enter any medical networks they participate in. Adding a network option will not enroll you into that network. You must be a part of the network before indicating participation here; you will also need to scan and attach a copy of your contract with the MCO or BHO in the “Attachments and Fees” panel.
Network Participation Panel
Using the drop down menu, providers may select from available Colorado networks:
Network Participation Panel – MCO/ BHO Network Drop Down
This section is NOT REQUIRED – even
though there is an *
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Once a network and its effective date have been chosen, click the Add button to add it to the list.
If a provider is a member of more than one network, click the plus sign to add another network. Repeat the same steps as above to do this until this page of the application is complete.
• Continue – To proceed to the next panel of the enrollment application. • Finish Later – To save your work and allow you to come back to the application
later. Please note that you must finish the required items on the panel before this button will save your work. Please see the Additional Links/Finish Later Option Section for more information.
• Cancel – To exit the application process without saving your work.
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Languages
The next panel shown is the Languages panel. On this panel, you may enter any languages spoken within your office or facility. You may add as many as needed. This information will be shown in the Colorado Medicaid Provider Look-up.
Languages Panel
The languages currently available for selection are:
Arabic Armenian Chamorro Chinese Creole English French German Greek Hawaiian Hebrew Hindi Hmong
Hungarian Iloko Indonesian Italian Japanese Khmer Korean Lao Norwegian Persian Polish Portuguese Romany
Romanian Russian Sign Language Slavic Samoan Spanish Tahitian Tagalog Thai Turkish Vietnamese Yiddish
Once you have selected the language, click the “Add” button. The screen will update and add the selected item to your list of languages. If you need to remove the language click the “Remove” link on the right of the screen. If you need to add an additional language, click the “+” symbol as highlighted below. You can add as many languages as you need to reflect your capabilities.
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Languages Panel – Add another Language
When you have completed this panel, click:
• Continue – To proceed to the next panel of the enrollment application. • Finish Later – To save your work and allow you to come back to the application
later. Please note that you must finish the required items on the panel before this button will save your work. Please see the Additional Links/Finish Later Option Section for more information.
• Cancel – To exit the application process without saving your work.
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EFT Enrollment
The next panel shown allows you to enter information to have your claim payments deposited into a bank account via Electronic Funds Transfer (EFT). EFT allows you quicker access to your claim payments by depositing them right into your bank account.
Not all enrollment types will see this panel. If you are an Individual within a Group, you will not see this panel as the Group submits claims on your behalf and would be responsible for submitting the information for this panel.
The following comprehensive list describes the fields on the EFT Enrollment panel:
ABA Routing Number – Enter as the 9-digit identifier of the financial institution where the provider maintains an account to which payments are to be deposited. This field allows nine numeric characters. This field is required.
Address (Agent) – Enter the number and street name of the agent address. This field allows up to 55 alphanumeric characters. Enter the number and street name of the agent address. This field is only required when the Agent Address check box has been checked.
Address (Financial Institution) – Enter the number and street name of the financial institution address. This field allows up to 55 alphanumeric characters. Field is only required when the Financial Institution Address check box has been checked.
Address (Provider) – This field is display only and supplied by the value from the Address page. This field allows up to 55 alphanumeric characters. Field is only required when the Provider “Pay To” Address check box has been checked.
Assigning Authority – Organization that issues and assigns the additional provider identifier. If applicable, this field is display only and supplied by the value from the Request Information page. Use the Drop Down Box to make a selection. Assigning Authority is a required field if Other Identifier is entered.
Business Name – The name under which the business or operation is conducted. If applicable, this field is display only and supplied by the value from the Provider Identification page. This field allows up to 70 alphanumeric characters.
Chain Number – Enter the identification number assigned to the entity allowing linkage for a business relationship, i.e. chain, buying groups or third party contracting organizations. Also may be known as Affiliation ID or Relation ID. This field allows five alphanumeric characters.
City (Agent) – Enter the city associated to the agent address. Enter as 30-Alphanumeric characters. Field is only required when the Agent Address check box has been checked.
City (Financial Institution) – Enter the city associated to the financial institution address. This fiels allows up to 30 alphanumeric characters. Field is only required when the Financial Institution Address check box has been checked.
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City (Provider) – Enter the city associated to the provider address. If applicable, this field is display only and supplied by the value from the Address page. This field allows up to 30 alphanumeric characters.
Country (Agent) – Country codes associated to the agent address. Use the Drop Down Box to make a selection. Field is only required when the Agent Address check box has been checked.
Country (Financial Institution) – Country codes associated to the financial institution address. Use the Drop Down Box to make a selection. Field is only required when the Financial Institution Address check box has been checked.
Country (Provider) – Country code associated to the providers address. This field is supplied by the values from the Addresses page.
Email (Agent Contact) – Email Address for the agent contact. This field allows up to 50 alphanumeric characters. Enter a valid email address with 'name@domain' format. Field is only required when the Provider Agent Information check box has been checked.
Email (Provider Contact) – Email Address for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows 50 alphanumeric characters. Enter a valid email address with 'name@domain' format.
Ext (Agent Contact) – Telephone Number Extension for the agent contact. This field allows four numeric characters. Field is only required when the Agent Address check box has been checked.
Ext (Financial Institution) – Telephone Number Extension for the provider's financial institution. This field allows four numeric characters. Field is only required when the Financial Institution Address check box has been checked.
Ext (Provider Contact) – Telephone Number Extension for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows four numeric characters.
Fax Number (Agent Contact) – Fax Number for the agent contact. Enter as 10-Numeric characters. Enter a fax number in the format '999-999-9999'. This field is required.
Fax Number (Provider Contact) – Fax Number for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten numeric characters. Enter a fax number in the format '999-999-9999'.
Federal Agency Location Code – Location Code of the Federal Program Agency. This field allows up to 25 alphanumeric characters.
Federal Program Agency Identifier – Identifier of the Federal Program Agency. This field allows up to ten alphanumeric characters.
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Federal Program Agency Name – Name of the Federal Program Agency. This field allows up to 70 alphanumeric characters.
Financial Institution Name – Name of the provider's financial institution. This field allows up tp 39 alphanumeric characters. This field is required.
Financial Institution Telephone Number – Phone number for the provider's financial institution. This field allows ten numeric characters. Enter a phone number in the format '999-999-9999'. Field is only required when the Financial Institution Address check box has been checked.
Include with Enrollment Submission – The bank account verification document type to be attached as part of the enrollment application. Use the Drop Down Box to make a selection between “Bank Letter” or “Voided Check”. You will need to attch the back letter or the voided check in the “Attachment and Fees” panel. License Issuer – Entity that issued the provider’s license number. This field allows up to 30 alphanumeric characters. License Issuer is supplied by the Request Information page.
Medicaid Provider Number – A number issued to a provider by the U.S. Department of Health and Human Services through state health and human services agencies. This field allows ten alphanumeric characters.
NCPDP Provider ID Number – The National Council for Prescription Drug Programs (NCPDP) assigned unique identification number. This field allows seven alphanumeric characters.
Other Identifier – Additional provider identifier. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten alphanumeric characters.
Parent Organization ID – Headquarter information for chains, buying groups or third party contracting organizations where multiple relationship entities exist and need to be linked to a common organization such as common ownership for several chains. This field allows ten alphanumeric characters.
Payment Center ID – The assigned payment center identifier associated with the provider/corporate entity. This field allows ten alphanumeric characters.
Pharmacy Name – Enter the Pharmacy Name. This field allows up to 70 alphanumeric characters. Field is only required when the Retail Pharmacy Information check box has been checked.
Phone (Agent Contact) – Phone number for the agent contact. This field allows ten numeric characters. Enter a phone number in the format '999-999-9999'. Field is only required when the Provider Agent Information check box has been checked.
Phone (Provider Contact) – Phone number for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten numeric characters.
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Provider Agent Contact Name – Enter the name of the agent contact. This field allows up to 70 alphanumeric characters. Field is only required when the Provider Agent Information check box has been checked.
Provider Agent Name – Name of the agent. This field allows up to 70 alphanumeric characters. Field is only required when the Provider Agent Information check box has been checked.
Provider Contact Name – Name of the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows up to 70 alphanumeric characters.
Provider License Number – Provider’s License Number. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows 20-alphanumeric characters.
Provider Name – Complete legal name of institution, corporate entity, practice, or individual provider. If applicable, this field is display only and supplied by the value from the Provider Identification page. This field allows up to 70 alphanumeric characters.
Provider National Provider Identifier (NPI) (Financial Institution Information) - Unique identification number for the provider. This field allows ten numeric characters. Either a provider’s NPI or TIN is required.
Provider National Provider Identifier (NPI) (Provider Identification Numbers) – Unique identification number for the provider. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten numeric characters.
Provider Tax Identification Number (TIN) – (Financial Institution Information) – Federal Tax Identification Number used to identify a business entity. This field allows nine numeric characters. Either a provider’s NPI or TIN is required.
Provider Type – Type of provider. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows 50 alphanumeric characters.
Provider's Account Number with Financial Institution – Provider's account number at the financial institution to which EFT payments are to be deposited. This field allows ten alphanumeric characters. This field is required.
Reason For Submission – Reason for the EFT enrollment. “New Enrollment” is the only option and should be chosen for both a new enrollment and a revalidation.
Requested EFT Start/Change/Cancel Date – Date on which the requested action is submitted. As part of the enrollment application this field is display only and defaulted to the current date. This field allows eight numeric (MM/DD/CCYY) characters.
State (Agent) – State associated to the agent address. Use the Drop Down Box to make a selection. Field is only required when the Agent Address check box has been checked.
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State (Financial Institution) – State associated to the financial institution address. Use the Drop Down Box to make a selection. Field is only required when the Financial Institution Address check box has been checked.
State (Provider) – State associated to the provider’s address.
Suffix (Agent Contact) – Suffix of the agent contact. This field allows up to 30 alphanumeric characters. Field is only required when the Agent Address check box has been checked.
Suffix (Provider Contact) – Suffix of the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows up to 30 alphanumeric characters.
Tax ID – A Federal Tax Identification Number used to identify the business entity. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows nine numeric characters.
Taxonomy Code – Provider’s Taxonomy Code. The code set is structured into three distinct levels including provider type, classification and area of specialization. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten alphanumeric characters.
Trading Partner ID –Provider’s submitter ID assigned by the health plan or the provider’s clearinghouse or vendor. This field is supplied by the value from the Request Information page. This field allows ten alphanumeric characters.
Type of Account at Financial Institution – The type of account the provider will use to receive EFT payments, e.g. Checking, Savings. Use the Drop Down to make a selection. Type of Account at Financial Institution is a required field.
Zip Code / Postal Code (Agent) – Zip Code associated to the agent address. This field allows nine numeric characters. Field is only required when the Agent Address check box has been checked.
Zip Code / Postal Code (Financial Institution) – Zip Code associated to the financial institution address. This field allows nine numeric characters. Field is only required when the Financial Institution Address check box has been checked.
Zip Code / Postal Code (Provider) – Zip Code associated to the provider address. If applicable, this field is display only and supplied by the value from the Address page. This field allows none numeric characters.
When you have completed this panel, click:
• Continue – To proceed to the next panel of the enrollment application. • Finish Later – To save your work and allow you to come back to the application
later. Please note that you must finish the required items on the panel before this button will save your work. Please see the Additional Links/Finish Later Option Section for more information.
• Cancel – To exit the application process without saving your work.
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EFT Enrollment Panel – Section I
The second half of this panel is shown on the next page.
Skip this section
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This panel also includes several optional sections that can be completed during the Enrollment process. These sections are indicated by blue arrows on the panel below. A scanned copy of a bank letter or voided check needs to be added on the “Attachments and Fees” panel.
EFT Enrollment Panel – Section II
Clicking on the white checkboxes above will open up each optional area. These areas can be completed if you desire. The areas are shown on the next page.
Either TIN or NPI is required
This will say “New Enrollment”, even if you are
completing revalidation
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The first optional section is for you to indicate a Provider Agent and contact information. This information is not required but can be entered if you choose. Unchecking the box will close this section and remove any information you have entered in these fields.
EFT Enrollment Panel – Provider Agent Information
The next optional section is for you to indicate any Federal Agency information. This information is not required but can be entered if you choose. Unchecking the box will close this section and remove any information you have entered in these fields.
EFT Enrollment Panel – Federal Agency Information
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The next optional section is for you to indicate any Retail Pharmacy information. This information is not required but can be entered if you choose. Unchecking the box will close this section and remove any information you have entered in these fields.
EFT Enrollment Panel – Retail Pharmacy Information
Within the Financial Institution section of the Enrollment page, there are several fields that are indicated with a red asterisk. These are required fields that must be completed. Additionally, you have the option to enter your Financial Institution’s address information. This can be done by clicking the white checkbox indicated by a blue arrow on the panel below.
EFT Enrollment Panel – Financial Institution Information
Either TIN or NPI is required
This will say “New Enrollment”, even if you are
completing revalidation
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On the panel below you will see that the Financial Institution address window has been opened. This information is not required but can be entered if you choose. Unchecking the box will close this section and remove any information you have entered in these fields.
EFT Enrollment Panel – Financial Institution Information Address Panel
Either TIN or NPI is required
This will say “New Enrollment”, even if you are
completing revalidation
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ERA Enrollment
The next panel shown is the Electronic Remittance Advice (ERA) signup panel. On this panel, you may sign up to receive claims payment information electronically.
If you do not wish to sign up for ERAs, click the “No” option at the top of this panel and click continue. You do not have to enter any other information.
An example of each ERA Enrollment Information panel is listed in the sections directly following this section. Below is a comprehensive list of all of the ERA Enrollment Information fields that could be present:
Assigning Authority – Organization that issues and assigns the additional provider identifier. If applicable, this field is display only and supplied by the value from the Request Information page. Use the Drop Down Box to make a selection. Assigning Authority is a required field if Other Identifier is entered.
Business Name – This field automatically completed when adding a ‘Doing Business As’ Name.
Chain Number – Enter the identification number assigned to the entity allowing linkage for a business relationship, i.e. chain, buying groups or third party contracting organizations. Also may be known as Affiliation ID or Relation ID. This field allows five alphanumeric characters.
Clearinghouse Contact Name –The name of the contact person with the ERA clearinghouse if applicable as entered here by the provider.
Clearinghouse Name –The name of the ERA clearinghouse to be used by the provider as entered here if applicable.
Email (ERA Clearinghouse Information) – The email address of the ERA Clearinghouse if applicable as entered here by the provider.
Email (ERA Vendor Information) – The email address for the ERA vendor if applicable as entered here by the provider.
Email (Provider Agent) – Email Address for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows 50 alphanumeric characters. Enter a valid email address with 'name@domain' format.
Email (Provider Contact) – Email Address for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows 50 alphanumeric characters. Enter a valid email address with 'name@domain' format.
ERA Download Method – Drop down menu to indicate how the ERA statements will be downloaded. Options are either “Download from Clearinghouse” or “Download from Health Plan Website”.
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Ext (Provider Agent) – Telephone Number Extension for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows four numeric characters.
Ext (Provider Contact) – Telephone Number Extension for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows four numeric characters.
Fax Number (Agent Contact) – Fax Number for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten numeric characters.
Fax Number (Provider Contact) – Fax Number for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten numeric characters.
Federal Agency Location Code – Location Code of the Federal Program Agency. This field allows up to 25 alphanumeric characters.
Federal Program Agency Identifier – Identifier of the Federal Program Agency. This field allows up to ten alphanumeric characters.
Federal Program Agency Name – Name of the Federal Program Agency. This field allows up to 70 alphanumeric characters.
License Issuer – Entity that issued the provider’s license number. This field allows up to 30 alphanumeric characters. License Issuer is supplied by the Request Information page.
Medicaid Provider Number – A number issued to a provider by the U.S. Department of Health and Human Services through state health and human services agencies. This field allows ten alphanumeric characters.
NCPDP Provider ID Number – The National Council for Prescription Drug Programs (NCPDP) assigned unique identification number. This field allows seven alphanumeric characters.
Other Identifier – Additional provider identifier. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten alphanumeric characters.
Parent Organization ID – Headquarter information for chains, buying groups or third party contracting organizations where multiple relationship entities exist and need to be linked to a common organization such as common ownership for several chains. This field allows ten alphanumeric characters.
Payment Center ID – The assigned payment center identifier associated with the provider/corporate entity. This field allows ten alphanumeric characters.
Pharmacy Name – Enter the Pharmacy Name. This field allows up to 70 alphanumeric characters. Field is only required when the Retail Pharmacy Information check box has been checked.
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Phone (ERA Clearinghouse Information) – The phone number of the ERA clearinghouse if applicable as entered here by the provider.
Phone (ERA Vendor Information) – The phone number for the ERA vendor if applicable as entered here by the provider.
Phone (Provider Agent) – Phone number for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten numeric characters.
Phone (Provider Contact) – Phone number for the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten numeric characters.
Provider Agent Contact Name – Name of the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows up to 70 alphanumeric characters.
Provider Agent Name – Name of the agent. This field allows up to 70 alphanumeric characters. Field is only required when the Provider Agent Information check box has been checked.
Provider Contact Name – Name of the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows up to 70 alphanumeric characters.
Provider License Number – Provider’s License Number. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows 20-alphanumeric characters.
Provider National Provider Identifier (NPI) (Electronic Remittance Advice Information) – Unique identification number for the provider. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows ten numeric characters.
Provider Tax Identification Number (TIN) (Electronic Remittance Advice Information) – Federal Tax Identification Number used to identify a business entity. This field allows nine numeric characters.
Provider Type – Type of provider. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows 50 alphanumeric characters.
Suffix (Agent Contact) – Suffix of the agent contact. This field allows up to 30 alphanumeric characters. Field is only required when the Agent Address check box has been checked.
Suffix (Provider Contact) – Suffix of the contact person. If applicable, this field is display only and supplied by the value from the Request Information page. This field allows up to 30 alphanumeric characters.
Taxonomy – Provider’s Taxonomy Code. The code set is structured into three distinct levels including provider type, classification and area of specialization. If applicable, this
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field is display only and supplied by the value from the Request Information page. This field allows ten alphanumeric characters.
Trading Partner ID – Provider’s submitter ID assigned by the health plan or the provider’s clearinghouse or vendor. This field is supplied by the value from the Request Information page. This field allows ten alphanumeric characters.
Vendor Contact Name (ERA Vendor Information) –The name of the contact person with the ERA vendor if applicable as entered here by the provider.
Vendor Name (ERA Vendor Information) – The name of the ERA vendor if applicable as entered here by the provider.
ERA Enrollment Panel
If you do wish to sign up for ERAs, click the “yes” option at the top and additional panels will open. This information must be completed as part of the ERA process.
If you are an existing Colorado Medicaid provider, complete this panel.
If you are a new Colorado Medicaid provider, complete this panel and the Trading Partner Agreement form on the Provider Next Steps web page.
This panel has been broken into sections on the next page.
The second half of this panel is shown on the next page.
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This panel also includes several optional sections that can be completed during the Enrollment process. These sections are indicated by blue arrows on the panel below.
ERA Information Panel – Section II
Clicking on the white checkboxes above will open up each optional section. These sections can be completed if you desire. The section panels are shown below.
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The first optional section is for you to indicate a Provider Agent and contact information. This information is not required but can be entered if you choose. Unchecking the checkbox will close this section and remove any information you have entered in these fields.
ERA Information Panel – Provider Agent Information
The next optional section is for you to indicate the Agent Address information. This information is not required but can be entered if you choose. Unchecking the checkbox will close this section and remove any information you have entered in these fields.
ERA Information Panel – Agent Address
The next optional section is for you to indicate any Federal Agency information. This information is not required but can be entered if you choose. Unchecking the checkbox will close this section and remove any information you have entered in these fields.
ERA Information Panel – Federal Agency Information
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The next optional section is for you to indicate any Retail Pharmacy information. This information is not required but can be entered if you choose. Unchecking the checkbox will close this section and remove any information you have entered in these fields.
ERA Information Panel – Retail Pharmacy Information
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The next section of the ERA Information panel is not optional. In this section, enter your Tax Identification Number or NPI and indicate how you wish to obtain your ERA.
ERA Information Panel –TIN, NPI, & Download Method
The next optional section is for you to indicate your Electronic Remittance Advice Clearinghouse contact information. This information is not required but can be entered if you choose. Unchecking the checkbox will close this section and remove any information you have entered in these fields.
ERA Information Panel – Clearinghouse Information
The next optional section is for you to indicate your Electronic Remittance Advice Vendor contact information. This information is not required but can be entered if you choose. Unchecking the checkbox will close this section and remove any information you have entered in these fields.
ERA Information Panel – Vendor Information
When you have completed this panel, click:
• Continue – To proceed to the next panel of the enrollment application. • Finish Later – To save your work and allow you to come back to the application
later. Please note that you must finish the required items on the panel before
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this button will save your work. Please see the Additional Links/Finish Later Option Section for more information.
• Cancel – To exit the application process without saving your work.
Other Information
The next panel shown is the Other Information panel. Here you may enter any other additional information as applicable to your practice or facility. The Provider Enrollment tool will automatically present the appropriate questions based on the Enrollment Type chosen earlier in the process. This can include degrees, schools attended, number of Medicaid-eligible or certified/licensed beds, liability insurance information and any board certifications.
An example of each Other Information panel is listed in the sections directly following this section. Below is a comprehensive list of all of the Other Information fields that could be present:
Carrier Name – Enter the name of the insurance carrier. This field allows up to 25 alphanumeric characters. This field is required. Certificate # - Enter the Board Certification number. This field allows 20 alphanumeric characters. This field is required. Certification – Select the Certification the provider has received associated to their specialty from the drop down list box characters. Values could include: Inpatient Hospital Certification, Nursing Facility Class I, etc. This field is required. CO Medicaid ID – Enter the Colorado Medicaid ID assigned to the supervising APN/MD. This field allows 15 Alphanumeric characters. This field is required. Commercial Insurance – Enter the Commercial Insurance carrier to be added. This field allows 25 alphanumeric characters. This field is required. Effective Date (Beds) – Enter the Effective date of the hospital bed. Enter eight characters in MM/DD/CCYY format. This field is required. Effective Date (Certification) – Enter the Effective date for the certification. This field allows allows eight numeric characters in MM/DD/CCYY format. Effective Date is a required field if Certificate # is entered. Effective Date (Insurance) – Enter the Effective Date for the provider insurance. This field allows eight numeric characters in MM/DD/CCYY format. This field is required Effective Date (Malpractice/General Liability) – Enter the Effective date for the certification. This field allows eight numeric characters characters in MM/DD/CCYY format. Effective Date is a required field if Liability # is entered. Effective Date cannot be a future date. End Date (Beds) – Enter the End date of the hospital bed. This field allows eight numeric characters in MM/DD/CCYY format. This field is required. End Date (Certification) – Enter the End date for the certification. This field allows eight numeric characters in MM/DD/CCYY format. End Date cannot be before Effective Date. This field is required.
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End Date (Malpractice/General Liability) – Enter the End date for the certification. This field allows eight numeric characters in MM/DD/CCYY format. End Date cannot be prior to Effective Date. This field is required. First Name – Enter the First name of the collaborating physician. This field allows up to 25 alphanumeric characters. This field is required. First Name – Enter the first name of the supervising APN/MD. This field allows up to 50 alphanumeric characters. First Name is a required field if Collaborating Physician Last Name or NPI is entered. Last Name – Enter the last name of the supervising APN/MD. This field allows up to 60 Alphanumeric characters. This field is required. License Expiration Date – Enter the Expiration Date of the providers insurance. This field allows eight numeric characters in MM/DD/CCYY format. The End Date cannot be before the Effective Date. This field is required. Malpractice/General Liability Insurance – Enter the insurance carrier to be added. This field allows up to 25 alphanumeric characters. This field is required. Number ACF Beds – Enter the number of Medicaid beds at the alternate care facility (ACF). This field allows five numeric characters. This field is required. Number of ICF Beds – Enter the number of beds at the nursing facility for Intermediate Care Facilities (ICF) patients. This field allows five numeric characters. This field is required. Number of Inpatient Beds – Enter the Number of beds in a facility that are allocated to Medicaid patients. This field allows five numeric characters. This field is required. Number of Skilled Beds – Enter the Number of beds in a facility that are certified and/or licensed. This field allows five numeric characters. This field is required. Nursing Home Visitor Program – Enter the name of the nursing home visitor program the registered nurse is participating in. This field allows up to 50 alphanumeric characters. This field is required. Nursing Home Visitor Program question – This checkbox is used to indicate if the registered nurse is exempt from entering information for the on premise supervision. Nurses participating only in the Nursing Home Visitor Program are not required to enter a supervising APN/MD. They are required to enter the program site name if the box is checked. This field is required. Policy ID – Enter the Policy ID for the insurance carrier. This field allows up to 20 alphanumeric characters. This field is required. Specialty – Select the board Specialty areas list from the drop down list box characters. Typical values could include: Ambulatory Care, Pharmacotherapy, Oncology, etc. This field is required. Supplemental Questions – Select Yes or No for the Supplemental Questions. This field is required. Answering ‘Yes’ to a question will open a required text box to elaborate on your answer. Web Site Address – Enter the Provider's web site URL. This field allows up to 55 alphanumeric characters. This field is not required.
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Atypical Other Information - Atypical
Board Certification section is NOT
REQUIRED – even though it looks like it
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On this panel, answering “Yes” to any of the questions within the Supplemental Questions panel, will open a text box to allow you to elaborate on your answers:
Other Information – Atypical – Supplemental Questions
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Facility Other Information – Facility
Board Certification section is NOT
REQUIRED – even though it looks like it
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On this panel, answering “Yes” to any of the questions within the Supplemental Questions panel, will open a text box to allow you to elaborate on your answers:
Other Information – Facility – Supplemental Questions
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Group Other Information – Group
Board Certification section is NOT
REQUIRED – even though it looks like it
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On this panel, answering “Yes” to any of the questions within the Supplemental Questions panel, will open a text box to allow you to elaborate on your answers:
Other Information – Group – Supplemental Questions
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Individual Other Information – Individual
Board Certification section is NOT
REQUIRED – even though it looks like it
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On this panel, answering “Yes” to any of the questions within the Supplemental Questions panel, will open a text box to allow you to elaborate on your answers:
Other Information – Individual – Supplemental Questions
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Individual within Group Other Information – Individual w ithin Group
Board Certification section is NOT
REQUIRED – even though it looks like it
This section is ONLY for Registered Nurses
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On this panel, answering “Yes” to any of the questions within the Supplemental Questions panel, will open a text box to allow you to elaborate on your answers:
Other Information – Individual w ithin Group – Supplemental Questions
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Addendums
This is an example of an Addendums panel. Only if you are enrolling as a pharmacy will there be anything to complete here.
Addendums Panel
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Addendums Panel - Pharmacy
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Disclosures
The next panel that is shown is the Disclosures panel. This is a required panel that will guide you through each Disclosure. Select each Disclosure link and answer all questions contained within the disclosure. For disclosures that require more entries, attach a separate list including the required information using the Attachments and Fees page. It is required that all Disclosures be completed before you can proceed with your enrollment.
All Disclosures indicate the word “New” on the right-hand side of the panel until each is complete.
Disclosures Panel
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The first questionnaire is for Ownership/Controlling Interest Disclosure. On this panel you will indicate information regarding Persons (individual or corporation) with an ownership or controlling interest in the disclosing entity, fiscal agent or managed care entity having direct or indirect ownership.
If you answer “Yes” to any of the questions, an additional section of the panel will open. You are required to complete this section of the panel as well.
After you have completed the questions on the Disclosure, click the “Add” button. The panel will update as shown below.
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Disclosures Panel – Ownership/ Controlling Interest – Enrollment Disclosure Questions – Add another Owner or Submit
If you have an additional Ownership or Controlling Interest to disclose, click on the “+” symbol on the left-hand side of the panel.
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If you have no further Ownership or Controlling Interests to disclose, click on the “Submit” button on the right-hand side of the panel. The panel will update and this item on the Disclosure list will now reflect “Completed”, as shown below.
The next panel is the Subcontractor Ownership Disclosure. On this panel you will indicate any persons or entities with an ownership or controlling interest in any subcontractor in which the disclosing entity has direct or indirect ownership.
Disclosures Panel – Subcontractor Ownership and Control
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If you answer “Yes” to any of the questions, an additional section of the panel will open. You are required to complete this section of the panel as well.
Disclosures Panel – Subcontractor Ownership and Control – Enrollment Disclosure Questions
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After you have completed the questions on the Disclosure, click the “Add” button. The panel will update as shown below.
Disclosures Panel – Subcontractor Ownership and Control – Enrollment Disclosure Questions – Add another Owner or Submit
If you have an additional Ownership or Controlling Interest to disclose, click on the “+” symbol on the left-hand side of the panel.
If you have no further Ownership or Controlling Interests to disclose, click on the “Submit” button on the right-hand side of the panel. The panel will update and this item on the Disclosure list will now reflect “Completed”.
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The next panel is the Individual Relationships Disclosure. On this panel you will indicate any persons mentioned in Disclosure A and Disclosure B related to one another as a spouse, parent, child, or sibling.
Disclosures Panel – Individual Relationships
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If you answer “Yes” to any of the questions, an additional section of the panel will open. You are required to complete this section of the panel as well.
After you have completed the questions on the Disclosure, click the “Add” button. The panel will update as shown below.
Disclosures Panel – Individual Relationships – Enrollment Disclosure Questions – Add another Individual or Submit
If you have an additional Ownership or Controlling Interest to disclose, click on the “+” symbol on the left-hand side of the panel.
If you have no further Ownership or Controlling Interests to disclose, click on the “Submit” button on the right-hand side of the panel. The panel will update and this item on the Disclosure list will now reflect “Completed”.
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The next panel is the Managing Individuals Disclosure. On this panel you will indicate any persons who hold a position of managing employee within the disclosing entity, fiscal agent or managed care entity.
Disclosures Panel – Managing Individuals
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If you answer “Yes” to any of the questions, an additional section of the panel will open. You are required to complete this section of the panel as well.
After you have completed the questions on the Disclosure, click the “Add” button. The panel will update as shown below.
Disclosures Panel – Managing Individuals – Enrollment Disclosure Questions – Add another Managing Employee or Submit
If you have an additional Ownership or Controlling Interest to disclose, click on the “+” symbol on the left-hand side of the panel.
If you have no further Ownership or Controlling Interests to disclose, click on the “Submit” button on the right-hand side of the panel. The panel will update and this item on the Disclosure list will now reflect “Completed”.
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The next panel is the Business Relationships Disclosure. On this panel you will indicate any persons, businesses, organizations or corporations with an ownership or controlling interest (identified in Disclosure A) that have an ownership or controlling interest in any other provider, fiscal agent or managed care entity.
Disclosures Panel – Business Relationships
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If you answer “Yes” to any of the questions, an additional section of the panel will open. You are required to complete this section of the panel as well.
Disclosures Panel – Business Relationships – Enrollment Disclosure Questions
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After you have completed the questions on the Disclosure, click the “Add” button. The panel will update as shown below.
Disclosures Panel – Business Relationships – Enrollment Disclosure Questions – Add another Business Relationship or Submit
If you have an additional Ownership or Controlling Interest to disclose, click on the “+” symbol on the left-hand side of the panel.
If you have no further Ownership or Controlling Interests to disclose, click on the “Submit” button on the right-hand side of the panel. The panel will update and this item on the Disclosure list will now reflect “Completed”.
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The next panel is the Conviction Disclosure. On this panel you will indicate any persons who have an ownership or controlling interest in the provider, or is an agent or managing employee of the provider who has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, Children's Health Insurance Program or the Title XX services since the inception of these programs.
Disclosures Panel – Conviction Disclosure
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If you answer “Yes” to any of the questions, an additional section of the panel will open. You are required to complete this section of the panel as well.
After you have completed the questions on the Disclosure, click the “Submit” button. The panel will update as shown below and will now indicate that all Disclosures have been completed.
Disclosures Panel – Conviction Disclosure – Enrollment Disclosure Questions – Add another Conviction or Submit
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After you have completed the questions on the Disclosure, click the “Submit” button. The panel will update as shown below and will now indicate that all Disclosures reflect “Completed”, as shown below.
• Continue – To proceed to the next panel of the enrollment application. • Finish Later – To save your work and allow you to come back to the application
later. Please note that you must finish the required items on the panel before this button will save your work. Please see the Additional Links/Finish Later Option Section for more information.
• Cancel – To exit the application process without saving your work.
Fingerprinting
Content will be added to this section at a later date.
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Attachments and Fees
The next panel that will be presented is the “Attachments and Fees” Panel. Any required attachments may be submitted electronically on this panel. The documents shown under Supporting Documentation, may NOT necessarily apply to you.
You will need to scan and attach:
• Insurance face sheet
• License or certifications (if applicable)
• W-9 (signed and dated within the past 6 months) o W-9 not required for “Individuals within a group”
• Voided check or bank letter (bank letter dated within the past 6 months) o not required for “Individuals within a group”
• Entire contract with MCO or BHO (if applicable)
• Proof of Lawful Presence (ONLY required for Billing Individuals or Atypical providers billing under their SSN)
• Supervising Physician Signature Form (ONLY required for Registered Nurses)
• Hardship waiver request letter and supporting documentation (if Appling for a hardship waiver)
• Proof of payment (if you have already paid the revalidation fee for Medicare or in another state, for this location).
• Please see Information by Provider Type web page for any additional documentation required for your provider type.
Blank copies of some of these documents are available at the top of the “Attachments and Fees” panel. You may need print, sign, and scan these documents if you cannot complete them electronically.
The Enrollment tool will also calculate any required Enrollment Fees and guide you through the payment process.
An example of the Attachments and Fees panel is shown on the next page.
To submit a required attachment, first click on the appropriate link to open the document. Some documents can be completed electronically while others will require you to print and scan a document. Please work with your IT Support if you are unfamiliar with this process.
If a fee is NOT required for your provider type, the application will say “No
Application Fee Required”
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Attachments and Fees Panel – Fee Required
If a fee IS required for your
provider type, this panel shows
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In the example shown the first required document is a standard W-9 tax form, as shown below.
Attachments and Fees Panel – W-9 Tax Form
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In the example show n the second required attachment is a completed Proof of Law ful Presence form, as show n below .
Attachments and Fees Panel – Affidavit for Law ful Presence for the State of Colorado
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In the example shown the third required attachment is a completed Supervising Physician Signature Form, as shown below .
Attachments and Fees Panel – Supervising Physician Signature Form
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The Affordable Care Act (ACA) requires certain providers to remit an enrollment application fee. The Centers for Medicare & Medicaid Services (CMS) sets the fee amount annually. This fee is assessed at initial enrollment and change of ownership, as required, and is assessed in full for each service location enrolled in Colorado Medicaid.
The Application Fee questions as shown in the panel below will only be displayed if the Enrollment Type selected previously should have a fee.
If the service location has enrolled or revalidated with Medicare or another state’s Medicaid program (in the last 12 months) and paid an application fee, no fee is required. A copy of the receipt indicating payment must be uploaded on this page with a selection type of “Other”.
Financial Hardship – If you are requesting a waiver for financial hardship, include a letter describing the financial hardship and why the hardship justifies an exception, as well as any additional documentation that you believe may aide CMS in its determination. If you choose to apply for an application fee waiver, your enrollment will be delayed while CMS makes its determination. Your letter explaining the reason for hardship must be uploaded on this page with a selection type of “Other”.
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Application Fee Panel
If it is determined that an application fee is due, click the “Online Bill Pay” link, and a payment form will open in a pop up window:
If you answer “Yes” to any of these
questions you do not need to pay the
fee. Just press “Continue” instead
Click this “Online Bill Pay” link to pay the fee
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Online Bill Pay Pop Up
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Agreement
Here is an example of the Agreement panel. The terms of enrollment are stated here. Acceptance of these terms is required in order to submit the enrollment application. Failure to accept these terms means that no enrollment application is retained or submitted.
Agreement Panel
Click the link to the “Provider Participation Agreement” and read the agreement in order to complete the page. A checkmark will then appear next to it:
Enter your Provider name as the electronic signature and click in the “I accept” box in order to complete the page. The “Submit” button will then become active:
Excerpt from Provider Participation Agreement: “PROVIDER SIGNATURE I certify that I am fully authorized to execute this Agreement on behalf of Provider; and that I have read, understand, certify, and agree to all the statements made in all parts of this Provider Participation Agreement. I further understand that any false claims, statements, documents, or concealment of material fact may be grounds for termination as a Colorado Medical Assistance Program Provider, and/or may be prosecuted under applicable federal and state laws.”
View full Provider Participation Agreement here: https://www.colorado.gov/pacific/sites/default/files/Provider%20Participation%20Agreement.pdf
This subsection describes how a provider may review and make any revisions to previous pages as needed. A provider may be requested to confirm the information and print a copy of the summary.
The last panel will open to display the entire application in a summary panel:
Enrollment Summary Panel – Section I
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Enrollment Summary Panel – Section II
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Enrollment Summary Panel – Section III
You will be asked if you have printed a copy of this enrollment for your records. If you have, printed one or choose not to print one, click “OK”. If you would like to print a copy, click “Cancel” to return to the application to print a copy.
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Once the confirmation dialog box shown above disappears, click “Confirm” to submit your application for processing.
PLEASE NOTE: The application is not submitted for processing until the Confirm button at the bottom of the summary page is clicked:
If you have not previously saved your application, you will be presented with the panel below. On this panel you can set up a password to so that you can access the application at a later date to check the enrollment status. If you have previously saved your application, you will be taken to the final Application Tracking Number panel as shown on page 143.
• Enter a password consisting of 8-20 alphanumeric characters containing at least one capital letter and one number.
• Retype this password to confirm • Enter answers to the security questions then click the “Submit” button.
After your application has been submitted
Please visit the Next Steps web page for further instructions.
The application is then submitted for processing and an Application Tracking Number (ATN) is generated for your records:
Enrollment Summary Panel – Application Tracking Number
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Resume Enrollment If you were unable to complete the enrollment process and elected to save your work, the application process can be resumed with the “Resume Enrollment” link as shown below.
If the application was completed, but you received a Return to Provider (RTP) email from HP stating additional or corrected information is needed, you use the same link.
Provider Enrollment Panel - Resume Enrollment Link
Resume Enrollment Panel - Login
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Enrollment Status Using the “Enrollment Status” link shown below, providers may check the current status of their application.
Provider Enrollment Panel - Enrollment Status Link
Enrollment Status Panel Login
Click on the “Enrollment Status” link shown above to display a panel that will allow you to enter your application tracking number (ATN) and tax ID number. Click the “Search” button:
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The Provider Enrollment - Summary panel will then display showing the current status of your application:
Enrollment Status Panel – Summary
Please Note: Enrollment analysts will perform two quality review checks before placing your application into a Return to Provider (RTP) status for correction (if needed).
Even if you see notes here indicating your application needs to be RTP’d, you WILL NOT be able to re-enter your application to make corrections until this status reads:
• Returned to provider for Missing Documentation • Returned to provider for Additional Information
You will receive an email once your application has been RTP’d (if needed).
To make the required corrections you will need to log back into your application by clicking Resume Enrollment (See Page 129). You will then need to press the continue button at the bottom of each page to navigate through the application.
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Site Visits Per federal requirement 42CFR 455.432, pre-enrollment site visits of providers who are designated as “moderate” or “high” categorical risks to the Medicaid program are required.
The purpose is to verify that the information submitted to the Department of Health Care Policy and Financing by a provider is accurate and to determine compliance with federal and state enrollment requirements. In the event that your provider type falls into one of these risk categories, you will be contacted for the required site visit. A representative will visit your service location to verify certain aspects of your enrollment. Providers that refuse a site visit may be excluded from the Colorado Medicaid Program.
For further information about risk categories by provider type please refer to the Federal Provider Screening Regulation.
Provider Enrollment Notifications You will receive several notifications via email during the Enrollment Process:
• Upon successful submission of an online enrollment application for review, you will receive an email at the email address entered in the contact information during the enrollment process acknowledging the submission.
• During the application review process by HP, if additional information and/or missing documentation is needed a RTP email will be sent to your email address entered in the contact information during the enrollment process. You will then be able to return to the application on the web portal to address the issues through the “Resume Enrollment” link. Once this is completed, HP will be notified of the application update and will continue processing.
• Once the application has been reviewed another email will be sent to the address entered in the contact information during the enrollment process advising you of the outcome.
o If you are already an enrolled provider and the application is approved, you will be advised that you are enrolled.
o If you are already an enrolled provider and the application is rejected, you will be advised of the reason and your rights to file a grievance.
o If you are a new provider and your application is approved, you will be advised that you are enrolled but that you must complete certain steps with the current fiscal agent in order to begin billing for services.
o If you are a new provider and the application is rejected, you will be advised of the reason and your rights to file a grievance.
